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Lau A, Haag H, Maharaj A. A Simulation-Based Assessment of Levetiracetam Concentrations Following Fixed and Weight-Based Loading Doses: A Meta-Regression and Pharmacokinetic Modeling Analysis. J Clin Pharmacol 2024; 64:1173-1180. [PMID: 38708556 DOI: 10.1002/jcph.2449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024]
Abstract
Current recommendations for refractory status epilepticus (SE) unresponsive to benzodiazepines suggest a loading dose of levetiracetam (LEV) of 60 mg/kg to a maximum of 4500 mg. LEV therapeutic drug monitoring can help guide therapy and is garnering increasing attention. The objective of this study is to simulate the probability of target attainment (PTA) of fixed dose and weight-based loading doses of LEV with respect to established therapeutic target concentrations. Meta-regression of the current literature was performed to evaluate the relationship between intravenous LEV loading dose and seizure cessation in refractory SE patients. A previously published pharmacokinetic model was used to simulate the PTA capacity of competing single intravenous dosing schemes (fixed vs weight-based dosing) to achieve maximum (Cpeak) and 12-h (C12h) plasma concentrations that exceed 12 mg/L. The meta-regression indicated that dosage was not a statistically significant modulator of seizure control at dosages between 20 and 60 mg/kg. Stochastic simulations showed all dosing schemes achieved plasma Cpeak >12 mg/L, but C12h levels were <12 mg/L in subjects over 60 kg with a fixed dose ≤2000 mg or in subjects <60 kg with a weight-based dose <30 mg/kg. Dosages of 40 and 60 mg/kg provided ≥90% PTAs across all weights. Using a weight-based loading dose of 40 mg/kg, up to a suggested maximum of 4500 mg, improves the likelihood of achieving a sustained therapeutic drug concentration after the initial LEV dose, whereas fixed <3000 mg may not achieve the desired concentration before maintenance dosing.
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Affiliation(s)
- Anthony Lau
- Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hans Haag
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- Infectious Disease, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Anil Maharaj
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Abi Tayeh R, Dozières-Puyravel B, Arnaud L, Titomanlio L, Dauger S, Höhn S, Le Guern E, Auvin S. Pharmacological management of prolonged seizures in Dravet syndrome including intravenous phenytoin. Epilepsia 2024. [PMID: 39215723 DOI: 10.1111/epi.18101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/07/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Dravet syndrome (DS) is an infantile onset developmental and epileptic encephalopathy. Sodium channel blockers are known to exacerbate seizures in this syndrome. Due to its high incidence, the management of prolonged seizures is crucial for DS patients. There is still ambiguity regarding the use of intravenous phenytoin for prolonged seizure in DS patients mainly due to the lack of data, raising concern about the safety of it use. We conducted a retrospective study (from January 2009 to January 2020) aiming to assess the management of prolonged seizures in DS with a focus on the use of intravenous phenytoin. Data were collected for patients admitted to our hospital for seizures lasting >5 min. Among 52 identified patients in our database, 23 experienced 59 prolonged seizures managed in our hospital. Only four seizures ceased without rescue medication. Notably, the use of intravenous phenytoin was not associated with discernible adverse effects and was effective in stopping status epilepticus in 71% of cases. This study suggests the safety and efficacy of intravenous phenytoin for prolonged seizure in DS. There is a need for broader investigations of emergency treatments for evidence-based recommendations for the emergency plan of each patient.
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Affiliation(s)
- Rana Abi Tayeh
- Pediatric Neurology Department, Centre de Référence Maladies Rares Epilepsies Rares, EpiCARE member, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | - Blandine Dozières-Puyravel
- Pediatric Neurology Department, Centre de Référence Maladies Rares Epilepsies Rares, EpiCARE member, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
- Université Paris Cité, Institut national de la santé et de la recherche médicale NeuroDiderot, Paris, France
| | - Lionel Arnaud
- Département de Génétique, Sorbonne Université, AP-HP, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Luigi Titomanlio
- Pediatric Emergency Department, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | - Stéphane Dauger
- Pediatric Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | - Sophie Höhn
- Pediatric Neurology Department, Centre de Référence Maladies Rares Epilepsies Rares, EpiCARE member, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | - Eric Le Guern
- Département de Génétique, Sorbonne Université, AP-HP, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Stéphane Auvin
- Pediatric Neurology Department, Centre de Référence Maladies Rares Epilepsies Rares, EpiCARE member, Assistance Publique - Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
- Université Paris Cité, Institut national de la santé et de la recherche médicale NeuroDiderot, Paris, France
- Institut Universitaire de France, Paris, France
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Cock H. Why have status epilepticus trials failed: Wrong drugs or wrong trials? Epilepsy Behav 2024; 159:110030. [PMID: 39217755 DOI: 10.1016/j.yebeh.2024.110030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 08/28/2024] [Accepted: 08/28/2024] [Indexed: 09/04/2024]
Abstract
Despite burgeoning interest in trials in status epilepticus over the last 20 years, outcomes have yet to improve and a number of high profile studies have failed to deliver for a range of reasons. The range of reasons a trial may fail to meet the intended outcomes are discussed. Recent well designed, adequately powered studies in established status epilepticus failed to meet primary endpoints, but are nonetheless influencing practice, reflecting the importance of interpreting results in the context of broader literature, safety and practical considerations. Studies in refractory and super-refractory status epilepticus have yet to do so, frequently failing to deliver as hoped despite huge financial and human cost. The importance of reviewing regulatory frameworks, and our approach to trial design to address important clinical questions is reviewed, reflecting on lessons from the COVID-19 RECOVERY trials, and other disease areas, together with the potential associated with the use artificial intelligence tools. This paper is based on a presentation made at the 9th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures in April 2024.
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Affiliation(s)
- Hannah Cock
- City St George's, University of London, School of Health and Medical Sciences, Neurosciences Clinical Academic Group, Cranmer Terrace, London SW17 0RE, UK.
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Kanaris C. Fifteen-minute consultation: A guide to paediatric post-resuscitation care following return of spontaneous circulation. Arch Dis Child Educ Pract Ed 2024:edpract-2023-325922. [PMID: 39122265 DOI: 10.1136/archdischild-2023-325922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
Paediatric resuscitation is a key skill for anyone in medicine who is involved in the care of children. Basic and advance paediatric life support courses are crucial in teaching those skills nationwide in a way that is memorable, protocolised and standardised. These courses are vital in the dissemination and upkeep of both theoretical and practical knowledge of paediatric resuscitation, with their primary aim being the return of spontaneous circulation. While sustaining life is important, preserving a life with quality, one with good functional and neurological outcomes should be the gold standard of any resuscitative attempt. Good neurological outcomes are dependent, in large part, on how well the postresuscitation stage is managed. This stage does not start in the intensive care unit, it starts at the point at which spontaneous circulation has been reinstated. The aim of this paper is to provide a basic overview of the main strategies that should be followed in order to minimise secondary brain injury after successful resuscitation attempts.
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Affiliation(s)
- Constantinos Kanaris
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
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Kartek M, Kannan A, Anand V, Sahoo MR. Intravenous levetiracetam versus intravenous phenytoin as second Line treatment in pediatric convulsive status epilepticus- open label randomized controlled trial. J Family Med Prim Care 2024; 13:3368-3373. [PMID: 39228645 PMCID: PMC11368275 DOI: 10.4103/jfmpc.jfmpc_1747_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 04/10/2024] [Accepted: 04/23/2024] [Indexed: 09/05/2024] Open
Abstract
Background Benzodiazepines (BZDs) are recommended as the initial therapy of choice in status epilepticus (SE). The age-old second-line treatment for BZD refractory convulsive SE is intravenous phenytoin (PHT) based predominantly on nonrandomized clinical trial data. We did this study to compare the efficacy and safety of intravenous levetiracetam (LEV) and PHT as second-line antiseizure medication (ASM) for children with SE. Methodology A prospective, randomized controlled, open-label study was conducted in children 3 months to 15 years of age with SE in Pediatric Emergency. A total of 41 children were randomly allocated to either group 1 (Levetiracetam) or group 2 (Phenytoin) on the basis of computer-generated randomization. Children who were already on antiseizure medications, either LEV or PHT, or receiving these drugs outside for SE were excluded. Data analysis was done by SPSS V25. Results The most common age group presenting with SE was 12 months to 5 years. Clinical cessation of seizure 5 minutes after the completion of drugs was 85% (17/20) in Levetiracetam group and 90.5% (19/21) in Phenytoin group. Recurrence of seizure within 24 hours was noted in 35% (7/20) in Levetiracetam group and 38.1% (8/21) in Phenytoin group. There was no statistically significant difference noted in both the groups in terms of seizure cessation, adverse events, and recurrence. Conclusion The efficacy and safety of LEV were found to be comparable to those of PHT in controlling seizure as second-line ASM in SE.
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Affiliation(s)
- Mamum Kartek
- Department of Pediatrics, TRIHMS, Naharlagun, Arunachal Pradesh, India
| | - Abinaya Kannan
- Department of Pediatrics, AIIMS, Raipur, Chhattisgarh, India
| | - Varun Anand
- Department of Trauma and Emergency, AIIMS, Raipur, Chhattisgarh, India
| | - Manas R. Sahoo
- Department of Pediatrics, AIIMS, Raipur, Chhattisgarh, India
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Ahmed N, Russo L, Kuo YH. Levetiracetam or Phenytoin as Prophylaxis for Status Epilepticus: Secondary Analysis of the "Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial" (ADAPT) Dataset, 2014-2017. Pediatr Crit Care Med 2024; 25:710-719. [PMID: 38717237 DOI: 10.1097/pcc.0000000000003526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
OBJECTIVES To compare levetiracetam and phenytoin as prophylaxis for the short-term development of status epilepticus (SE) during care of pediatric patients with acute severe traumatic brain injury (TBI). DESIGN Nonprespecified secondary analysis using propensity score matching. SETTING We used the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT NCT04077411) dataset (2014-2017). SUBJECTS Patients less than 18 years old with Glasgow Coma Scale Score less than or equal to 8 who received levetiracetam or phenytoin as a prophylactic anticonvulsant therapy. INTERVENTION None. MEASUREMENT AND MAIN RESULTS Of the 516 total patients who qualified for the case-control study, 372 (72.1%) patients received levetiracetam, and 144 (27.9%) received phenytoin. After propensity score matching, the pair-matched analysis with 133 in each group failed to identify an association between levetiracetam versus phenytoin use and occurrent of SE (3.8% vs. 0.8%, p = 0.22), or mortality (i.e., in-hospital, 30-d and 60-d). However, on closer inspection of the statistical testing, we cannot exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with the following: up to a mean difference of 7.3% greater prevalence of SE; up to a mean difference of 13.9%, 12.1%, and 13.9% greater mortality during the hospital stay, and 30-, and 60-days after hospital arrival, respectively. Last, analysis of 6 months Glasgow Outcome Scale Extended score in those without premorbid comorbidities, there was an association between favorable outcomes and use of phenytoin rather than levetiracetam prophylaxis. CONCLUSIONS In ADAPT, the decision to use prophylactic levetiracetam versus phenytoin failed to show an association with occurrence of subsequent SE, or mortality. However, we are unable to exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with greater prevalence of SE and mortality. We are unable to make any recommendation about one prophylactic anticonvulsant medication over the other, but recommend that further larger, contemporary studies in severe pediatric TBI are carried out.
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Affiliation(s)
- Nasim Ahmed
- Department of Surgery, Hackensack Meridian School of Medicine, Nutley, NJ
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ
| | - Larissa Russo
- Division of Trauma, Jersey Shore University Medical Center, Neptune, NJ
| | - Yen-Hong Kuo
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ
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Wasim A, Al Maawali SS, AlJabri AS, Al Amrani F, Ahmad F, Mansi A, Al Futaisi A. Aetiology and Outcome of Childhood Convulsive Status Epilepticus: A tertiary care experience in Oman. Sultan Qaboos Univ Med J 2024; 24:367-374. [PMID: 39234323 PMCID: PMC11370940 DOI: 10.18295/squmj.6.2024.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/22/2024] [Accepted: 05/22/2024] [Indexed: 09/06/2024] Open
Abstract
Objectives This study aimed to evaluate the aetiology, management and outcomes of convulsive status epilepticus (CSE) in children and highlight the factors influencing patient outcomes in such cases. Methods In a retrospective study spanning the 2020-2023 period, 93 children with CSE treated at Sultan Qaboos University Hospital's emergency department (ED), high dependency unit (HDU) and intensive care unit (ICU) were analysed. The Modified Rankin Scale at discharge was used to determine CSE outcomes. Results Among the 93 children studied (mean age 4.84 ± 3.64 years), predominantly Omani (92.47%), 14 aetiologies were noted. Of them, acute symptomatic (37.7%) and febrile status (31.2%) were the primary causes of CSE. Diazepam was administered as the first-line treatment in 58 (67.44%) cases, with a median seizure duration of 45 minutes. Successful seizure control was achieved in 71 (76.34%) cases within 60 minutes. A return to baseline was observed in 55.9% of cases, while mortality and disability were noted in 5.38% and 38.7% of cases, respectively. For 17 cases, aetiology and duration significantly impacted patient outcomes (P <0.05). Conclusion Acute symptomatic status is the most common aetiology of CSE. A longer duration of CSE is associated with higher mortality and neurological disability. Prompt and appropriate management of CSE is essential. Furthermore, identifying and treating the underlying cause of CSE is a crucial step in reducing its duration and improving patient outcomes.
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Affiliation(s)
- Areeba Wasim
- Department of Child Health, Sultan Qaboos University Hospital, University Medical City, Muscat, Oman
| | | | | | - Fatema Al Amrani
- Department of Child Health, Sultan Qaboos University Hospital, University Medical City, Muscat, Oman
| | - Faraz Ahmad
- Department of Child Health, Sultan Qaboos University Hospital, University Medical City, Muscat, Oman
| | - Ahmed Mansi
- Department of Child Health, Sultan Qaboos University Hospital, University Medical City, Muscat, Oman
| | - Amna Al Futaisi
- Department of Child Health, Sultan Qaboos University, Muscat, Oman
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Hepsø SW, Lee M, Noszka K, Wollertsen YM, Holmaas G, Kristensen E, Eichele T, Bjork MH, Griffiths ST, Hikmat O. Refractory and super-refractory status epilepticus in children and adolescents: A population-based study. Seizure 2024; 120:116-123. [PMID: 38941802 DOI: 10.1016/j.seizure.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/10/2024] [Accepted: 06/23/2024] [Indexed: 06/30/2024] Open
Abstract
PURPOSE Refractory (RSE) and super-refractory status epilepticus (SRSE) are serious medical emergencies whose long-term outcomes depend on the timeliness of their management. Population-based clinical and epidemiological data on these conditions are sparse. We aimed to provide a detailed description of the epidemiology and clinical course of RSE and SRSE in children and adolescents and identify potential prognostic biomarkers. METHODS In this retrospective population-based study, patients aged one month to 18 years who fulfilled the RSE/SRSE diagnostic criteria and were admitted to the intensive care unit of Haukeland University Hospital from 2012 to 2021 were considered eligible. Detailed clinical and laboratory findings along with information on management and outcomes were systematically analyzed. RESULTS Forty-three patients with 52 episodes of RSE/SRSE were identified. The incidence rate was 3.13 per 100,000 per year. The median time from SE onset to the administration of the first rescue drug was 13 min, and from the first rescue drug to second- and third-line treatments, 83 and 66 min, respectively. All patients were alive at discharge. CONCLUSION Delays in treatment were observed in various stages of the clinical course of RSE/SRSE. Improvement measures targeting the prompt administration of recuse mediation and subsequent treatment escalation are needed.
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Affiliation(s)
- Seline W Hepsø
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Maya Lee
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Kristoffer Noszka
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | | | - Gunhild Holmaas
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway; Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Tom Eichele
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Marte-Helene Bjork
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Silja T Griffiths
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Omar Hikmat
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway; Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.
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Pais-Cunha I, Valente D, Abreu DB, Fonseca J, Melo C, Sampaio M, Santos LA, Sousa R. Status epilepticus-Therapeutic management at the pediatric emergency department. Neurologia 2024; 39:426-431. [PMID: 38830721 DOI: 10.1016/j.nrleng.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/02/2021] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Status epilepticus is an important cause of pediatric neurological emergency. Immediate treatment is essential to prevent definitive neurological damage. Several antiepileptic drugs are available for the management of status epilepticus. METHODS Retrospective study of patients admitted at the emergency department of a tertiary hospital for 5 years (2014-2019). We analyzed the compliance to the treatment guidelines for pediatric status epilepticus. RESULTS One hundred and seventeen admissions were identified, 23.9% of these were febrile status epilepticus. Among the other cases, the most frequent cause was genetic (22.2%). The majority were convulsive status epilepticus (93.1%), 58.7% of which were generalized tonic-clonic seizures. Benzodiazepines were the most used first and second line drug (98.2% and 94.8%). The most frequent third drug used was diazepam (56.4%) followed by phenytoin (18.2%). An infra-therapeutic antiepileptic drug dose was given in 48.7% of cases. 49.6% presented with a prolonged status epilepticus and 6.8% needed intensive care. Incorrect sequence of drugs and infra-therapeutic doses were associated with prolonged status (p<0.001 and p<0.05) and an increased number of antiepileptic drugs used (p<0.001 and p<0.05). CONCLUSIONS Benzodiazepines were the most frequently first and second line drugs used for status epilepticus management. Surprisingly, the most frequently third line drugs used were also benzodiazepines. These findings were partially explained by the misuse of infra-therapeutic doses of these drugs. Noncompliance with the implemented guidelines was associated with unfavorable outcomes.
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Affiliation(s)
- I Pais-Cunha
- Serviço de Pediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - D Valente
- Serviço de Pediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - D B Abreu
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - J Fonseca
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - C Melo
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - M Sampaio
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - L A Santos
- Serviço de Pediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Serviço de Urgência Pediátrico, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - R Sousa
- Unidade de Neuropediatria, Unidade Autónoma Gestão da Mulher e da Criança, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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10
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Rubinos C. Emergent Management of Status Epilepticus. Continuum (Minneap Minn) 2024; 30:682-720. [PMID: 38830068 DOI: 10.1212/con.0000000000001445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. LATEST DEVELOPMENTS Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. ESSENTIAL POINTS As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Fong MWK, Stephens E, Brockington A, Jayabal J, Scott S, Zhang T, Litchfield R, Beilharz E, Dalziel SR, Jones P, Yates K, Thornton V, Bergin PS. Status epilepticus in Auckland, New Zealand: Treatment patterns and determinants of outcome in a prospective population-based cohort. Epilepsia 2024; 65:1605-1619. [PMID: 38634858 DOI: 10.1111/epi.17975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/01/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Determination of the real-world performance of a health care system in the treatment of status epilepticus (SE). METHODS Prospective, multicenter population-based study of SE in Auckland, New Zealand (NZ) over 1 year, with data recorded in the EpiNet database. Focus on treatment patterns and determinants of SE duration and 30-day mortality. The incidence, etiology, ethnic discrepancies, and seizure characteristics of this cohort have been published previously. RESULTS A total of 365 patients were included in this treatment cohort; 326 patients (89.3%) were brought to hospital because of SE, whereas 39 patients (10.7%) developed SE during a hospital admission for another reason. Overall, 190 (52.1%) had a known history of epilepsy and 254 (70.0%) presented with SE with prominent motor activity. The mean Status Epilepticus Severity Score (STESS) was 2.15 and the mean SE duration of all patients was 44 min. SE self-terminated without any treatment in 84 patients (22.7%). Earlier administration of appropriately dosed benzodiazepine in the pre-hospital setting was a major determinant of SE duration. Univariate analysis demonstrated that mortality was significantly higher in older patients, patients with longer durations of SE, higher STESS, and patients who developed SE in hospital, but these did not maintain significance with multivariate analysis. There was no difference in the performance of the health care system in the treatment of SE across ethnic groups. SIGNIFICANCE When SE was defined as 10 continuous minutes of seizure, overall mortality was lower than expected and many patients had self-limited presentations for which no treatment was required. Although there were disparities in the incidence of SE across ethnic groups there was no difference in treatment or outcome. The finding highlights the benefit of a health care system designed to deliver universal health care.
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Affiliation(s)
- Michael W K Fong
- Westmead Comprehensive Epilepsy Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eleanor Stephens
- Westmead Comprehensive Epilepsy Centre, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Alice Brockington
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Jayaganth Jayabal
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Pantai-Gleneagles Hospital, Penang and Sungai Petani, Malaysia
| | - Shona Scott
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Western General Hospital, Edinburgh, UK
| | - Tony Zhang
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | | | - Erica Beilharz
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Stuart R Dalziel
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Department of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Kim Yates
- Waitematā District Health Board, Auckland, New Zealand
| | | | - Peter S Bergin
- Auckland District Health Board, Grafton, Auckland, New Zealand
- Centre for Brain Research, University of Auckland, Auckland, New Zealand
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13
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Forsyth R, Allen M, Bedson E, Downes A, Gough C, Hartshorn S, Lawton K, Lyttle MD, Messahel S, Mullen N, Raper J, Rosala-Harris A, Taggart L, Urron J, Walton E, Gamble C. Seizure control via pH manipulation: a phase II double-blind randomised controlled trial of inhaled carbogen as adjunctive treatment of paediatric convulsive status epilepticus (Carbogen for Status Epilepticus in Children Trial (CRESCENT)). Trials 2024; 25:349. [PMID: 38812049 PMCID: PMC11135009 DOI: 10.1186/s13063-024-08188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Paediatric convulsive status epilepticus is the most common neurological emergency presenting to emergency departments. Risks of resultant neurological morbidity and mortality increase with seizure duration. If the seizure fails to stop within defined time-windows, standard care follows an algorithm of stepwise escalation to more intensive treatments, ultimately resorting to induction of general anaesthesia and ventilation. Additionally, ventilatory support may also be required to treat respiratory depression, a common unwanted effect of treatment. There is strong pre-clinical evidence that pH (acid-base balance) is an important determinant of seizure commencement and cessation, with seizures tending to start under alkaline conditions and terminate under acidic conditions. These mechanisms may be particularly important in febrile status epilepticus: prolonged fever-related seizures which predominantly affect very young children. This trial will assess whether imposition of mild respiratory acidosis by manipulation of inhaled medical gas improves response rates to first-line medical treatment. METHODS A double-blind, placebo-controlled trial of pH manipulation as an adjunct to standard medical treatment of convulsive status epilepticus in children. The control arm receives standard medical management whilst inhaling 100% oxygen; the active arm receives standard medical management whilst inhaling a commercially available mixture of 95% oxygen, 5% carbon dioxide known as 'carbogen'. Due to the urgent need to treat the seizure, deferred consent is used. The primary outcome is success of first-line treatment in seizure cessation. Planned subgroup analyses will be undertaken for febrile and non-febrile seizures. Secondary outcomes include rates of induction of general anaesthesia, admission to intensive care, adverse events, and 30-day mortality. DISCUSSION If safe and effective 95% oxygen, 5% carbon dioxide may be an important adjunct in the management of convulsive status epilepticus with potential for pre-hospital use by paramedics, families, and school staff. TRIAL REGISTRATION EudraCT: 2021-005367-49. CTA: 17136/0300/001. ISRCTN 52731862. Registered on July 2022.
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Affiliation(s)
- Rob Forsyth
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
- Newcastle University, Newcastle Upon Tyne, UK.
| | - Maria Allen
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Emma Bedson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | | | - Chris Gough
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | | | - Niall Mullen
- Sunderland and South Tyneside NHS Foundation Trust, Sunderland, UK
| | - Joseph Raper
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anna Rosala-Harris
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Leigh Taggart
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Jason Urron
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Emily Walton
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
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14
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Giannaccini C, Almendras C, Li I, DiNapoli M, Macnow T. Determining the Safety and Tolerability of Rapid Administration of Undiluted Intravenous Levetiracetam in Pediatrics. J Child Neurol 2024:8830738241255992. [PMID: 38798130 DOI: 10.1177/08830738241255992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Objective: Levetiracetam is widely used in the emergency setting. Safety and tolerability of undiluted levetiracetam is prevalent in adults but is limited in pediatrics. The purpose is to determine the safety and tolerability of rapid administration of undiluted levetiracetam in pediatric patients. Methods: A retrospective, single-center, observational study was conducted in pediatric patients who received undiluted levetiracetam intravenous push. The primary outcome was adverse reactions, extravasation, need for intravenous line replacement, and discontinuation due to adverse reactions. The secondary outcome was turnaround time between ordering and administering first doses. Results: One hundred fourteen patients were included. Injection site reactions occurred in 7 patients. Extravasation occurred in 4 patients. Two patients required intravenous line replacement. There were no adverse events leading to discontinuation of levetiracetam. No difference was seen in the time from order to administration. Conclusion: Rapid administration of undiluted levetiracetam in pediatric patients was safe and well tolerated.
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Affiliation(s)
| | | | - Irene Li
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Michael DiNapoli
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Theodore Macnow
- Department of Pediatrics, UMass Chan Medical School, Worcester, MA, USA
- Department of Pediatrics, UMass Memorial Children's Medical Center, Worcester, MA, USA
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15
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Price L, Garrity L, Stiehl S. Response to comment on "Evaluation of the safety and tolerability of intravenous undiluted levetiracetam at a pediatric institution". Pharmacotherapy 2024; 44:411-412. [PMID: 38853603 DOI: 10.1002/phar.2919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Lily Price
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Garrity
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sarah Stiehl
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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16
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Sharawat IK, Murugan VK, Bhardwaj S, Tomar A, Tiwari L, Dhamija P, Panda PK. Efficacy and safety of phenytoin and levetiracetam for acute symptomatic seizures in children with acute encephalitis syndrome: an open label, randomised controlled trial. Seizure 2024; 118:110-116. [PMID: 38678766 DOI: 10.1016/j.seizure.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/06/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
INTRODUCTION Seizures represent a significant comorbidity in children with acute encephalitis syndrome (AES). Despite this, there is a notable absence of randomized controlled trials (RCTs) directly comparing antiseizure medications (ASMs) in children with AES. MATERIALS AND METHODS This RCT aimed to assess the efficacy and safety of phenytoin and levetiracetam in controlling seizures among children with AES. Both ASMs were administered with a loading followed by maintenance dose. After a 12-week period, children exhibiting a normal electroencephalogram and no seizure recurrence underwent tapering and discontinuation of ASM. Clinical follow-up occurred daily for the first week, and subsequently at 4, 12, and 24 weeks, evaluating seizure recurrence, incidence of status epilepticus, cognition, behavior, functional status, ASM acquisition cost, and adverse effects. RESULTS A total of 100 children (50 in each group) were enrolled. Within the first week, 5 and 3 children in the phenytoin and levetiracetam groups expired. Up to 1 week or death (whichever occurred earliest), 46 (92 %) and 44 (88 %) children remained seizure-free. Intention-to-treat analysis for both best and worst-case scenarios showed insignificant differences (p=0.52 and 1.0). No children experienced seizure recurrence after 1 week in either group. The number of patients with breakthrough status epilepticus, need for mechanical ventilation, duration of hospital stay, presence of epileptiform abnormalities in repeat electroencephalogram at 12 weeks, functional outcomes at 1, 12, and 24 weeks, as well as cognition and behavioral profiles at 24 weeks, were comparable in both groups (p>0.05 for all). However, the incidence of treatment-emergent adverse events (TEAEs) causally related to study medications was significantly higher in the phenytoin group (p=0.04). CONCLUSION Levetiracetam and phenytoin are comparable in efficacy in terms of achieving clinical seizure control in children with acute encephalitis syndrome, although levetiracetam group demonstrated fewer adverse effects.
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Affiliation(s)
- Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Vignesh Kaniyappan Murugan
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Sanjot Bhardwaj
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Apurva Tomar
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Lokesh Tiwari
- Pediatric Intensive Care Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Puneet Dhamija
- Department of Pharmacology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India.
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17
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Suthar R, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey). Indian J Crit Care Med 2024; 28:504-510. [PMID: 38738206 PMCID: PMC11080095 DOI: 10.5005/jp-journals-10071-24707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/06/2024] [Indexed: 05/14/2024] Open
Abstract
Aim Survey of treatment practices and adherence to pediatric status epilepticus (PSE) management guidelines in India. Methods This eSurvey was conducted over 35 days (15th October to 20th November 2023) and included questions related to hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines. Results A total of 170 respondents participated, majority of them were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2-10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1 and 51.2%, respectively). In cases with refractory status epilepticus (RSE), the most commonly used ASM is midazolam infusion (92.4%). For super-refractory status epilepticus (SRSE), the commonly used third-line ASMs include midazolam infusion (34.1%), thiopentone infusion (26.5%), high dose phenobarbitone (18.2%), and ketamine infusion (15.3%). Overall, in cases with SRSE, 44.7% respondents use ketamine infusion, 42.5% use add-on oral topiramate, and 34.7% use high-dose phenobarbitone (1-3 mg/kg/hour) infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (60.6%, 52.4%, and 37.1%, respectively). Facilities available included pediatric intensive care units (PICU) (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5 to 88.8%. Conclusion Intravenous midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first-, second-, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to PSE management guidelines. How to cite this article Suthar R, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey). Indian J Crit Care Med 2024;28(5):504-510.
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Affiliation(s)
- Renu Suthar
- Division of Pediatric Neurology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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18
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Rublee C, Hynes EC, Paavola N, Tremolet de Villers K, McLaughlin J. An Emergency Department Quality Improvement Project for Intravenous Levetiracetam Administration. J Pharm Pract 2024; 37:265-270. [PMID: 36189751 DOI: 10.1177/08971900221131920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Levetiracetam is a readily available, safe anticonvulsive medication. It is frequently administered as IV piggyback with a pump, carrier fluid, and tubing. The Established Status Epilepticus Treatment Trial demonstrated levetiracetam being similarly effective to previously used treatments in doses up to 4500 mg administered over 10 minutes. Objective: We sought to compare usage, cost, and waste of IV piggyback with IV push administration of levetiractam following implementation of an IV push protocol in an academic emergency department. Methods: A three-month review of levetiracetam administration was done following protocol implementation using IV push for initial treatment of benzodiazepine-refractory status epilepticus. The review quantified the number of IV push vs IV piggyback doses for all indications and evaluated cost of supplies necessary for administration. Results: During the study period, 137 patients received 142 doses of IV levetiracetam. Fifty-one doses (36%) were given as IV push rather than IV piggyback. The majority of doses 116 (82%) were 1000-2000 mg and 11 doses (8%) 3500-4500 mg. Estimated three-month savings with complete transition of IV piggyback to IV push would exceed $6000 just in our ED. The amount of sterile solution carrier fluid was also reduced and IV pump time freed. Conclusion: Implementation of an emergency department IV push levetiracetam protocol resulted in cost savings. Opportunities remain to improve clinical implementation practices. Medication administration represents one crucial target area where healthcare systems can implement policies to reduce waste and commit to climate-smart health care.
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Affiliation(s)
- Caitlin Rublee
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Emilie Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Paavola
- University of Colorado Health, University of Colorado Hospital, Aurora, CO, USA
| | | | - Julie McLaughlin
- University of Colorado Health, University of Colorado Hospital, Aurora, CO, USA
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19
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Rojas-Anaya H, Kapur A, Roberts G, Roland D, Gupta A, Lazner M, Bayreuther J, Pappachan J, Jones C, Bremner S, Cantle F, Seddon P. High-Flow Humidified Oxygen as an Early Intervention in Children With Acute Severe Asthma: Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e54081. [PMID: 38546733 PMCID: PMC11009849 DOI: 10.2196/54081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Acute severe asthma (ASA) is a leading cause of hospital attendance in children. Standard first-line therapy consists of high-dose inhaled bronchodilators plus oral corticosteroids. Treatment for children who fail to respond to first-line therapy is problematic: the use of intravenous agents is inconsistent, and side effects are frequent. High-flow humidified oxygen (HiFlo) is widely used in respiratory conditions and is increasingly being used in ASA, but with little evidence for its effectiveness. A well-designed, adequately powered randomized controlled trial (RCT) of HiFlo therapy in ASA is urgently needed, and feasibility data are required to plan such an RCT. In this study, we describe the protocol for a feasibility study designed to fill this knowledge gap. OBJECTIVE This study aims to establish whether a full RCT of early HiFlo therapy in children with ASA can be conducted successfully and safely, to establish whether recruitment using deferred consent is practicable, and to define appropriate outcome measures and sample sizes for a definitive RCT. The underlying hypothesis is that early HiFlo therapy in ASA will reduce the need for more invasive treatments, allow faster recovery and discharge from hospital, and in both these ways reduce distress to children and their families. METHODS We conducted a feasibility RCT with deferred consent to assess the use of early HiFlo therapy in children aged 2 to 11 years with acute severe wheeze not responding to burst therapy (ie, high-dose inhaled salbutamol with or without ipratropium). Children with a Preschool Respiratory Assessment Measure score ≥5 after burst therapy were randomized to commence HiFlo therapy or follow standard care. The candidate primary outcomes assessed were treatment failure requiring escalation and time to meet hospital discharge criteria. Patient and parent experiences were also assessed using questionnaires and telephone interviews. RESULTS The trial was opened to recruitment in February 2020 but was paused for 15 months owing to the COVID-19 pandemic. The trial was reopened at the lead site in July 2021 and opened at the other 3 sites from August to December 2022. Recruitment was completed in June 2023. CONCLUSIONS This feasibility RCT of early HiFlo therapy in children with ASA recruited to the target despite major disturbances owing to the COVID-19 pandemic. The data are currently being analyzed and will be published separately. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN78297040; https://www.isrctn.com/ISRCTN78297040. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54081.
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Affiliation(s)
- Hector Rojas-Anaya
- University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Akshat Kapur
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Graham Roberts
- Department of Paediatric Allergy and Respiratory Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, United Kingdom
- Social science APPlied Healthcare and Improvement REsearch Group, Department of Population Health Sciences, Leicester University, Leicester, United Kingdom
| | - Atul Gupta
- Paediatric Respiratory Medicine, King's College Hospital, London, United Kingdom
| | - Michaela Lazner
- Children's Emergency Department, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Jane Bayreuther
- Children's Emergency Department, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - John Pappachan
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Christina Jones
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Stephen Bremner
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Fleur Cantle
- Emergency Department, King's College Hospital, London, United Kingdom
| | - Paul Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
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20
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Martinez S, Bonnin SS, Radosevich J, Haller JT. Rapid administration of undiluted loading doses of levetiracetam. Epilepsia 2024; 65:615-619. [PMID: 38116700 DOI: 10.1111/epi.17872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE Rapid administration of antiseizure medications is a critical concept in the treatment of status epilepticus. Although undiluted levetiracetam (LEV) doses of up to 2500 mg have been evaluated, minimal data exist to support the safety of loading doses up to 4500 mg. This study will evaluate intravenous (IV) push administration of undiluted LEV from 2500 to 4500 mg for safety outcomes as well as tolerability. METHODS This is a retrospective, observational, cohort analysis of adult patients who received at least one loading dose of undiluted IV push LEV from October 15, 2019, to April 30, 2022, at a large academic medical center in Phoenix, Arizona. Relevant outcomes include the safety and tolerability of rapid administration of undiluted LEV at higher loading doses. RESULTS We evaluated 518 loading doses in 518 unique patients included during the study period. LEV was a new medication for witnessed or suspected seizures in 80.3% of patients, with 31.2% having a documented history of epilepsy or seizure disorder. At the time of LEV administration, 52.9% of patients were on a general medicine floor, 34.3% were in the intensive care unit, and 12.7% were in the emergency department. The median loading dose of LEV was 3600 mg (3000-4000 mg), with 4000 mg being the most common loading dose given. Peripheral IV lines were documented as the only available line in 78.6% of patients for loading dose administration. No adverse events associated with LEV administration were documented. SIGNIFICANCE Rapid IV administration of undiluted doses of LEV is both safe and tolerable in loading doses of 2500-4500 mg, allowing for rapid drug administration in the setting of status epilepticus.
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Affiliation(s)
- Sydni Martinez
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sophia S Bonnin
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John Radosevich
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - J Tyler Haller
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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21
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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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Price L, Garrity L, Stiehl S. Evaluation of the safety and tolerability of intravenous undiluted levetiracetam at a pediatric institution. Pharmacotherapy 2024; 44:141-148. [PMID: 38050327 DOI: 10.1002/phar.2898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 12/06/2023]
Abstract
STUDY OBJECTIVE Recent studies suggest rapid administration of high-dose, undiluted levetiracetam is safe in adults; however, no information exists in pediatric patients. The purpose of this study was to evaluate the safety and tolerability of undiluted levetiracetam at a pediatric institution. DESIGN Retrospective, single-center, cohort study. SETTING Pediatric Academic Medical Center. PATIENTS All patients who received high-dose >60 mg/kg (-10%) up to 4500 mg undiluted or diluted intravenous levetiracetam were included. INTERVENTION Rapid intravenous administration of undiluted versus diluted levetiracetam. MEASUREMENTS AND MAIN RESULTS A total of 776 levetiracetam doses were included, 358 doses administered and 418 doses wasted. The doses administered (61 undiluted and 297 diluted) accounted for a total of 252 patients (39 received undiluted, and 213 received diluted levetiracetam) (median [minimum-maximum range] age, 2 years [1 day to 32.7 years]; mean (standard deviation [SD]) weight, 20.1 kg [22.1 kg]). The incidence of hemodynamic disturbances and infusion-related reactions was not statistically significant between undiluted (24.6%) and diluted (26.3%) groups (p = 0.87). The median (interquartile range [IQR]) time difference between first-line antiseizure medication and levetiracetam administration in patients with status epilepticus was 18 min (10.5-30.5) in the undiluted group versus 36.5 min (21.8-67.3) in the diluted group (p < 0.01). Additionally, there was a significant amount of drug waste from dispensed but not administered doses of the diluted bag compared to undiluted vials (57.6% diluted vs. 18.7% undiluted, p < 0.001). CONCLUSION Undiluted levetiracetam was not associated with an increased incidence of adverse effects compared to diluted levetiracetam in high-doses, up to 4500 mg given over 5 min in pediatric patients.
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Affiliation(s)
- Lily Price
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Garrity
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sarah Stiehl
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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23
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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24
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Wang SJ, Zhao MY, Zhao PC, Zhang W, Rao GW. Research Status, Synthesis and Clinical Application of Antiepileptic Drugs. Curr Med Chem 2024; 31:410-452. [PMID: 36650655 DOI: 10.2174/0929867330666230117160632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 01/19/2023]
Abstract
According to the 2017 ILAE's official definition, epilepsy is a slow brain disease state characterized by recurrent episodes. Due to information released by ILAE in 2017, it can be divided into four types, including focal epilepsy, generalized epilepsy, combined generalized, and focal epilepsy, and unknown epilepsy. Since 1989, 24 new antiepileptic drugs have been approved to treat different types of epilepsy. Besides, there are a variety of antiepileptic medications under clinical monitoring. These novel antiepileptic drugs have plenty of advantages. Over the past 33 years, there have been many antiepileptic drugs on the mearket, but no one has been found that can completely cure epilepsy. In this paper, the mentioned drugs were classified according to their targets, and the essential information, and clinical studies of each drug were described. The structure-activity relationship of different chemical structures was summarized. This paper provides help for the follow-up research on epilepsy drugs.
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Affiliation(s)
- Si-Jie Wang
- College of Pharmaceutical Science, Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, P.R. China
| | - Min-Yan Zhao
- College of Pharmaceutical Science, Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, P.R. China
| | - Peng-Cheng Zhao
- College of Pharmaceutical Science, Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, P.R. China
| | - Wen Zhang
- College of Pharmaceutical Science, Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, P.R. China
| | - Guo-Wu Rao
- College of Pharmaceutical Science, Institute of Drug Development & Chemical Biology, Zhejiang University of Technology, Hangzhou 310014, P.R. China
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25
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Jones KEA, Howells R, Mallick AA, Paul SP, Dey I. NICE guideline review: Epilepsies in children, young people and adults NG217. Arch Dis Child Educ Pract Ed 2023; 108:416-421. [PMID: 37339862 DOI: 10.1136/archdischild-2022-324427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Affiliation(s)
| | - Rachel Howells
- Department of Paediatrics, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Andrew A Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Indranil Dey
- Department of Paediatrics, Torbay and South Devon NHS Foundation Trust, Torquay, UK
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26
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Purwien L, Schubert-Bast S, Kieslich M, Ronellenfitsch MW, Merker M, Czabanka M, Willems LM, Rosenow F, Strzelczyk A. Trends and Differences in Status Epilepticus Treatment of Children and Adults Over 10 Years: A Comparative Study of Medical Records (2012-2021) from a University Hospital in Germany. CNS Drugs 2023; 37:993-1008. [PMID: 37979095 PMCID: PMC10667152 DOI: 10.1007/s40263-023-01049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Over the last decade, significant advancements have been made in status epilepticus (SE) management, influenced by landmark trials such as ESETT and RAMPART. The objectives of this study were to explore the evolution of drug treatments for patients with SE, to investigate its association with outcomes and mortality, and to evaluate differences in treatment patterns between adults and children for a potential shift in medication trends due to the above mentioned trials. METHODS The medical records of patients with SE treated at University Hospital Frankfurt between 2012 and 2021 were evaluated for medication trends and outcomes. Children and adults were analyzed separately and jointly. RESULTS This study included 1151 SE episodes in 1021 patients (mean age = 53.3 ± 28.3 years; 52.5 % female [n = 533]). The overall percentage of patients with SE treated prehospital was stable over the last decade. More than half (53.6 %) of children were treated prehospital, compared with less than one-third (26.7 %) of adults. Prehospital midazolam use increased over time, while diazepam use decreased. Lorazepam was the most commonly used benzodiazepine in hospitals in 2012-2013, used in 40.8 % of all episodes. However, its use declined to 27.2 % in 2020-2021, while midazolam use increased to 44.0 %. While the use of older antiseizure medications (ASMs) such as phenobarbital (p = 0.02), phenytoin (p < 0.001), and valproate (p < 0.001) decreased, the use of newer ASMs such as levetiracetam and lacosamide significantly increased (p < 0.001). Propofol and continuous midazolam infusion remained the most used third-line therapy drugs. Overall mortality was 16.5 % at discharge and 18.9 % at 30 days. Mortality rates did not change between 2012 and 2021. CONCLUSION Midazolam has become the preferred benzodiazepine in pre- and in-hospital settings, both in children and adults. The same applies to the increased use of levetiracetam and lacosamide over time in children and adults, while phenobarbital, phenytoin, and valproate use decreased. Continuous midazolam infusion and propofol remain the most frequently used anesthetic drugs. Mortality and outcome remain stable despite changes in medication patterns.
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Affiliation(s)
- Leonore Purwien
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Matthias Kieslich
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael W Ronellenfitsch
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-oncology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michael Merker
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
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27
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Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
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Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
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28
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Jindal M, Neligan A, Rajakulendran S. Early and established status epilepticus: The impact of timing of intervention, treatment escalation and dosing on outcome. Seizure 2023; 111:98-102. [PMID: 37556986 DOI: 10.1016/j.seizure.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/23/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE We investigated the management and outcome of early and established status epilepticus including timing, dosing and selection of benzodiazepines along with the timing and efficacy of second line treatments. METHODS Retrospective single tertiary centre observational cohort study to identify all cases of SE between January 2019 and February 2022. RESULTS 252 cases were identified. Seizures terminated spontaneously in 136 (54%) cases. 116 (46%) were given benzodiazepines, of which 29 (25%) were given at least one benzodiazepine by family/carers, and 72 (62.1%) received benzodiazepines by ambulance services. Benzodiazepines terminated seizures in 83 (71.6%) cases. The commonest benzodiazepine used was buccal midazolam (35.5%). Median time to first benzodiazepine was 14.5 (6-27) minutes. There was a positive correlation between time to first benzodiazepine and time to seizure cessation, progression to second- and third-line treatment, and respiratory complications (p<0.05). 73 (62.9%) cases received a correct benzodiazepine dose. Benzodiazepine underdosing was associated with longer seizure duration (p<0.05). 33 (28.4%) cases progressed to second-line treatment where mean time to treatment was 59.4 min (±32.3 min). The commonest second-line treatment was Levetiracetam (53.8%), followed by Phenytoin (43.6%) with SE termination in 57.5% cases. 14 (12.1%) cases progressed to third-line treatment; mean time to treatment was 60.6 min (±22.24 min). Respiratory complications occurred in 17 (6.75%) cases; none due to benzodiazepines. There were two deaths in refractory SE. CONCLUSION Early administration of benzodiazepines and optimal dosing is associated with a higher rate of SE termination. Levetiracetam was the most commonly used second line treatment.
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Affiliation(s)
- Malaika Jindal
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Aidan Neligan
- UCL Queen Square Institute of Neurology, London, United Kingdom; Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, London, United Kingdom; National Hospital for Neurology & Neurosurgery, London WC1N 3BG United Kingdom; North Middlesex University Hospital, London, United Kingdom.
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29
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Umana E, Mills C, Norman-Bruce H, Wilson K, Mitchell H, McFetridge L, Woolfall K, Lynn FA, McKeeman G, Foster S, Barrett M, Roland D, Lyttle MD, Watson C, Waterfield T. Applying clinical decision aids for the assessment and management of febrile infants presenting to emergency care in the UK and Ireland: Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study protocol. BMJ Open 2023; 13:e075823. [PMID: 37730397 PMCID: PMC10514651 DOI: 10.1136/bmjopen-2023-075823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Febrile infants 90 days and younger are at risk of invasive bacterial infections (bacteraemia and meningitis) and urinary tract infections. Together this is previously termed serious bacterial infection with an incidence of approximately 10-20%. The National Institute for Health and Care Excellence guidance advocates a cautious approach with most infants requiring septic screening, parenteral broad-spectrum antibiotics and hospital admission. Internationally, variations exist in the approach to febrile infants, with European and North American guidance advocating a tailored approach based on clinical features and biomarker testing. None of the available international clinical decision aids (CDAs) has been validated in the UK and Irish cohorts. The aim of the Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study is to prospectively validate a range of CDAs in a UK and Irish population including CDAs that use procalcitonin testing. METHODS AND ANALYSIS The FIDO Study is a prospective multicentre mixed-methods cohort study conducted in UK and Irish hospitals. All infants aged 90 days and younger presenting with fever or history of fever (≥38°C) are eligible for inclusion. Infants will receive standard emergency clinical care without delay. Clinical data and blood samples will be collected, and consent will be obtained at the earliest appropriate opportunity using research without prior consent methodology. The performance and cost-effectiveness of CDAs will be assessed. An embedded qualitative study will explore clinician and caregiver views on different approaches to care and perceptions of risk. ETHICS AND DISSEMINATION This study was reviewed and approved by the Office for Research Ethics Committees Northern Ireland-Health and Social Care Research Ethics Committee B, Public Benefit and Privacy Panel for Health and Social Care Scotland, and Children's Health Ireland Research and Ethics Committee Ireland. The results of this study will be presented at academic conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05259683.
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Affiliation(s)
- Etimbuk Umana
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Clare Mills
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Hannah Norman-Bruce
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kathryn Wilson
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Hannah Mitchell
- Mathematical Sciences Research Centre, School of Mathematics & Physics, Queen's University Belfast, Belfast, UK
| | - Lisa McFetridge
- Mathematical Sciences Research Centre, School of Mathematics & Physics, Queen's University Belfast, Belfast, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Fiona A Lynn
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Gareth McKeeman
- Department of Clinical Biochemistry, HCS Belfast Health and Social Care Trust, Belfast, UK
| | - Steven Foster
- Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Michael Barrett
- Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Crumlin, Ireland
- Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland
| | - Damian Roland
- Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Science, University of the West of England, Bristol, UK
| | - Chris Watson
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Thomas Waterfield
- Wellcome Wolfson Institute For Experimental Medicine, Queen's University Belfast, Belfast, UK
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
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30
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Mrad Y, El Jammal R, Hajjar H, Alturk S, Salah H, Chehade HD, Dandash F, Mallah Z, Kobeissy F, Habib A, Hamade E, Obeid M. Lestaurtinib (CEP-701) reduces the duration of limbic status epilepticus in periadolescent rats. Epilepsy Res 2023; 195:107198. [PMID: 37467703 DOI: 10.1016/j.eplepsyres.2023.107198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/30/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The timely abortion of status epilepticus (SE) is essential to avoid brain damage and long-term neurodevelopmental sequalae. However, available anti-seizure treatments fail to abort SE in 30% of children. Given the role of the tropomyosin-related kinase B (TrkB) receptor in hyperexcitability, we investigated if TrkB blockade with lestaurtinib (CEP-701) enhances the response of SE to a standard treatment protocol and reduces SE-related brain injury. METHODS SE was induced with intra-amygdalar kainic acid in postnatal day 45 rats under continuous electroencephalogram (EEG). Fifteen min post-SE onset, rats received intraperitoneal (i.p.) CEP-701 (KCEP group) or its vehicle (KV group). Controls received CEP-701 or its vehicle following intra-amygdalar saline. All groups received two i.p. doses of diazepam, followed by i.p. levetiracetam at 15 min intervals post-SE onset. Hippocampal TrkB dimer to monomer ratios were assessed by immunoblot 24 hr post-SE, along with neuronal densities and glial fibrillary acid protein (GFAP) levels. RESULTS SE duration was 50% shorter in the KCEP group compared to KV (p < 0.05). Compared to controls, SE induced a 1.5-fold increase in TrkB dimerization in KV rats (p < 0.05), but not in KCEP rats which were comparable to controls (p > 0.05). The KCEP group had lower GFAP levels than KV (p < 0.05), and both were higher than controls (p < 0.05). KCEP and KV rats had comparable hippocampal neuronal densities (p > 0.05), and both were lower than controls (p < 0.05). CONCLUSIONS Given its established human safety, CEP-701 is a promising adjuvant drug for the timely abortion of SE and the attenuation of SE-related brain injury.
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Affiliation(s)
- Yara Mrad
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Reem El Jammal
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Helene Hajjar
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Sana Alturk
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Houssein Salah
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hiba-Douja Chehade
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA
| | - Fatima Dandash
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Zahraa Mallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Laboratory of Cancer Biology and Molecular Immunology, Faculty of Sciences, Lebanese University, Hadath, Beirut, Lebanon
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Department of Neurobiology, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Aida Habib
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Eva Hamade
- Laboratory of Cancer Biology and Molecular Immunology, Faculty of Sciences, Lebanese University, Hadath, Beirut, Lebanon
| | - Makram Obeid
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Child Neurology, Department of Neurology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA.
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31
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Dedeoglu Ö, Akça H, Emeksiz S, Kartal A, Kurt NÇ. Management of Status Epilepticus by Different Pediatric Departments: Neurology, Intensive Care, and Emergency Medicine. Eur Neurol 2023; 86:315-324. [PMID: 37647871 PMCID: PMC10623395 DOI: 10.1159/000533191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/15/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The aim of this study was to explore the differences in status epilepticus (SE) management among pediatric neurology, emergency medicine, and intensive care specialists in Turkey. METHODS A 22-item questionnaire regarding first-, second-, and third-line management strategies of SE including demographic characteristics and common etiologies according to the specialty of participants was mailed to 370 specialists working in Turkey. RESULTS A total of 334 participants (response rate 90%) comprising 136 pediatric neurologists, 102 pediatric emergency medicine specialists, and 96 pediatric intensive care specialists completed the survey. While intensive care specialists frequently managed SE due to metabolic and autoimmune reasons, the most common etiologies encountered by emergency medicine specialists were epilepsy and infections. More than half of the intensive care specialists (64.6%) reported using non-BZD antiseizure medications in the 5th minute of the seizure. Most of the neurologists (76.4%) preferred to administer intravenous (IV) levetiracetam infusion as a second-line agent. About half of intensive care specialists and neurologists tried immunomodulatory therapies in super-refractory SE. Intensive care and emergency medicine specialists were less likely to favor ketogenic diet and pyridoxine therapy for the treatment of super-refractory SE. The rate of requesting EEG monitoring to recognize nonconvulsive SE (NCSE) was found to be very low except for neurologists. CONCLUSION There was no consensus among neurologists, intensive care specialists, and emergency medicine specialists in the management of SE in Turkey. Familiarity with particular antiseizure medications and the etiologies they manage seem to be the most important factors influencing the attitudes.
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Affiliation(s)
- Özge Dedeoglu
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
| | - Halise Akça
- Department of Pediatric Emergency Medicine, Ankara City Hospital, Ankara, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Ankara City Hospital, Ankara, Turkey
| | - Ayşe Kartal
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
| | - Neşe Çıtak Kurt
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
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Becker LL, Gratopp A, Prager C, Elger CE, Kaindl AM. Treatment of pediatric convulsive status epilepticus. Front Neurol 2023; 14:1175370. [PMID: 37456627 PMCID: PMC10343462 DOI: 10.3389/fneur.2023.1175370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Status epilepticus is one of the most common life-threatening neurological emergencies in childhood with the highest incidence in the first 5 years of life and high mortality and morbidity rates. Although it is known that a delayed treatment and a prolonged seizure can cause permanent brain damage, there is evidence that current treatments may be delayed and the medication doses administered are insufficient. Here, we summarize current knowledge on treatment of convulsive status epilepticus in childhood and propose a treatment algorithm. We performed a structured literature search via PubMed and ClinicalTrails.org and identified 35 prospective and retrospective studies on children <18 years comparing two and more treatment options for status epilepticus. The studies were divided into the commonly used treatment phases. As a first-line treatment, benzodiazepines buccal/rectal/intramuscular/intravenous are recommended. For status epilepticus treated with benzodiazepine refractory, no superiority of fosphenytoin, levetirazetam, or phenobarbital was identified. There is limited data on third-line treatments for refractory status epilepticus lasting >30 min. Our proposed treatment algorithm, especially for children with SE, is for in and out-of-hospital onset aids to promote the establishment and distribution of guidelines to address the treatment delay aggressively and to reduce putative permanent neuronal damage. Further studies are needed to evaluate if these algorithms decrease long-term damage and how to treat refractory status epilepticus lasting >30 min.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumonology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E. Elger
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Beta Clinic, Bonn, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Morgan LA, Hrachovec JB, Goodkin HP. Pediatric Status Epilepticus: Treat Early and Avoid Delays. Paediatr Drugs 2023:10.1007/s40272-023-00570-1. [PMID: 37178271 DOI: 10.1007/s40272-023-00570-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Abstract
Pediatric convulsive status epilepticus (cSE) is a neurologic emergency with potential for morbidity and mortality. Rapid treatment and escalation of therapies to achieve early seizure control is paramount in preventing complications and providing the best patient outcomes. Although guidelines recommend early treatment, cessation of out-of-hospital SE is undermined by treatment delay and inadequate dosing. Logistical challenges include prompt seizure recognition, first-line benzodiazepine (BZD) availability, comfort and expertise in administration of BZD, and timely arrival of emergency personnel. In-hospital, SE onset is additionally impacted by delays to first- and second-line treatment and availability of resources. This review presents an evidence-based, clinically oriented review of pediatric cSE, including its definitions and treatments. It provides evidence and rationale for timely treatment of first-line BZD treatment followed by prompt escalation to second-line antiseizure medication therapies for established SE. Treatment delays and barriers to care are discussed, with practical considerations for opportunities for areas of improvement in the initial treatment of cSE.
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Affiliation(s)
- Lindsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, 4800 Sand Point Way NE, Neurology, MB.7.420, Seattle, WA, 98105, USA.
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Jennifer B Hrachovec
- Quality and Clinical Effectiveness, Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, WA, USA
| | - Howard P Goodkin
- Departments of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
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Tyson M, Trenear R, Skellett S, Maconochie I, Mullen N. Survey About Second-Line Agents for Pediatric Convulsive Status Epilepticus. Pediatr Emerg Care 2023; 39:247-252. [PMID: 35510724 DOI: 10.1097/pec.0000000000002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Convulsive status epilepticus (CSE) is the most common neurological emergency in children. It is a frequent cause of admission to pediatric intensive care units and is associated with significant short- and long-term morbidity. Management of CSE is a step-wise approach: first-line antiseizure agents (typically benzodiazepines) followed by a second-line agent before deeper anesthesia usually accompanied by intubation and ventilation. Current guidelines in the United Kingdom specify phenytoin as the second-line agent of choice for CSE. Two recent large international randomized controlled trials compared the efficacy of phenytoin with that of another second-line agent levetiracetam. Both studies found levetiracetam to be noninferior to phenytoin. METHODS We conducted an online survey of clinicians across 67 emergency departments that treat children and 29 pediatric intensive care units in the United Kingdom and Ireland to assess their current and preferred second-line agents for treating pediatric CSE in light of recently published evidence. The survey was distributed via the Pediatric Emergency Research in United Kingdom and Ireland network and the Pediatric Critical Care Society. RESULTS We found that although most clinicians use phenytoin, as per current guidelines, they seek greater flexibility in choice of second-line agent, with levetiracetam being the preferred alternative to phenytoin. CONCLUSIONS To facilitate use of levetiracetam for treatment of CSE in pediatrics, it should be included as a second-line agent in addition to phenytoin in the next update of the National Institute for Health and Care Excellence and other United Kingdom clinical guidelines.
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Affiliation(s)
- Marguerite Tyson
- From the Paediatric Intensive Care Unit, Great Ormond Street Hospital
| | | | - Sophie Skellett
- Paediatric Intensive Care Unit, Great Ormond Street Hospital
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London
| | - Niall Mullen
- Department of Paediatric Emergency Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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Coles L, Rosenthal ES, Bleck TP, Elm J, Zehtabchi S, Chamberlain J, Cloyd J, Shinnar S, Silbergleit R, Kapur J. Why ketamine. Epilepsy Behav 2023; 141:109066. [PMID: 36609129 PMCID: PMC10073319 DOI: 10.1016/j.yebeh.2022.109066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
We present the rationale for testing ketamine as an add-on therapy for treating benzodiazepine refractory (established) status epilepticus. In animal studies, ketamine terminates benzodiazepine refractory status epilepticus by interfering with the pathophysiological mechanisms and is a neuroprotectant. Ketamine does not suppress respiration when used for sedation and anesthesia. A Series of reports suggest that ketamine can help terminate refractory and super refractory status epilepticus. We propose to use 1 or 3 mg/Kg ketamine intravenously based on animal-to-human conversion and pharmacokinetic studies. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Lisa Coles
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, Downstate Health Sciences University, Brooklyn, NY, United States
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital Washington, DC, United States
| | - James Cloyd
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, School of Medicine, Ann Arbor, MI, United States
| | - Jaideep Kapur
- Department of Neurology and Neuroscience, University of Virginia, School of Medicine, Charlottesville, VA, United States.
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Rollo E, Romozzi M, Dono F, Bernardo D, Consoli S, Anzellotti F, Ricciardi L, Paci L, Sensi SL, Della Marca G, Servidei S, Calabresi P, Vollono C. Treatment of benzodiazepine-refractory status epilepticus: A retrospective, cohort study. Epilepsy Behav 2023; 140:109093. [PMID: 36739634 DOI: 10.1016/j.yebeh.2023.109093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Status epilepticus (SE) is a frequent neurological emergency, derived from the failure of mechanisms responsible for seizure termination. The present study aims to compare the efficacy of the most common antiseizure medications (ASMs) employed for the treatment of benzodiazepine-refractory SE. METHODS We performed a retrospective cohort study of all SE episodes treated in our hospital between January 2016 and December 2020. Inclusion criteria were: age ≥ 18 years; a diagnosis of status epilepticus. Exclusion criteria were: status epilepticus resolved by initial therapy with benzodiazepines; impossibility to retrieve medical records. We considered as effective the ASM that was the last drug introduced or increased in dose before termination of SE and without changes in the co-medication. RESULTS A total of 244 episodes in 219 patients were included in the study. The mean age of the final study cohort was 63.6 ± 19.2, with 108 (49%) men. In the total cohort, phenytoin (PHT) showed the highest response rate (57.6%), followed by lacosamide (LCM) (40.7%) and valproate (VPA) (39.8%). The comparative efficacy among the different drugs was significantly different (p < 0.001). In the pairwise comparisons, VPA was superior to levetiracetam (LEV) (response rate: 39.75% vs 24.71%; p = 0.004), but not to LCM. Phenytoin had a significantly higher resolution rate compared to VPA (response rate: 57.63% vs 39.75%; p = 0.02) and LEV (response rate: 57.63% vs 24.71; p < 0.001). The clinical predictors of anaesthetics administration were a disorder of consciousness upon clinical presentation, previous diagnosis of epilepsy, and younger age. CONCLUSION In our cohort of SE, PHT showed higher effectiveness in terminating established SE, as well as refractory SE in the subgroup of patients treated with anaesthetics.
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Affiliation(s)
- Eleonora Rollo
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marina Romozzi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fedele Dono
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy.
| | - Daniela Bernardo
- Centro Clinico NEMO, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Consoli
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy
| | - Francesca Anzellotti
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy
| | | | | | - Stefano L Sensi
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy
| | - Giacomo Della Marca
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Serenella Servidei
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Catello Vollono
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Soydan E, Guzin Y, Topal S, Atakul G, Colak M, Seven P, Sandal OS, Ceylan G, Unalp A, Agin H. Clinical Features and Management of Status Epilepticus in the Pediatric Intensive Care Unit. Pediatr Emerg Care 2023; 39:142-147. [PMID: 36790917 DOI: 10.1097/pec.0000000000002915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES Status epilepticus (SE) is associated with significant morbidity and mortality in children. SE in the pediatric intensive care unit (PICU) are not well characterized. The aim of this study is to retrospectively investigate the clinical features and treatment of seizures in children admitted to the PICU of our hospital. METHODS We retrospectively examined the clinical characteristics of patients aged between 1 month and 18 years who were admitted to our hospital with SE or who were diagnosed with SE after hospitalization and were followed up with continuous electroencephalographic monitoring between January 2015 and December 2019. RESULTS A total of 88 patients with SE, 50 (56.8%) boys and 38 (43.2%) girls, were included. The median age was 24 months (interquartile range, 12-80 months). When we evaluate the continuous electroencephalographic monitoring data, 27 (30.7%) were lateralized, 20 (22.7%) were multifocal, 30 (34.1%) were generalized, and 11 (12.5%) were bilateral independent epileptic activity. Seventy nine patients (89.8%) were evaluated as convulsive status epilepticus (CSE) and 9 (10.2%) as nonconvulsive status epilepticus (NCSE). Pediatric Risk of Mortality (PRISM III) score and mortality of patients with NCSE were higher ( P = 0.004 and P = 0.046, respectively). Thirteen eight patients (43.1%) were diagnosed as SE, 38 patients (43.1%) as refractory SE, and 12 patients (13.6%) as super-refractory SE. The overall mortality rate was 10.2%. CONCLUSIONS Status epilepticus is a neurological emergency that causes mortality and morbidity. Electroencephalographic monitoring is important for the recognition of seizures and rapid intervention. No superiority of second-line treatments or combined treatments was demonstrated in patients with SE.
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Affiliation(s)
| | - Yigithan Guzin
- Department of Pediatric Neurology, Dr. Behcet Uz Children's Hospital, University of Health Sciences, Izmir, Turkey
| | | | | | | | | | | | | | - Aycan Unalp
- Department of Pediatric Neurology, Dr. Behcet Uz Children's Hospital, University of Health Sciences, Izmir, Turkey
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Russell AM, Shepherd V, Woolfall K, Young B, Gillies K, Volkmer A, Jayes M, Huxtable R, Perkins A, Noor NM, Nickolls B, Wade J. Complex and alternate consent pathways in clinical trials: methodological and ethical challenges encountered by underserved groups and a call to action. Trials 2023; 24:151. [PMID: 36855178 PMCID: PMC9973248 DOI: 10.1186/s13063-023-07159-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Informed consent is considered a fundamental requirement for participation in trials, yet obtaining consent is challenging in a number of populations and settings. This may be due to participants having communication or other disabilities, their capacity to consent fluctuates or they lack capacity, or in emergency situations where their medical condition or the urgent nature of the treatment precludes seeking consent from either the participant or a representative. These challenges, and the subsequent complexity of designing and conducting trials where alternative consent pathways are required, contribute to these populations being underserved in research. Recognising and addressing these challenges is essential to support trials involving these populations and ensure that they have an equitable opportunity to participate in, and benefit from, research. Given the complex nature of these challenges, which are encountered by both adults and children, a cross-disciplinary approach is required. DISCUSSION A UK-wide collaboration, a sub-group of the Trial Conduct Working Group in the MRC-NIHR Trial Methodology Research Partnership, was formed to collectively address these challenges. Members are drawn from disciplines including bioethics, qualitative research, trials methodology, healthcare professions, and social sciences. This commentary draws on our collective expertise to identify key populations where particular methodological and ethical challenges around consent are encountered, articulate the specific issues arising in each population, summarise ongoing and completed research, and identify targets for future research. Key populations include people with communication or other disabilities, people whose capacity to consent fluctuates, adults who lack the capacity to consent, and adults and children in emergency and urgent care settings. Work is ongoing by the sub-group to create a database of resources, to update NIHR guidance, and to develop proposals to address identified research gaps. CONCLUSION Collaboration across disciplines, sectors, organisations, and countries is essential if the ethical and methodological challenges surrounding trials involving complex and alternate consent pathways are to be addressed. Explicating these challenges, sharing resources, and identifying gaps for future research is an essential first step. We hope that doing so will serve as a call to action for others seeking ways to address the current consent-based exclusion of underserved populations from trials.
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Affiliation(s)
- Amy M Russell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Anna Volkmer
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Mark Jayes
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alexander Perkins
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nurulamin M Noor
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Beverley Nickolls
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Bacon M, Appleton R, Bangalore H, Brand C, Browning J, Chin RF, Mahal S, Saranga Estevan S, McHale K, McLellan A, Milne N, Pujar S, Rao T, Short S, Warriner S, Yoong M. Review of the new APLS guideline (2022): Management of the convulsing child. Arch Dis Child Educ Pract Ed 2023; 108:43-48. [PMID: 35732467 DOI: 10.1136/archdischild-2021-323351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/07/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Melody Bacon
- Paediatric neurology, Barts Health NHS Trust, London, UK
| | - Richard Appleton
- Paediatric neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Harish Bangalore
- Paediatric neurology, paediatric intensive care, Great Ormond Street Hospital for Children, London, UK
| | - Celia Brand
- Paediatric neurology, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Juliet Browning
- Paediatric neurology, University Hospitals Dorset NHS Foundation Trust, Poole, Bournemouth Christchurch, UK
| | - Richard Fm Chin
- Paediatric neurology, Royal Hospital for Children and Young People, Edinburgh, UK.,Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
| | - Satvinder Mahal
- Paediatric neurology, paediatric intensive care, Great Ormond Street Hospital for Children, London, UK
| | | | - Kirsten McHale
- Paediatric neurology, Royal Alexandra Children's Hospital, Brighton, Brighton and Hove, UK
| | - Ailsa McLellan
- Paediatric neurology, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Nicola Milne
- Training and Staff Development Manager, Epilepsy Scotland, Glasgow, UK
| | - Suresh Pujar
- Paediatric neurology, paediatric intensive care, Great Ormond Street Hospital for Children, London, UK
| | - Tekki Rao
- Paediatrics, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Steven Short
- Ambulance Service, Scottish Ambulance Service, Edinburgh, UK
| | - Stephen Warriner
- Paediatrics, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Michael Yoong
- Paediatric neurology, Barts Health NHS Trust, London, UK
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42
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Pare BC, Camara AM, Camara A, Kourouma M, Enogo K, Camara MS, Akilimali L, Sani S, de Sainte Fare EB, Lame P, Mouly N, Castro-Rial ML, Sivahera B, Cherif MS, Beavogui AH, Muamba D, Tamba JB, Moumié B, Kojan R, Lang HJ. Ebola outbreak in Guinea, 2021: Clinical care of patients with Ebola virus disease. S Afr J Infect Dis 2023; 38:454. [PMID: 36756241 PMCID: PMC9900378 DOI: 10.4102/sajid.v38i1.454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background Experience from the Zaire Ebolavirus epidemic in the eastern Democratic Republic of the Congo (2018-2020) demonstrates that early initiation of essential critical care and administration of Zaire Ebolavirus specific monoclonal antibodies may be associated with improved outcomes among patients with Ebola virus disease (EVD). Objectives This series describes 13 EVD patients and 276 patients with suspected EVD treated during a Zaire Ebolavirus outbreak in Guinea in 2021. Method Patients with confirmed or suspected EVD were treated in two Ebola treatment centres (ETC) in the region of N'zérékoré. Data were reviewed from all patients with suspected or confirmed EVD hospitalised in these two ETCs during the outbreak (14 February 2021 - 19 June 2021). Ebola-specific monoclonal antibodies, were available 2 weeks after onset of the outbreak. Results Nine of the 13 EVD patients (age range: 22-70 years) survived. The four EVD patients who died, including one pregnant woman, presented with multi-organ dysfunction and died within 48 h of admission. All eight patients who received Ebola-specific monoclonal antibodies survived. Four of the 13 EVD patients were health workers. Improvement of ETC design facilitated implementation of WHO-recommended 'optimized supportive care for EVD'. In this context, pragmatic clinical training was integrated in routine ETC activities. Initial clinical manifestations of 13 confirmed EVD patients were similar to those of 276 patients with suspected, but subsequently non confirmed EVD. These patients suffered from other acute infections (e.g. malaria in 183 of 276 patients; 66%). Five of the 276 patients with suspected EVD died. One of these five patients had Lassa virus disease and a coronavirus disease 2019 (COVID-19) co-infection. Conclusion Multidisciplinary outbreak response teams can rapidly optimise ETC design. Trained clinical teams can provide WHO-recommended optimised supportive care, including safe administration of Ebola-specific monoclonal antibodies. Pragmatic training in essential critical care can be integrated in routine ETC activities. Contribution This article describes clinical realities associated with implementation of WHO-recommended standards of 'optimized supportive care' and administration of Ebola virus specific treatments. In this context, the importance of essential design principles of ETCs is underlined, which allow continuous visual contact and verbal interaction of health workers and families with their patients. Elements that may contribute to further quality of care improvements for patients with confirmed or suspected EVD are discussed.
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Affiliation(s)
- Boyo C. Pare
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Alseny M. Camara
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Aminata Camara
- Ministry of Health, Agence Nationale de Sécurité Sanitaire, N’zérékoré, Guinea,Ministry of Health, Hôpital Régionale de N’zérékoré, N’zérékoré, Guinea
| | - Moussa Kourouma
- Ministry of Health, Agence Nationale de Sécurité Sanitaire, N’zérékoré, Guinea,Ministry of Health, Hôpital Régionale de N’zérékoré, N’zérékoré, Guinea
| | - Koivogui Enogo
- Ministry of Health, Agence Nationale de Sécurité Sanitaire, N’zérékoré, Guinea
| | | | | | - Sayadi Sani
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | | | - Papys Lame
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Nicolas Mouly
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | | | - Billy Sivahera
- Alliance for International Medical Action (ALIMA), Dakar, Senegal,World Health Organization (WHO), Geneva, Switzerland
| | - Mahamoud S. Cherif
- Centre National de Formation et de Recherche en Santé Rural de Maferinyah, Maferenya, Guinea
| | - Abdoul H. Beavogui
- Centre National de Formation et de Recherche en Santé Rural de Maferinyah, Maferenya, Guinea
| | - Dally Muamba
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Joachim B. Tamba
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Barry Moumié
- Ministry of Health, Agence Nationale de Sécurité Sanitaire, N’zérékoré, Guinea
| | - Richard Kojan
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Hans-Joerg Lang
- Alliance for International Medical Action (ALIMA), Dakar, Senegal,Witten/Herdecke- University, Global Child Health, Witten, Germany
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43
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Insight into Drug Resistance in Status Epilepticus: Evidence from Animal Models. Int J Mol Sci 2023; 24:ijms24032039. [PMID: 36768361 PMCID: PMC9917109 DOI: 10.3390/ijms24032039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 01/22/2023] Open
Abstract
Status epilepticus (SE), a condition with abnormally prolonged seizures, is a severe type of epilepsy. At present, SE is not well controlled by clinical treatments. Antiepileptic drugs (AEDs) are the main therapeutic approaches, but they are effective for SE only with a narrow intervening window, and they easily induce resistance. Thus, in this review, we provide an updated summary for an insight into drug-resistant SE, hoping to add to the understanding of the mechanism of refractory SE and the development of active compounds. Firstly, we briefly outline the limitations of current drug treatments for SE by summarizing the extensive experimental literature and clinical data through a search of the PubMed database, and then summarize the common animal models of refractory SE with their advantages and disadvantages. Notably, we also briefly review some of the hypotheses about drug resistance in SE that are well accepted in the field, and furthermore, put forward future perspectives for follow-up research on SE.
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44
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Status Epilepticus. Crit Care Clin 2023; 39:87-102. [DOI: 10.1016/j.ccc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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45
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Neligan A, Rajakulendran S. Has the mortality of status epilepticus changed over the past few decades? Epilepsy Behav 2023; 138:109050. [PMID: 36549100 DOI: 10.1016/j.yebeh.2022.109050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Earlier and more aggressive treatment of status epilepticus has long been established orthodoxy. In addition to increasing therapeutic options, it is of critical importance to understand whether or not this has translated into improved prognosis. In this review, we examine the evidence as to whether the mortality of convulsive status epilepticus changed over the past few decades. In particular, we discuss a recent systematic review and meta-analysis examining this question and its implications. We discuss potential reasons why there is no evidence of improved prognosis in terms of mortality and ways in which this may be addressed. Finally, we advocate the urgent need for accurate data on functional outcomes in non-fatal cases of status epilepticus. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- A Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK; UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.
| | - Sanjeev Rajakulendran
- UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK; National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK; North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
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46
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Nakamura K, Marushima A, Takahashi Y, Mochizuki M, Kimura A, Fukuda Y, Asami M, Nakamoto H, Egawa S, Kaneko J, Unemoto K, Kondo Y, Yonekawa C, Uchida M, Hoshiyama E, Yamada T, Maruo K, Ishikawa E, Matsumaru Y, Inoue Y. Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus: a multicentre non-inferiority randomised control trial. J Neurol Neurosurg Psychiatry 2023; 94:42-48. [PMID: 36207063 PMCID: PMC9763167 DOI: 10.1136/jnnp-2022-329485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/05/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is crucial. Although fosphenytoin (FPHT) is recommended as a second-line treatment, levetiracetam (LEV) reportedly has similar efficacy, but higher safety. Therefore, we herein compared LEV with FPHT in adult SE. METHODS We initiated a multicentre randomised control trial in emergency departments with adult patients with convulsive SE. Diazepam was initially administered, followed intravenously by FPHT at 22.5 mg/kg or LEV at 1000-3000 mg. The primary outcome was assigned as the seizure cessation rate within 30 min of the administration of the study drug. RESULTS A total of 176 adult patients with SE were enrolled (82 FPHT and 94 LEV), and 3 were excluded from the full analysis set. Seizure cessation rates within 30 min were 83.8% (67/80) in the FPHT group and 89.2% (83/93) in the LEV group. The difference in these rates was 5.5% (95% CI -4.7 to 15.7, p=0.29). The non-inferiority of LEV to FPHT was confirmed with p<0.001 by the Farrington-Manning test. No significant differences were observed in the seizure recurrence rate or intubation rate within 24 hours. Serious adverse events developed in three patients in the FPHT group and none in the LEV group (p=0.061). CONCLUSION The efficacy of LEV was similar to that of FPHT for adult SE following the administration of diazepam. LEV may be recommended as a second-line treatment for SE along with phenytoin/FPHT. TRIAL REGISTRATION NUMBER jRCTs031190160.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan.,Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Aiki Marushima
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan .,Division of Stroke prevention and treatment, Department of Neurosurgery, Faculty of Medicine,University of Tsukuba, Tsukuba, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Epilepsy Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Toyama Shinjuku, Tokyo, Japan
| | - Yu Fukuda
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Toyama Shinjuku, Tokyo, Japan
| | - Masahiro Asami
- Department of Emergency Medicine, Teikyo University Hospital, Itabashi, Tokyo, Japan
| | - Hidetoshi Nakamoto
- Neurointensive Care Unit, Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Asaka, Saitama, Japan
| | - Satoshi Egawa
- Neurointensive Care Unit, Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Asaka, Saitama, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama, Tokyo, Japan
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama, Tokyo, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Chikara Yonekawa
- Department of Emergency and Critical Care Medicine, Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan
| | - Masatoshi Uchida
- Emergency and Critical Care Medical Center, Dokkyo Medical University, Shimotsuga, Tochigi, Japan
| | - Eisei Hoshiyama
- Emergency and Critical Care Medical Center, Dokkyo Medical University, Shimotsuga, Tochigi, Japan
| | - Takeshi Yamada
- Tsukuba Clinical Research and Development Organization (T-CReDO), University of Tsukuba, Tsukuba, Ibaraki, Japan.,Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Epilepsy Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Yuji Matsumaru
- Division of Stroke prevention and treatment, Department of Neurosurgery, Faculty of Medicine,University of Tsukuba, Tsukuba, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Epilepsy Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
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Swarnalingam E, Woodward K, Esser M, Jacobs J. Management and prognosis of pediatric status epilepticus. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Pediatric status epilepticus is a neurological emergency with the potential for severe developmental and neurological consequences. Prompt diagnosis and management are necessary.
Objectives
To outline the existing best available evidence for managing pediatric and neonatal status epilepticus, in the light of emerging randomized controlled studies. We also focus on short and long-term prognoses.
Materials and methods
This is a systematic overview of the existing literature.
Results
Status epilepticus, its treatment, and prognosis are usually based on the continuation of seizure activity at 5 and 30 min. Refractory and super-refractory status epilepticus further complicates management and requires continuous EEG monitoring with regular reassessment and adjustment of therapy. Benzodiazepines have been accepted as the first line of treatment on the basis of reasonable evidence. Emerging randomized controlled trials demonstrate equal efficacy for parenterally administered phenytoin, levetiracetam, and valproic acid as second-line agents. Beyond this, the evidence for third-line options is sparse. However, encouraging evidence for midazolam and ketamine exists with further data required for immunological, dietary, and surgical interventions.
Conclusion
Our overview of the management of pediatric and neonatal status epilepticus based on available evidence emphasizes the need for evidence-based guidelines to manage status epilepticus that fails to respond to second-line treatment.
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48
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Jain P, Aneja S, Cunningham J, Arya R, Sharma S. Treatment of benzodiazepine-resistant status epilepticus: Systematic review and network meta-analyses. Seizure 2022; 102:74-82. [DOI: 10.1016/j.seizure.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 10/31/2022] Open
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Zographos GA, Russ‐Hall SJ, Scheffer IE. Does long-term phenytoin have a place in Dravet syndrome? Ann Clin Transl Neurol 2022; 9:2036-2040. [PMID: 36314457 PMCID: PMC9735367 DOI: 10.1002/acn3.51684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/04/2022] [Indexed: 12/14/2022] Open
Abstract
Anti-seizure medications that block sodium channels are generally considered contraindicated in Dravet syndrome. There is, however, considerable debate about the sodium-channel blocker phenytoin, which is often used for status epilepticus, a frequent feature of Dravet syndrome. We describe four patients with Dravet syndrome in whom long-term phenytoin therapy reduced seizure frequency and duration. In two patients, phenytoin produced prolonged periods without status epilepticus for the first time. Attempting to wean phenytoin in all patients after 1 to 20 years of use resulted in seizure exacerbation. Reintroducing phenytoin improved seizure control, suggesting phenytoin is beneficial in some patients with Dravet syndrome.
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Affiliation(s)
- George A. Zographos
- Epilepsy Research Centre, Department of MedicineUniversity of Melbourne, Austin HealthMelbourneAustralia
| | - Sophie J. Russ‐Hall
- Epilepsy Research Centre, Department of MedicineUniversity of Melbourne, Austin HealthMelbourneAustralia
| | - Ingrid E. Scheffer
- Epilepsy Research Centre, Department of MedicineUniversity of Melbourne, Austin HealthMelbourneAustralia,Florey Institute of Neuroscience and Mental HealthMelbourneAustralia,Murdoch Children's Research Institute and Department of PaediatricsUniversity of Melbourne, Royal Children's HospitalMelbourneAustralia
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50
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Messahel S, Bracken L, Appleton R. Optimal Management of Status Epilepticus in Children in the Emergency Setting: A Review of Recent Advances. Open Access Emerg Med 2022; 14:491-506. [PMID: 36158897 PMCID: PMC9491331 DOI: 10.2147/oaem.s293258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/23/2022] [Indexed: 01/19/2023] Open
Abstract
Convulsive status epilepticus (CSE) is the most common neurological emergency in children and the second most common neurological emergency in adults. Mortality is low, but morbidity, including neuro-disability, learning difficulties, and a de-novo epilepsy, may be as high as 22%. The longer the duration of CSE, the more difficult it is to terminate, and the greater the risk of morbidity. Convulsive status epilepticus is usually managed using specific national or local algorithms. The first-line treatment is administered when a tonic-clonic or focal motor clonic seizure has lasted five minutes (impending or premonitory CSE). Second-line treatment is administered when the CSE has persisted after two doses of a first-line treatment (established CSE). Randomised clinical trial (RCT) evidence supports the use of benzodiazepines as a first-line treatment of which the most common are buccal or intra-nasal midazolam, rectal diazepam and intravenous lorazepam. Alternative drugs, for which there are considerably less RCT data, are intra-muscular midazolam and intravenous clonazepam. Up until 2019, phenobarbital and phenytoin (or fosphenytoin) were the preferred second-line treatments but with no good supporting RCT evidence. Robust RCT data are now available which has provided important information on second-line treatments, specifically phenytoin (or fosphenytoin), levetiracetam and sodium valproate. Lacosamide is an alternative second-line treatment but with no supporting RCT evidence. Current evidence indicates that first, buccal or intranasal midazolam or intravenous lorazepam are the most effective and the most patient and carer-friendly first-line anti-seizure medications to treat impending or premonitory CSE and second, that there is no difference in efficacy between levetiracetam, phenytoin (or fosphenytoin) or sodium valproate for the treatment of established CSE. Pragmatically, levetiracetam or sodium valproate are preferred to phenytoin (or fosphenytoin) because of their ease of administration and lack of serious adverse side-effects, including potentially fatal cardiac arrhythmias. Sodium valproate must be used with caution in children aged three and under because of the rare risk of hepatotoxicity and particularly if there is an underlying mitochondrial disorder.
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Affiliation(s)
- Shrouk Messahel
- NIHR NWC Speciality Research Lead for Trauma and Emergency Care, The Emergency Department, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Louise Bracken
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UK
| | - Richard Appleton
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 3BX, UK
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