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Bowman A, Domke C, Morton S. What is the Evidence for Using Intranasal Medicine in the Prehospital Setting? A Systematic Review. PREHOSP EMERG CARE 2024; 28:787-802. [PMID: 38848591 DOI: 10.1080/10903127.2024.2357598] [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: 12/21/2023] [Revised: 04/02/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVES Intranasal (IN) medications offer a safe non-invasive way to rapidly deliver drugs in situations where intravenous (IV) access and intramuscular (IM) administration is challenging or not feasible. In the prehospital setting, this can be an essential alternative in time critical situations including trauma management, seizures, and agitated patients. However, there is a paucity of evidence summarizing its efficacy in this environment. This systematic review aims to assess the current evidence supporting the use of IN medicine (midazolam, ketamine, fentanyl, morphine, glucagon, and naloxone) in the prehospital setting alone. METHODS A systematic literature search (PROSPERO CRD42023440713) of PubMed, Web of Science, OVID Medline, "Cochrane Central Register of Controlled Trials," Cochrane reviews and Embase was performed from inception to June 2023 to identify studies where IN medications were administered to patients in the prehospital setting. All randomized controlled trials, observational cohort studies, case series, and case reports were included. Papers not written in English, review articles, abstracts, and non-published data (including letters to the editor) were excluded. The methodological quality of the included studies was interpreted using the Cochrane risk of bias tool and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. No funding was received. RESULTS From 4818 studies, 39 were included (seven for midazolam, five for ketamine, twelve for fentanyl, one for diamorphine, two for glucagon, and twelve for naloxone). A total of 24,097 patients were treated with IN medications across all the studies. There were five moderate quality, four low quality, and thirty very low quality studies. The potential efficacy of IN fentanyl and ketamine was demonstrated consistently throughout the studies with less clear evidence for midazolam, morphine, glucagon, and naloxone. This review was severely limited by the study quality, with most studies demonstrating "high concerns" for bias. CONCLUSIONS Prehospital IN medication administration has wide-ranging potential, particularly for administering analgesia. There are likely to be certain populations, for example, pediatrics, that will benefit the most, although conclusions are limited by the quality of evidence currently available. We encourage additional research in this area, particularly with robust prospective double-blind RCTs.
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Ramgopal S, Owusu-Ansah S, Crowe RP, Okubo M, Martin-Gill C. Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services. Epilepsia 2024; 65:1294-1303. [PMID: 38470335 DOI: 10.1111/epi.17940] [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: 12/18/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE National guidelines in the United States recommend the intramuscular and intranasal routes for midazolam for the management of seizures in the prehospital setting. We evaluated the association of route of midazolam administration with the use of additional benzodiazepine doses for children with seizures cared for by emergency medical services (EMS). METHODS We conducted a retrospective cohort study from a US multiagency EMS dataset for the years 2018-2022, including children transported to the hospital with a clinician impression of seizures, convulsions, or status epilepticus, and who received an initial correct weight-based dose of midazolam (.2 mg/kg intramuscular, .1 mg/kg intravenous, .2 mg/kg intranasal). We evaluated the association of route of initial midazolam administration with provision of additional benzodiazepine dose in logistic regression models adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient. RESULTS We included 2923 encounters with patients who received an appropriate weight-based dose of midazolam for seizures (46.3% intramuscular, 21.8% intranasal, 31.9% intravenous). The median time to the first dose of midazolam from EMS arrival was similar between children who received intramuscular (7.3 min, interquartile range [IQR] = 4.6-12.5) and intranasal midazolam (7.8 min, IQR = 4.5-13.4) and longer for intravenous midazolam (13.1 min, IQR = 8.2-19.4). At least one additional dose of midazolam was given to 21.4%. In multivariable models, intranasal midazolam was associated with higher odds (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.10-1.76) and intravenous midazolam was associated with similar odds (OR = 1.00, 95% CI = .80-1.26) of requiring additional doses of benzodiazepines relative to intramuscular midazolam. SIGNIFICANCE Intranasal midazolam was associated with greater odds of repeated benzodiazepine dosing relative to initial intramuscular administration, but confounding factors could have affected this finding. Further study of the dosing and/or the prioritization of the intranasal route for pediatric seizures by EMS clinicians is warranted.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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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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Svoboda M, Blahova J, Jarkovsky J, Zacharda A, Hajkova S, Vanhara J, Vasek J. Efficacy of the intranasal application of azaperone for sedation in weaned piglets. VET MED-CZECH 2023; 68:145-151. [PMID: 37982086 PMCID: PMC10581517 DOI: 10.17221/21/2023-vetmed] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/05/2023] [Indexed: 11/21/2023] Open
Abstract
The aim of the study was to compare the efficacy of the intranasal and parenteral administration of azaperone in order to achieve pig sedation. A total of 32 weaned piglets divided into 4 groups (8 piglets in each group) were used. Group A was injected intramuscularly (i.m.) with azaperone (Stresnil®, 40 mg/ml inj.; Elanco Animal Health) at a dose of 2 mg/kg of body weight (b.w.). Group B received a dose of 2 mg/kg b.w. of azaperone intranasally. Group C was given azaperone intranasally at a dose of 4 mg/kg b.w. Group D was given 1 ml of saline intranasally and served as the control group. The response to the defined stimulus (a blunt blow of a metal rod into a metal edge of a pen), the degree of salivation, movement level, body temperature and serum azaperone concentration were included in the trial. We found that in order to induce an adequate level of sedation comparable to the standard method of application, i.e., 2 mg/kg b.w. i.m., the intranasal administration of azaperone at a dose of 4 mg/kg body weight is required.
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Affiliation(s)
- Martin Svoboda
- Ruminant and Swine Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic
| | - Jana Blahova
- Department of Animal Protection and Welfare and Veterinary Public Health, Faculty of Veterinary Hygiene and Ecology, University of Veterinary Sciences Brno, Brno, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University Brno, Brno, Czech Republic
| | - Adam Zacharda
- Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic
| | - Suzana Hajkova
- Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic
| | - Jonas Vanhara
- Ruminant and Swine Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic
| | - Jan Vasek
- Ruminant and Swine Clinic, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic
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Cornett EM, Nemomsa MA, Turbeville B, Busby MA, Kaye JS, Kaye AJ, Choi J, Ramírez GF, Varrassi G, Kaye AM, Kaye AD, Wilson J, Ganti L. Midazolam nasal spray to treat intermittent, stereotypic episodes of frequent seizure activity: pharmacology and clinical role, a comprehensive review. Health Psychol Res 2022; 10:38536. [PMID: 36262479 PMCID: PMC9560890 DOI: 10.52965/001c.38536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
An intranasal formulation of midazolam, Nayzilam, has been FDA-approved to treat intermittent, stereotypic episodes of frequent seizure activity. Nayzilam is easy to administer and can quickly treat seizures that occur outside of the hospital. The intra-nasal route of administration allows non-medical personal to administer the drug which makes it more accessible and user-friendly in the event of a seizure. Many studies have indicated quick cessation of seizures with Nayzilam compared to rectal diazepam, which has been the standard of care treatment. Nayzilam has been proven to be safe and effective for acute seizures in children, deeming it a revolutionary alternative in times where intravenous administration is not possible.
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Affiliation(s)
| | | | | | | | - Jessica S Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific
| | - Aaron J Kaye
- Department of Anesthesiology, Medical University of South Carolina
| | | | | | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Shreveport
| | - James Wilson
- University of Central Florida College of Medicine
| | - Latha Ganti
- University of Central Florida College of Medicine
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Guterman EL, Sporer KA, Newman TB, Crowe RP, Lowenstein DH, Josephson SA, Betjemann JP, Burke JF. Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States. Ann Emerg Med 2022; 80:319-328. [PMID: 35931608 PMCID: PMC9930617 DOI: 10.1016/j.annemergmed.2022.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Guidelines recommend 10-mg intramuscular midazolam as the first-line treatment option for status epilepticus. However, in real-world practice, it is frequently administered intranasally or intravenously and is dosed lower. Therefore, we used conventional and instrumental variable approaches to examine the effectiveness of midazolam in a national out-of-hospital cohort. METHODS This retrospective cohort study of adults with status epilepticus used the ESO Data Collaborative research dataset (January 1, 2019, to December 31, 2019). The exposures were the route and dose of midazolam. We performed hierarchical logistic regression and 2-stage least squares regression using agency treatment patterns as an instrument to examine our outcomes, rescue therapy, and ventilatory support. RESULTS There were 7,634 out-of-hospital encounters from 657 EMS agencies. Midazolam was administered intranasally in 20%, intravenously in 46%, and intramuscularly in 35% of the encounters. Compared with intramuscular administration, intranasal midazolam increased (risk difference [RD], 6.5%; 95% confidence interval [CI], 2.4% to 10.5%) and intravenous midazolam decreased (RD, -11.1%; 95% CI, -14.7% to -7.5%) the risk of rescue therapy. The differences in ventilatory support were not statistically significant (intranasal RD, -1.5%; 95% CI, -3.2% to 0.3%; intravenous RD, -0.3%; 95% CI, -1.9% to 1.2%). Higher doses were associated with a lower risk of rescue therapy (RD, -2.6%; 95% CI, -3.3% to -1.9%) and increased ventilatory support (RD, 0.4%; 95% CI, 0.1% to 0.7%). The instrumental variable analysis yielded similar results, except that dose was not associated with ventilatory support. CONCLUSION The route and dose of midazolam affect clinical outcomes. Compared with intramuscular administration, intranasal administration may be less effective and intravenous administration more effective in terminating status epilepticus, although the differences between these and previous results may reflect the nature of real-world data as opposed to randomized data.
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Affiliation(s)
- Elan L Guterman
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA.
| | - Karl A Sporer
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA
| | - Remle P Crowe
- ESO, Inc. Kaiser Permanente, Northern California, San Francisco, CA
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA
| | - John P Betjemann
- Department of Neurology, Kaiser Permanente, Northern California, San Francisco, CA
| | - James F Burke
- Department of Neurology, Ohio State Wexner Medical Center, Columbus, OH; Department of Neurology, University of Michigan, Ann Arbor, MI
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Ramgopal S, McCans K, Martin-Gill C, Owusu-Ansah S. Variation in Prehospital Protocols for Pediatric Seizure Within the United States. Pediatr Emerg Care 2021; 37:e1331-e1338. [PMID: 32011553 DOI: 10.1097/pec.0000000000002029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to compare statewide prehospital protocols for the management of pediatric seizures. METHODS We performed a descriptive analysis comparing statewide protocols for emergency medical services management of pediatric seizures within the United States, excluding states for which no statewide protocol/model was available. We compared antiepileptic drugs (AEDs), routes and doses of administration, and differences in febrile seizure management. RESULTS Of 50 states, 34 had either statewide protocols or models and were included. All had a protocol for the management of seizures and provided specific recommendations for the management of pediatric seizures. Twelve states (35%) preferentially recommended midazolam over other benzodiazepines. Thirty-two (94%) of 34 allowed for use of midazolam, with variable use of other AEDs. All allowed for use of intramuscular AED. Twenty-six (77%) allowed for intranasal AED. Nine (27%) allowed emergency medical services to administer a patient's own abortive AED, and 6 (18%) allowed for use of a patient's vagal nerve stimulator, when present. There was a wide variability with respect to dosing ranges for medications. Thirty-two (94%) of 34 included blood glucose measurement within the protocol. Twenty-one protocols (62%) provided recommendations for febrile seizures, including recommending active/passive cooling (8/34, 24%) and antipyretic administration (9/34, 26%). CONCLUSIONS All statewide protocols carried specific guidelines for the prehospital management of pediatric seizures; however, there was wide variability with respect to specific AEDs, routes of administration, and drug dosages. In addition to broader availability of statewide guidance, areas of potential protocol improvement and research include AED dose optimization, reprioritization of blood glucose, and greater emphasis on intranasal or intramuscular medication dosing.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL
| | - Kerry McCans
- UPMC Center for Emergency Medicine, School of Health and Rehabilitation Sciences
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Intranasal midazolam versus intravenous/rectal benzodiazepines for acute seizure control in children: A systematic review and meta-analysis. Epilepsy Behav 2021; 125:108390. [PMID: 34740090 DOI: 10.1016/j.yebeh.2021.108390] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/04/2021] [Accepted: 10/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute seizure activity might cause complications including bodily harm, progression to status epilepticus, and poor quality of life in children. The introduction of a venous line may be difficult in children with seizures which would delay the initiation of treatment. Rectal drug administration can be socially awkward for patients and providers. Intranasal (IN) midazolam offers a valuable substitute that is easier and faster to administer. OBJECTIVE To assess the efficacy, safety, and acceptability of intranasal midazolam in children with acute seizure when compared to conventional IV or rectal benzodiazepine (BDZ). METHODS PubMed, google scholar, websites clinicaltrials.gov and the WHO-international clinical trials registry platform, were searched. Randomized controlled/prospective randomized trials comparing IN midazolam against IV/rectal BDZ in the treatment of acute seizures in pediatric patients were included in the meta-analysis. RESULTS Data of 10 studies were quantitatively analyzed. Intranasal midazolam (n = 169) when compared to IV/rectal BDZ (n = 161) has a shorter interval between hospital arrival and seizure cessation {(mean difference = -3.51; 95% CI [-6.84, -0.18]) P = 0.04}. Regarding time to seizure cessation after midazolam (n = 326) or BDZ (n = 322) administration, there is no significant difference between the two groups {(mean difference = -0.03; 95% CI [-1.30, 1.25]), P = 0.97} and both are equally effective for controlling acute seizures (odds ratio = 1.06; 95% CI [0.43, 2.63]; n = 737). CONCLUSION In children with acute seizures, IN midazolam is equally effective in aborting seizure and decreases the total time from hospital arrival and cessation of seizures, eventually leading to faster cessation of seizure as compared to IV/rectal BDZ.
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Samanta D. Rescue therapies for seizure emergencies: current and future landscape. Neurol Sci 2021; 42:4017-4027. [PMID: 34269935 PMCID: PMC8448953 DOI: 10.1007/s10072-021-05468-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Seizure emergencies-status epilepticus and seizure clusters-require rapid evaluation and treatment. Several consensus-based guidelines support a prompt use of intravenous benzodiazepines as the first-line therapy in seizure emergencies. However, most seizure emergencies start outside the hospital settings. Until recently, approved prehospital rescue therapies were limited to rectal diazepam and buccal midazolam (Europe only). METHODS The author provides a narrative review of rescue therapies for seizure emergencies based on a comprehensive literature review (PubMed and OvidSP vendors with appropriate keywords to incorporate recent evidence) to highlight the changing landscape of seizure recue therapies. RESULTS A commercial version of intranasal midazolam was approved by the FDA in 2019 for 12 ≥ years old with seizure clusters. In 2020, the FDA also approved a proprietary vitamin E solution-based diazepam nose spray to abort seizure clusters in ≥ 6 years old subjects. Other than these two new options, the author discussed two previously approved therapies: rectal diazepam and buccal midazolam. The review also includes the use of intramuscular diazepam and midazolam, clonazepam wafer, sublingual and intranasal lorazepam in seizure emergencies. Besides the availability of new therapies from successful trials in controlled settings, the real-world challenges of using rescue medicines in community settings are slowly emerging. DISCUSSION With multiple options, a more robust and updated cost-effective analysis of different rescue medicines needs to be performed using effectiveness data from the literature and cost data from publicly available market prices. Further research is also ongoing to develop alternative non-intravenous treatment options for outpatient settings. Lastly, several other non-benzodiazepine drugs, such as allopregnanolone, propofol, and brivaracetam, are also currently under development for seizure emergencies.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA.
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Whitfield D, Bosson N, Kaji AH, Gausche-Hill M. The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. PREHOSP EMERG CARE 2021; 26:339-347. [PMID: 33656973 DOI: 10.1080/10903127.2021.1897197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.
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Becker S, Maier A, Peters S, Büttner K, Reiner G. S-ketamine and intranasal application: alternatives for the castration of male suckling piglets? BMC Vet Res 2021; 17:122. [PMID: 33726749 PMCID: PMC7968208 DOI: 10.1186/s12917-021-02826-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/02/2021] [Indexed: 11/24/2022] Open
Abstract
Background The intramuscular injection of ketamine and azaperone was proposed as a suitable anaesthesia for male suckling piglets for surgical castration. However, this can be opposed by massive defensive movements, hypothermia and tachycardia during castration and a long recovery period. The aim of the present study was to test whether the use of S-ketamine and/or a change in the route of application from intramuscular to intranasal could reduce stress responses and the duration of recovery compared to the intramuscular route and the use of racemic ketamine. Seventy-eight healthy, five-day-old male piglets were randomized to six treatment groups in a blinded experimental study, matched by litter and weight. Experimental groups were A (15 mg kg-1 S-ketamine + 2 mg kg-1 azaperone, i.m., surgical castration), B (15 mg kg-1 R/S-ketamine racemate + 2 mg kg-1 azaperone, i.m., surgical castration), C (30 mg kg-1 S-ketamine + 2 mg kg-1 azaperone, i.n., surgical castration), D (15 mg kg-1 R/S-ketamine racemate + 2 mg kg-1 azaperone, i.m.; not castrated), E (positive control group; no anesthesia, surgical castration) and F (negative control group; no anesthesia, not castrated). Results S-ketamine reduced the defensive movement score during castration to a similar extent to racemic ketamine when administered intramuscularly but not via the intranasal route. However, the effects of S-ketamine (both routes) on the increase in cortisol levels and decrease in body temperature were similar to those induced by racemic ketamine. A reduction of the long recovery time known for ketamine-azaperone anaesthesia could not be achieved with S-ketamine in the given dosage, regardless of the route of application. The intranasal administration of ketamine was difficult with the available formulation as the necessary amount exceeded the capacity of the nose cavity. Conclusions Neither the use of S-ketamine nor intranasal administration can be suitable alternatives for the anaesthesia of male suckling piglets for castration.
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Affiliation(s)
- Sabrina Becker
- Department for Clinical Veterinary Sciences, Clinic for Swine, Justus-Liebig-University, Giessen, Germany
| | - Anna Maier
- Department for Clinical Veterinary Sciences, Clinic for Swine, Justus-Liebig-University, Giessen, Germany
| | - Saskia Peters
- Department of Animal Welfare, Justus-Liebig-University, Giessen, Germany
| | - Kathrin Büttner
- Unit for Biomathematics and Data Processing, Faculty of Veterinary Medicine, Justus Liebig University, Frankfurter Str. 95, 35392, Giessen, Germany
| | - Gerald Reiner
- Department for Clinical Veterinary Sciences, Clinic for Swine, Justus-Liebig-University, Giessen, Germany.
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Charalambous M, Volk HA, Van Ham L, Bhatti SFM. First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines. BMC Vet Res 2021; 17:103. [PMID: 33663513 PMCID: PMC7934266 DOI: 10.1186/s12917-021-02805-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium.
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
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13
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Seizure Rescue Medications for Out-Of-Hospital Use in Children. J Pediatr 2021; 229:19-25. [PMID: 33228949 DOI: 10.1016/j.jpeds.2020.10.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 11/23/2022]
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14
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Gidal B, Klein P, Hirsch LJ. Seizure clusters, rescue treatments, seizure action plans: Unmet needs and emerging formulations. Epilepsy Behav 2020; 112:107391. [PMID: 32898744 DOI: 10.1016/j.yebeh.2020.107391] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The aim of the study was to provide an overview of the prevalence, risk factors, burden, and current and emerging pharmacologic treatments for seizure clusters in patients with epilepsy. RECENT FINDINGS Close to half of patients with active epilepsy experience seizure clusters, and the clinical, social, and financial burdens of seizure clusters are high. However, there is no widely accepted definition of seizure clusters; their prevalence is underappreciated, contingencies for addressing them (seizure action plans) are often lacking, and their effects are not well-studied. These issues have resulted in an insufficient number of investigations and approved medications for this condition. Novel formulations are in late-stage development to meet this unmet need.
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Affiliation(s)
- Barry Gidal
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI, USA.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
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15
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Sánchez Fernández I, Gaínza-Lein M, Barcia Aguilar C, Amengual-Gual M, Loddenkemper T. The burden of decisional uncertainty in the treatment of status epilepticus. Epilepsia 2020; 61:2150-2162. [PMID: 32959410 DOI: 10.1111/epi.16646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Treatments for convulsive status epilepticus (SE) have a wide range of effectiveness. The estimated effectiveness of non-intravenous benzodiazepines (non-IV BZDs) ranges from approximately 70% to 90% and the estimated effectiveness of non-benzodiazepine antiseizure medications (non-BZD ASMs) ranges from approximately 50% to 80%. This study aimed to quantify the clinical and economic burden of decisional uncertainty in the treatment of SE. METHODS We performed a decision analysis that evaluates how decisional uncertainty on treatment choices for SE impacts hospital admissions, intensive care unit (ICU) admissions, and costs in the United States. We evaluated treatment effectiveness based on the available literature. RESULTS Use of a non-IV BZD with high estimated effectiveness, like intranasal midazolam, rather than one with low estimated effectiveness, like rectal diazepam, would result in a median (p25 -p75 ) reduction in hospital admissions from 6 (3.9-8.8) to 1.1 (0.7-1.8) per 100 cases and associated cost reductions of $638 ($289-$1064) per pediatric patient and $1107 ($972-$1281) per adult patient. For BZD-resistant SE, use of a non-BZD ASM with high estimated effectiveness, like phenobarbital, rather than one with low estimated effectiveness, like phenytoin/fosphenytoin, would result in a reduction in ICU admissions from 9.1 (7.3-11.2) to 3.9 (2.6-5.5) per 100 cases and associated cost reduction of $1261 ($445-$2223) per pediatric patient and $319 ($-93-$806) per adult patient. Sensitivity analyses showed that relatively minor improvements in effectiveness may lead to substantial reductions in downstream hospital admissions, ICU admissions, and costs. SIGNIFICANCE Decreasing decisional uncertainty and using the most effective treatments for SE may substantially decrease hospital admissions, ICU admissions, and costs.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile.,Servicio de Neuropsiquiatría Infantil. Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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16
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Shah MI, Ostermayer DG, Browne LR, Studnek JR, Carey JM, Stanford C, Fumo N, Lerner EB. Multicenter Evaluation of Prehospital Seizure Management in Children. PREHOSP EMERG CARE 2020; 25:475-486. [PMID: 32589502 DOI: 10.1080/10903127.2020.1788194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing. OBJECTIVE We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline. METHODS Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care. RESULTS We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients. CONCLUSIONS Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.
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17
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Kashyap K, Shukla R. Drug Delivery and Targeting to the Brain Through Nasal Route: Mechanisms, Applications and Challenges. Curr Drug Deliv 2020; 16:887-901. [PMID: 31660815 DOI: 10.2174/1567201816666191029122740] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/05/2019] [Accepted: 10/15/2019] [Indexed: 02/06/2023]
Abstract
Blood-brain barrier (BBB) provides restrictions for the transportation of various therapeutic agents to the brain. Efforts to directly target the brain by olfactory as well as trigeminal nerve pathway, bypassing BBB, have grown significantly in recent times. The intranasal route of transportation of the drug encompasses ability for the delivery of drug directly to the brain, improves site-specificity in the brain and avoids systemic side effects. In the current era, novel drug delivery systems are useful tools for targeting the brain without providing any harmful effects in nasal mucosa as well as the central nervous system. The complex structure of nasal cavity, mucociliary clearance, degradation by the enzymes present in nasal cavity and pathological conditions like rhinitis, common cold, etc. are the major disputes for nasal drug delivery. The use of nanotechnological approaches like solid lipid nanoparticles, polymeric nanoparticles, nanoemulsions, liposomes and polymeric micelles provides the ability to overcome these barriers. There are several emerging nasal drug delivery technologies produced by various pharmaceutical companies to conquer these hurdles. This review tries to address the recent developments in the area of direct drug delivery to the brain through the nasal route.
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Affiliation(s)
- Kanchan Kashyap
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Raebareli, India
| | - Rahul Shukla
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Raebareli, India
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18
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von Blomberg A, Kay L, Knake S, Fuest S, Zöllner JP, Reif PS, Herrmann E, Balaban Ü, Schubert-Bast S, Rosenow F, Strzelczyk A. Efficacy, Tolerability, and Safety of Concentrated Intranasal Midazolam Spray as Emergency Medication in Epilepsy Patients During Video-EEG Monitoring. CNS Drugs 2020; 34:545-553. [PMID: 32219682 PMCID: PMC7198639 DOI: 10.1007/s40263-020-00720-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An efficient, well tolerated, and safe emergency treatment with a rapid onset of action is needed to prevent seizure clusters and to terminate prolonged seizures and status epilepticus. OBJECTIVES This study aimed to examine the efficacy, tolerability, and safety of intranasal midazolam (in-MDZ) spray in clinical practice. METHODS In this retrospective, multicenter observational study, we evaluated all patients with peri-ictal application of in-MDZ during video-EEG monitoring at the epilepsy centers in Frankfurt and Marburg between 2 014 and 2017. For every patient, we analyzed the recurrence of any seizure or generalized tonic-clonic seizures after index seizures with and without in-MDZ administration. Treatment-emergent adverse events (TEAEs) were also evaluated. RESULTS In-MDZ was used in 243 patients with epilepsy (mean age 35.5 years; range 5-76 years; 46.5% female) for treatment of 459 seizures. A median dose of in-MDZ 5 mg (i.e., two puffs; range 2.5-15 mg) was administered within a median time from EEG seizure onset until in-MDZ application of 1.18 min [interquartile range (IQR) 1.27], while median time from clinical seizure onset until in-MDZ administration was 1.08 min (IQR 1.19). In-MDZ was given within 1 min after EEG seizure onset in 171 seizures. An intraindividual comparison of seizures with and without application of in-MDZ was feasible in 171 patients, demonstrating that in-MDZ reduced the occurrence of any (Cox proportional-hazard model p < 0.001) and generalized tonic-clonic seizure (Cox proportional-hazard model p = 0.0167) over a period of 24 h. The seizure-free timespan was doubled from a median of 5.0 h in controls to a median of 10.67 h after in-MDZ administration. We additionally clustered in-MDZ administrations for the 119 patients who received in-MDZ more than once, comparing them with the index cases without in-MDZ. Even when considering subsequent seizures with in-MDZ administration, a patient receiving in-MDZ is still half as likely to incur another seizure in the upcoming 24 h as compared with when the same patient does not receive in-MDZ (hazard ratio 0.50; 95% CI 0.42-0.60; p < 0.01). In-MDZ was well tolerated without major adverse events. The most common side effects were irritation of the nasal mucosa [37 cases (8.1%)], prolonged sedation [26 cases (5.7%)], and nausea and vomiting [12 cases (2.6%)]. A decline in oxygen saturation was measured after 78 seizures (17%). CONCLUSION We conclude that in-MDZ is a safe and efficient treatment option to prevent short-term recurrence of seizures. In-MDZ can be administered very quickly by trained staff within 1-2 min after seizure onset. No major cardiocirculatory or respiratory adverse events were observed.
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Affiliation(s)
- Anemone von Blomberg
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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
| | - Lara Kay
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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 Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Sven Fuest
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Ümniye Balaban
- Institute for Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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 Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, 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.
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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19
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Huebinger RM, Zaidi HQ, Tataris KL, Weber JM, Pearlman KS, Markul E, Stein-Spencer L, Richards CT. Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies. West J Emerg Med 2020; 21:677-683. [PMID: 32421519 PMCID: PMC7234702 DOI: 10.5811/westjem.2020.3.45552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/08/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration. Methods We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014–June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene’s test for assessing variance among study groups, and t-test to evaluate effectiveness based on route. Results In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24–42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient’s condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24). Conclusion A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.
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Affiliation(s)
- Ryan M Huebinger
- McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Department of Emergency Medicine, Houston, Texas
| | - Hashim Q Zaidi
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Katie L Tataris
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Joseph M Weber
- Chicago Emergency Medical Services System, Chicago, Illinois.,John H. Stroger, Jr., Hospital of Cook County, Department of Emergency Medicine, Chicago, Illinois
| | - Kenneth S Pearlman
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Eddie Markul
- Chicago Emergency Medical Services System, Chicago, Illinois.,Advocate Illinois Masonic Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Leslee Stein-Spencer
- Chicago Emergency Medical Services System, Chicago, Illinois.,Illinois Department of Public Health, Springfield, Illinois
| | - Christopher T Richards
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois.,Northwestern Feinberg School of Medicine Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, Illinois.,University of Cincinnati School of Medicine, Division of EMS, Department of Emergency Medicine, Cincinnati, Ohio
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20
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Charalambous M, Volk HA, Tipold A, Erath J, Huenerfauth E, Gallucci A, Gandini G, Hasegawa D, Pancotto T, Rossmeisl JH, Platt S, De Risio L, Coates JR, Musteata M, Tirrito F, Cozzi F, Porcarelli L, Corlazzoli D, Cappello R, Vanhaesebrouck A, Broeckx BJG, Van Ham L, Bhatti SFM. Comparison of intranasal versus intravenous midazolam for management of status epilepticus in dogs: A multi-center randomized parallel group clinical study. J Vet Intern Med 2019; 33:2709-2717. [PMID: 31580527 PMCID: PMC6872604 DOI: 10.1111/jvim.15627] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background The intranasal (IN) route for rapid drug administration in patients with brain disorders, including status epilepticus, has been investigated. Status epilepticus is an emergency, and the IN route offers a valuable alternative to other routes, especially when these fail. Objectives To compare IN versus IV midazolam (MDZ) at the same dosage (0.2 mg/kg) for controlling status epilepticus in dogs. Animals Client‐owned dogs (n = 44) with idiopathic epilepsy, structural epilepsy, or epilepsy of unknown origin manifesting as status epilepticus. Methods Randomized parallel group clinical trial. Patients were randomly allocated to the IN‐MDZ (n = 21) or IV‐MDZ (n = 23) group. Number of successfully treated cases (defined as seizure cessation within 5 minutes and lasting for ≥10 minutes), seizure cessation time, and adverse effects were recorded. Comparisons were performed using the Fisher's exact and Wilcoxon rank sum tests with statistical significance set at α < .05. Results IN‐MDZ and IV‐MDZ successfully stopped status epilepticus in 76% and 61% of cases, respectively (P = .34). The median seizure cessation time was 33 and 64 seconds for IN‐MDZ and IV‐MDZ, respectively (P = .63). When the time to place an IV catheter was taken into account, IN‐MDZ (100 seconds) was superior (P = .04) to IV‐MDZ (270 seconds). Sedation and ataxia were seen in 88% and 79% of the dogs treated with IN‐MDZ and IV‐MDZ, respectively. Conclusions and Clinical Importance Both routes are quick, safe, and effective for controlling status epilepticus. However, the IN route demonstrated superiority when the time needed to place an IV catheter was taken into account.
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Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Andrea Tipold
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Johannes Erath
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Enrice Huenerfauth
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Antonella Gallucci
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Gualtiero Gandini
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Daisuke Hasegawa
- Department of Clinical Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan
| | - Theresa Pancotto
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia
| | - John H Rossmeisl
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia
| | - Simon Platt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Luisa De Risio
- Small Animal Referral Centre, Animal Health Trust, Newmarket, United Kingdom
| | - Joan R Coates
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
| | - Mihai Musteata
- Department of Clinical Veterinary Medicine, Faculty of Veterinary Medicine, University of Agricultural Science and Veterinary Medicine Iasi, Iasi, Romania
| | | | | | | | | | | | - An Vanhaesebrouck
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Bart J G Broeckx
- Department of Nutrition, Genetics and Ethology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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21
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Press CA, Chapman KE. Status epilepticus. Neurology 2019; 92:931-932. [DOI: 10.1212/wnl.0000000000007494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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22
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Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31:533-541. [PMID: 31041848 DOI: 10.1111/1742-6723.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/30/2022]
Abstract
Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
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Affiliation(s)
- Pieter F Fouche
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, South Africa
| | | | - Malcolm Boyle
- School of Medicine, Griffith University, Griffith, Queensland, Australia
| | - Stephen Bernard
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
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A hospital-based study on caregiver preferences on acute seizure rescue medications in pediatric patients with epilepsy: Intranasal midazolam versus rectal diazepam. Epilepsy Behav 2019; 92:53-56. [PMID: 30611934 DOI: 10.1016/j.yebeh.2018.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/09/2018] [Accepted: 12/09/2018] [Indexed: 11/22/2022]
Abstract
RATIONALE About 20 per 100,000 children have convulsive status epilepticus every year, a life-threatening condition. Benzodiazepines are the first-line treatment for prolonged and recurrent seizures. Our study was designed to gain understanding of caregiver perception of acute seizure treatments. METHODS Our project uses a cross-sectional survey study design using the electronic medical record and a survey at a large academic tertiary children's medical center. Subjects were patients with epilepsy prescribed intranasal (IN) midazolam and/or per rectum (PR) diazepam. The survey was administered to caregivers of children with epilepsy regarding information on the comfort, efficacy, ease of use, and time of administration for patients receiving both abortive seizure medications. Exact binomial tests were employed to determine whether or not differences in caregiver preference exist. RESULTS One hundred and sixty responses were obtained. Incomplete and duplicate surveys were excluded, leaving 153 responses. Of those responses, 59 respondents reported administering both medications. Among parents who expressed a preference for one medication over the other, more parents felt overall greater comfort with IN midazolam compared with rectal diazepam (p = 0.0004 and p = 0.001), IN midazolam was perceived as easier to use (68%, p = 0.0038 and 74%, p = 0.0004) and more effective (87%, p < 0.0001) than rectal diazepam. Intranasal midazolam was found to be superior to rectal diazepam in several other categories as well. CONCLUSIONS These parents of children with epilepsy report increased ease of use, comfort, and efficacy with IN midazolam as compared with rectal diazepam suggesting that a readily available form of IN midazolam would be well received in the pediatric population.
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Nunley S, Glynn P, Rust S, Vidaurre J, Albert DVF, Patel AD. Healthcare Utilization Characteristics for Intranasal Midazolam Versus Rectal Diazepam. J Child Neurol 2018; 33:158-163. [PMID: 29233042 DOI: 10.1177/0883073817744696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
To investigate connections between patient demographics, health care utilization, prescription use, and refills for patients using intranasal midazolam, per rectum diazepam, or both. A retrospective cohort contained patients with epilepsy prescribed intranasal midazolam, per rectum diazepam, or both. We analyzed number of emergency department visits, ambulance services, urgent care visits, and unplanned hospitalizations. A total of 5458 patients were identified. Patients on intranasal midazolam had on average 1.53 fewer emergency department visits (95% confidence interval 1.16-1.89, P < .0001), 0.29 fewer uses of ambulance services (95% confidence interval 0.17-0.41, P < .0001), and 0.60 fewer urgent care visits (95% confidence interval 0.36-0.83, P < .0001) compared to patients in the per rectum diazepam group. Patients with commercial insurance were more likely to have intranasal midazolam prescription (odds ratio = 1.73, 95% confidence interval 1.42-2.11, P < .0001). The results substantiate the cost-effective benefits of prescribing intranasal midazolam compared to per rectum diazepam because several aspects of health care utilization were decreased in those using intranasal midazolam.
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Affiliation(s)
- Sunjay Nunley
- 1 Division of Neurology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter Glynn
- 1 Division of Neurology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Steve Rust
- 2 Research Information Solutions & Innovation, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jorge Vidaurre
- 1 Division of Neurology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dara V F Albert
- 1 Division of Neurology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Anup D Patel
- 1 Division of Neurology, Nationwide Children's Hospital, Columbus, Ohio, USA
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Perna SJ, Rhinewalt JM, Currie ER. Seizing the Opportunity: Exploring Barriers to Use of Transmucosal Midazolam in Hospice Patients. J Palliat Med 2018; 21:674-677. [PMID: 29303424 DOI: 10.1089/jpm.2017.0438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Status epilepticus seizures are distressing events for hospice and palliative care patients. Currently, rectal diazepam is the only abortive therapy approved by the U.S. Food and Drug Administration for seizures occurring out of hospital. However, transmucosal (buccal and intranasal) midazolam hydrochloride is a less expensive, equally effective, and a more socially acceptable alternative. OBJECTIVE To explore the use of transmucosal midazolam in out-of-hospital hospice patients in the State of Alabama. DESIGN A cross-sectional survey was used explore hospice providers' knowledge and use of transmucosal midazolam in clinical practice within Alabama. Setting Subjects: Hospice providers (physicians, nurses, and administrators) in the State of Alabama (n = 27). MEASUREMENTS An electronic survey was used to elicit transmucosal midazolam use among hospice providers. RESULTS Transmucosal midazolam has been documented throughout the literature and reported by expert clinicians as an efficacious, safe, and appropriate pharmaceutical intervention for the abortive treatment of seizures in adult and pediatric out-of-hospital patients. However, barriers to the use of transmucosal midazolam with hospice patients included unfamiliarity with transmucosal route and lack of provider orders. None of the participants reported transmucosal midazolam use in out-of-hospital hospice settings. CONCLUSION Evidence in the literature supports the use of transmucosal midazolam; however, further research is necessary to understand and address barriers in a more diverse and generalizable population.
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Affiliation(s)
- Samuel J Perna
- 1 Center for Palliative and Supportive Care, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - James M Rhinewalt
- 2 The Internal Medicine and Pediatric Clinic of New Albany , New Albany, Mississippi
| | - Erin R Currie
- 3 School of Nursing, University of Alabama at Birmingham , Birmingham, Alabama
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Mellion SA, Bourne D, Brou L, Brent A, Adelgais K, Galinkin J, Wathen J. Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair. J Emerg Med 2017; 53:397-404. [PMID: 28992870 DOI: 10.1016/j.jemermed.2017.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing. OBJECTIVES We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair. METHODS Children 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events. RESULTS Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients. CONCLUSIONS Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.
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Affiliation(s)
- Sarah A Mellion
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - David Bourne
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Colorado
| | - Lina Brou
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Alison Brent
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Kathleen Adelgais
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Jeffrey Galinkin
- Department of Anesthesiology, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Joseph Wathen
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
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Berg AK, Myrvik MJ, Van Ess PJ. Pharmacokinetics, pharmacodynamics, and tolerability of USL261, midazolam nasal spray: Randomized study in healthy geriatric and non-geriatric adults. Epilepsy Behav 2017; 71:51-59. [PMID: 28544992 DOI: 10.1016/j.yebeh.2017.02.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/10/2017] [Indexed: 02/01/2023]
Abstract
AIM Characterize pharmacokinetics, pharmacodynamics, and safety/tolerability of USL261 in geriatric adults to inform its potential for treating bouts of increased seizure activity. METHODS Phase 1, randomized, double-blind, 2-way crossover study in healthy geriatric (≥65years; n=18) and non-geriatric (18-40years; n=12) adults evaluated single USL261 doses (2.5 and 5.0mg) administered intranasally. Pharmacokinetic parameters were estimated for midazolam and 1-hydroxymidazolam (active metabolite), including area under the plasma concentration-time curve (AUC), maximum plasma concentration (Cmax), time to Cmax (Tmax), and half-life (t1/2). Stanford Sleepiness Scale and Observer's Assessment of Alertness/Sedation assessed sedation; Digit-Symbol Substitution Test assessed psychomotor performance. RESULTS Midazolam exposure and plasma concentrations were higher in geriatric versus non-geriatric adults (geometric mean AUC0-∞ [ng*h/mL] 2.5mg: 70 vs 54, respectively; 5.0mg: 157 vs 110; Cmax [ng/mL] 2.5mg: 27.1 vs 22.5; 5.0mg: 55.8 vs 46.1). USL261 was rapidly absorbed, with no differences in median Tmax (14.5-17.3min); mean t1/2 was longer in geriatric subjects. Similar age-related trends were observed for 1-hydroxymidazolam. Mean maximum observed pharmacodynamic effects were not significantly different between age groups, though were more pronounced following 5.0 versus 2.5mg (P<.05); return to baseline was generally achieved within 4h. USL261 was generally well tolerated, with similar adverse event rates between age groups. CONCLUSIONS Despite increased midazolam exposure in geriatric subjects, there were no differences between age groups in pharmacodynamic effects or adverse event rates. USL261 was rapidly absorbed and pharmacodynamic effects returned to baseline within ~4h, regardless of age. Dose-dependent pharmacokinetic and maximum pharmacodynamic effects were observed. Overall, pharmacokinetic findings for USL261 were similar to studies evaluating intravenous midazolam, whereas pharmacodynamic effects were less pronounced in the elderly than previously reported.
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Affiliation(s)
| | | | - Peter J Van Ess
- Upsher-Smith Laboratories, Inc., Maple Grove, MN, United States.
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Charalambous M, Bhatti SFM, Van Ham L, Platt S, Jeffery ND, Tipold A, Siedenburg J, Volk HA, Hasegawa D, Gallucci A, Gandini G, Musteata M, Ives E, Vanhaesebrouck AE. Intranasal Midazolam versus Rectal Diazepam for the Management of Canine Status Epilepticus: A Multicenter Randomized Parallel-Group Clinical Trial. J Vet Intern Med 2017; 31:1149-1158. [PMID: 28543780 PMCID: PMC5508334 DOI: 10.1111/jvim.14734] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 02/28/2017] [Accepted: 04/12/2017] [Indexed: 01/22/2023] Open
Abstract
Background Intranasal administration of benzodiazepines has shown superiority over rectal administration for terminating emergency epileptic seizures in human trials. No such clinical trials have been performed in dogs. Objective To evaluate the clinical efficacy of intranasal midazolam (IN‐MDZ), via a mucosal atomization device, as a first‐line management option for canine status epilepticus and compare it to rectal administration of diazepam (R‐DZP) for controlling status epilepticus before intravenous access is available. Animals Client‐owned dogs with idiopathic or structural epilepsy manifesting status epilepticus within a hospital environment were used. Dogs were randomly allocated to treatment with IN‐MDZ (n = 20) or R‐DZP (n = 15). Methods Randomized parallel‐group clinical trial. Seizure cessation time and adverse effects were recorded. For each dog, treatment was considered successful if the seizure ceased within 5 minutes and did not recur within 10 minutes after administration. The 95% confidence interval was used to detect the true population of dogs that were successfully treated. The Fisher's 2‐tailed exact test was used to compare the 2 groups, and the results were considered statistically significant if P < .05. Results IN‐MDZ and R‐DZP terminated status epilepticus in 70% (14/20) and 20% (3/15) of cases, respectively (P = .0059). All dogs showed sedation and ataxia. Conclusions and Clinical Importance IN‐MDZ is a quick, safe and effective first‐line medication for controlling status epilepticus in dogs and appears superior to R‐DZP. IN‐MDZ might be a valuable treatment option when intravenous access is not available and for treatment of status epilepticus in dogs at home.
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Affiliation(s)
- M Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.,Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - S F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - L Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - S Platt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - N D Jeffery
- Small Animal Department, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX
| | - A Tipold
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - J Siedenburg
- Clinical Department for Small Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria
| | - H A Volk
- Department of Clinical Science and Services, Royal Veterinary College, London, UK
| | - D Hasegawa
- Department of Clinical Veterinary Medicine, Nippon Veterinary and Life Science University, Tokyo, Japan
| | - A Gallucci
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - G Gandini
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - M Musteata
- Department of Clinical Veterinary Medicine, Faculty of Veterinary Medicine, University of Agricultural Science and Veterinary Medicine Iasi, Iasi, Romania
| | - E Ives
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK.,Anderson Moores Veterinary Specialists, Winchester, Hampshire, UK
| | - A E Vanhaesebrouck
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
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Silverman EC, Sporer KA, Lemieux JM, Brown JF, Koenig KL, Gausche-Hill M, Rudnick EM, Salvucci AA, Gilbert GH. Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations. West J Emerg Med 2017; 18:419-436. [PMID: 28435493 PMCID: PMC5391892 DOI: 10.5811/westjem.2016.12.32066] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/14/2016] [Accepted: 12/30/2016] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California. METHODS We performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately. RESULTS Protocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered. CONCLUSION Protocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Eric C. Silverman
- University of California, San Francisco, School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Karl A. Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Justin M. Lemieux
- Stanford School of Medicine, Department of Emergency Medicine, Stanford, California
| | - John F. Brown
- University of California, San Francisco, School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Kristi L. Koenig
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Marianne Gausche-Hill
- University of California, Los Angeles, David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California
| | | | | | - Greg H. Gilbert
- Stanford School of Medicine, Department of Emergency Medicine, Stanford, California
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Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med 2017; 70:203-211. [PMID: 28366351 DOI: 10.1016/j.annemergmed.2017.02.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/10/2017] [Accepted: 02/15/2017] [Indexed: 11/15/2022]
Abstract
The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.
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Affiliation(s)
- Megan A Rech
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL; Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL.
| | - Brian Barbas
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
| | - Whitney Chaney
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
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Alleviation of Oxidative Damage and Involvement of Nrf2-ARE Pathway in Mesodopaminergic System and Hippocampus of Status Epilepticus Rats Pretreated by Intranasal Pentoxifylline. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:7908072. [PMID: 28386312 PMCID: PMC5366206 DOI: 10.1155/2017/7908072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/06/2017] [Accepted: 02/21/2017] [Indexed: 12/17/2022]
Abstract
The current studies were aimed at evaluating the efficacy of intranasal pentoxifylline (Ptx) pretreatment in protecting mesodopaminergic system and hippocampus from oxidative damage of lithium-pilocarpine induced status epilepticus (SE) and the involvement of nuclear factor erythroid 2-related factor 2- (Nrf2-) antioxidant response elements pathway. Pentoxifylline was administered to rats intranasally or intraperitoneally 30 minutes before inducing SE. Our results showed the impaired visuospatial memory, the defected mesodopaminergic system, and the oxidative damage and the transient activation of Nrf2 in SE rats. The transient activation of Nrf2 in SE rats was enhanced by Ptx pretreatment, which was followed by the upregulation of heme oxygenase-1 and NAD(P)H:quinone oxidoreductase-1. Ptx pretreatment to SE rats significantly suppressed the epileptic seizures, decreased the levels of lipid peroxide and malondialdehyde, and elevated the ratio of reduced glutathione/oxidized glutathione. Compared with intraperitoneal injection, intranasal Ptx delivery completely restored the visuospatial memory and the activity of mesodopaminergic system in SE rats. Intranasal administration of Ptx may hopefully become a noninvasive, painless, and easily administered option for epileptic patients.
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Abstract
Benzodiazepines represent the first-line treatment for the acute management of epileptic seizures and status epilepticus. The emergency use of benzodiazepines must be timely, and because most seizures occur outside of the hospital environment, there is a significant need for delivery methods that are easy for nonclinical caregivers to use and administer quickly and safely. In addition, the ideal route of administration should be reliable in terms of absorption. Rectal diazepam is the only licensed formulation in the USA, whereas rectal diazepam and buccal midazolam are currently licensed in the EU. However, the sometimes unpredictable absorption with rectal and buccal administration means they are not ideal routes. Several alternative routes are currently being explored. This is a narrative review of data about delivery methods for benzodiazepines alternative to the intravenous and oral routes for the acute treatment of seizures. Unconventional delivery options such as direct delivery to the central nervous system or inhalers are reported. Data show that intranasal diazepam or midazolam and the intramuscular auto-injector for midazolam are as effective as rectal or intravenous diazepam. Head-to-head comparisons with buccal midazolam are urgently needed. In addition, the majority of trials focused on children and adolescents, and further trials in adults are warranted.
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Affiliation(s)
- Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK.
- Institute of Medical and Biomedical Sciences, St George's University of London, London, UK.
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Implementation of Intranasal Midazolam for Prolonged Seizures in a Child Neurology Practice. J Neurosci Nurs 2016; 48:315-321. [DOI: 10.1097/jnn.0000000000000234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kapoor M, Cloyd JC, Siegel RA. A review of intranasal formulations for the treatment of seizure emergencies. J Control Release 2016; 237:147-59. [PMID: 27397490 DOI: 10.1016/j.jconrel.2016.07.001] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 12/20/2022]
Abstract
Epileptic seizure emergencies are life-threatening conditions, which in their most severe form, status epilepticus, have a high mortality rate if not quickly terminated. Treatment requires rapid delivery of anti-epileptics such as benzodiazepines to the brain. The nasal route is attractive due to its non-invasiveness, potential for direct nose to brain delivery, high vascularity, relatively large absorptive surface area, and avoidance of intestinal/liver metabolism. However, the limited volume of the nasal cavity and poor water solubility of anti-epileptics restrict absorption, leading to insufficient therapeutic brain levels. This review covers various formulation approaches adopted to improve nasal delivery of drugs, especially benzodiazepines, used to treat seizure emergencies. Other general topics such as nasal anatomy, challenges to nasal delivery, and drug/formulation considerations for nose to brain delivery are also discussed.
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Affiliation(s)
- Mamta Kapoor
- Department of Pharmaceutics, University of Minnesota, Minneapolis, MN, USA
| | - James C Cloyd
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA; Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Ronald A Siegel
- Department of Pharmaceutics, University of Minnesota, Minneapolis, MN, USA; Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA.
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Corrigan M, Wilson SS, Hampton J. Safety and efficacy of intranasally administered medications in the emergency department and prehospital settings. Am J Health Syst Pharm 2016; 72:1544-54. [PMID: 26346210 DOI: 10.2146/ajhp140630] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety and efficacy of medications that may be administered via the intranasal route in adult patients in the prehospital and emergency department (ED) settings are reviewed. SUMMARY When medications of appropriate molecular character and concentration are delivered intranasally, they are quickly transported across this capillary network and delivered to the systemic circulation, thereby avoiding the absorption-limiting effects of first-pass metabolism. Therapeutic drug concentrations are rapidly attained in the cerebrospinal fluid, making intranasal administration a very effective mode of delivery. To optimize the bioavailability of intranasally administered drugs, providers must minimize the barriers to absorption, minimize the volume by maximizing the concentration, maximize the absorptive surface of the nasal mucosa, and use a delivery system that maximizes drug dispersion and minimizes drug runoff. Medications can be instilled into the nasal cavity with syringes or droppers by applying a few drops at a time or via atomization. The intranasal route of administration may be advantageous for patients who require analgesia, sedation, anxiolysis, termination of seizures, hypoglycemia management, narcotic reversal, and benzodiazepine reversal in the ED or prehospital settings. Medications that have been studied in the adult population include fentanyl, sufentanil, hydromorphone, ketamine, midazolam, haloperidol, naloxone, flumazenil, and glucagon. The available data do indicate, however, that intranasal administration may be a safe, effective, and well tolerated route of administration. CONCLUSION Based on the published literature, intranasal administration of fentanyl, sufentanil, ketamine, hydromorphone, midazolam, haloperidol, naloxone, glucagon, and, in limited cases, flumazenil may be a safe, effective, and well-tolerated alternative to intramuscular or intravenous administration in the prehospital and ED settings.
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Affiliation(s)
- Megan Corrigan
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City
| | - Suprat Saely Wilson
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City
| | - Jeremy Hampton
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City.
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Sahin S, Yazici MU, Ayar G, Karalok ZS, Arhan EP. Seizures in a Pediatric Intensive Care Unit: A Prospective Study. J Trop Pediatr 2016; 62:94-100. [PMID: 26892503 PMCID: PMC4886111 DOI: 10.1093/tropej/fmv076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The aim of the research is to determine the etiology and clinical features of seizures in critically ill children admitted to a pediatric intensive care unit (PICU). METHODS A total of 203 children were admitted from June 2013 to November 2013; 45 patients were eligible. Age ranged from 2 months to 19 years. Seizures were organized as epileptic or acute symptomatic. Pediatric risk of mortality score III, Glasgow coma scale, risk factors, coexistent diagnosis, medications administered before admission, type and duration of seizures, drugs used, requirement and duration of mechanical ventilation, length of stay and neuroimaging findings were collected as demographic data prospectively. RESULTS The male-female ratio was 0.8. Mean age was 5.4. The most common causes of seizures were acute symptomatic. Most frequent coexistent diagnosis was infectious diseases, and 53.3% had recurrent seizures. Medications were administered to 51.1% of the patients before admission. Seizures were focal in 21 (46.7%), generalized in 11 (24.4%) and 13 (28.9%) had status epilepticus. Intravenous midazolam was first-line therapy in 48.9%. Acute symptomatic seizures were usually new-onset, and duration was shorter. Epileptic seizures tended to be recurrent and were likely to progress to status epilepticus. However, type of seizures did not change severity of the disease. Also, laboratory test results, medications administered before admission, requirement and duration of ventilation, mortality and length of stay were not significant between epileptic/acute symptomatic patients. CONCLUSION Seizures in critically ill children, which may evolve into status epilepticus, is an important condition that requires attention regardless of cause. Intensified educational programs for PICU physicians and international guidelines are necessary for a more efficient approach to children with seizures.
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Affiliation(s)
- Sanliay Sahin
- Pediatric Intensive Care Unit, Ankara Children's, Hematology Oncology Education and Research Hospital, Ankara, 06110 Turkey
| | - Mutlu Uysal Yazici
- Pediatric Intensive Care Unit, Hacettepe University School of Medicine, Ankara, 06110 Turkey
| | - Ganime Ayar
- Pediatric Intensive Care Unit, Ankara Children's, Hematology Oncology Education and Research Hospital, Ankara, 06110 Turkey
| | - Zeynep Selen Karalok
- Pediatric Neurology Division, Ankara Children's, Hematology Oncology Education and Research Hospital, Ankara, 06110 Turkey
| | - Ebru Petek Arhan
- Pediatric Neurology Division, Gazi University School of Medicine, Ankara, 06110 Turkey
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Roundy LM, Filloux FM, Kerr L, Rimer A, Bonkowsky JL. Seizure Action Plans Do Not Reduce Health Care Utilization in Pediatric Epilepsy Patients. J Child Neurol 2016; 31:433-8. [PMID: 26245799 PMCID: PMC4744144 DOI: 10.1177/0883073815597755] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 06/29/2015] [Indexed: 11/17/2022]
Abstract
Management of pediatric epilepsy requires complex coordination of care. We hypothesized that an improved seizure management care plan would reduce health care utilization and improve outcomes. The authors conducted a cohort study with historical controls of 120 epilepsy patients before and after implementation of a "Seizure Action Plan." The authors evaluated for differences in health care utilization including emergency department visits, hospitalizations, clinic visits, telephone calls, and the percentage of emergency department visits that resulted in hospitalization in patients who did or did not have a Seizure Action Plan. The authors found that there was no decrease in these measures of health care utilization, and in fact the number of follow-up clinic visits was increased in the group with Seizure Action Plans (4.2 vs 3.3, P = .006). However, the study was underpowered to detect smaller differences. This study suggests that pediatric epilepsy quality improvement measures may require alternative approaches to reduce health care utilization and improve outcomes.
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Affiliation(s)
- Lindsi M Roundy
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Francis M Filloux
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lynne Kerr
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Alyssa Rimer
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Bancke LL, Dworak HA, Rodvold KA, Halvorsen MB, Gidal BE. Pharmacokinetics, pharmacodynamics, and safety of USL261, a midazolam formulation optimized for intranasal delivery, in a randomized study with healthy volunteers. Epilepsia 2015; 56:1723-31. [PMID: 26332539 DOI: 10.1111/epi.13131] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare the pharmacokinetics, pharmacodynamics, and tolerability of USL261, a midazolam formulation optimized for intranasal delivery, versus midazolam intravenous (IV) solution administered intranasally (MDZ-inj IN) or intravenously (MDZ-inj IV) in healthy adults. METHODS In this phase 1, five-way crossover, open-label study, 25 healthy adults (aged 18-42 years) were randomly assigned to receive 2.5, 5.0, and 7.5 mg USL261; 2.5 mg MDZ-inj IV; and 5.0 mg MDZ-inj IN. Blood samples were collected for 12 h post dose to determine pharmacokinetic profiles. Pharmacodynamic assessments of sedation and psychomotor impairment also were conducted. Adverse events, oxygen saturation, and vital signs were recorded. RESULTS Increasing USL261 dose corresponded with increases in midazolam area under the concentration time curve (AUC) and maximum observed plasma concentration (Cmax ), with all doses demonstrating rapid median time to Cmax (Tmax ; 10-12 min). USL261 also demonstrated increased absorption, with a 134% relative bioavailability, compared with the same MDZ-inj IN dose. USL261 was associated with dose-dependent increases in sedation and psychomotor impairment (p < 0.05); however, these effects lasted <4 h and generally did not differ from MDZ-inj IN or MDZ-inj IV at comparable doses. No serious adverse events (SAEs) or deaths were reported, and no treatment-emergent adverse events (TEAEs) led to study discontinuation. SIGNIFICANCE Compared with intranasal delivery of a midazolam formulation intended for IV delivery, USL261, optimized for intranasal administration demonstrated improved bioavailability with similar pharmacodynamic effects. Therefore, USL261 may be a preferable alternative to the currently approved rectal diazepam treatment for intermittent bouts of increased seizure activity.
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Affiliation(s)
- Lindy L Bancke
- Upsher-Smith Laboratories, Inc, Maple Grove, Minnesota, U.S.A
| | | | - Keith A Rodvold
- Colleges of Pharmacy and Medicine, University of Illinois at Chicago, Chicago, Illinois, U.S.A
| | | | - Barry E Gidal
- Department of Neurology, School of Pharmacy, University of Wisconsin, Madison, Wisconsin, U.S.A
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Alford EL, Wheless JW, Phelps SJ. Treatment of Generalized Convulsive Status Epilepticus in Pediatric Patients. J Pediatr Pharmacol Ther 2015; 20:260-89. [PMID: 26380568 PMCID: PMC4557718 DOI: 10.5863/1551-6776-20.4.260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Generalized convulsive status epilepticus (GCSE) is one of the most common neurologic emergencies and can be associated with significant morbidity and mortality if not treated promptly and aggressively. Management of GCSE is staged and generally involves the use of life support measures, identification and management of underlying causes, and rapid initiation of anticonvulsants. The purpose of this article is to review and evaluate published reports regarding the treatment of impending, established, refractory, and super-refractory GCSE in pediatric patients.
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Affiliation(s)
- Elizabeth L. Alford
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| | - James W. Wheless
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Pediatric Neurology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Neuroscience Center and Comprehensive Epilepsy Program, Memphis, Tennessee
| | - Stephanie J. Phelps
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
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Abstract
The case of a 2-month-old boy with previously diagnosed tetralogy of Fallot who was brought to the emergency department with a hypercyanotic spell is described. Because partly of the difficulty of intravenous placement, especially in an infant crying with marked hypernea and deeply cyanotic, intranasal midazolam was administered. Before 3 minutes of hypernea terminated increasing the oxygen saturation successfully and intravenous line was easily placed with the baby remaining in calm. Sedation is an important step in the management of patients with cyanotic spells. Intranasal midazolam offers an alternative use as an initial method of calming the child that was effective in a patient with a severe cyanotic spell because of tetralogy of Fallot in the emergency department.
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Verrotti A, Milioni M, Zaccara G. Safety and efficacy of diazepam autoinjector for the management of epilepsy. Expert Rev Neurother 2015; 15:127-33. [DOI: 10.1586/14737175.2015.1003043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
OBJECTIVE This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-hospital seizure. METHODS This is a retrospective study of pediatric patients with seizure transported by paramedics to the pediatric emergency department (PED) of a tertiary center from July 2008 to June 2009. Patients with traumatic injury and those with another diagnosis after PED evaluation were excluded. We evaluated the effect of field diazepam and other potential risk factors on the occurrence of apnea, defined as the need for airway management, that is, bag-mask ventilation by paramedics or bag-mask ventilation or intubation by PED staff within 30 minutes of arrival. RESULTS There were 336 pediatric patients meeting inclusion criteria. The median age was 1.9 years (interquartile range,1.3-3.0 years); 193 patients (57%) were male. Fifty-four patients (16%) were treated with diazepam before PED arrival. There were 28 apneic events (8.3%). The adjusted relative risk for apnea given diazepam in the field by any route was 10.2 (95% confidence interval, 3.9-21.8; P < 0.0001), adjusted for age and seizure on arrival. Persistent seizure on PED arrival was also highly associated with apnea, with an adjusted relative risk of 15.8 (95% confidence interval, 6.5-28.9; P < 0.0001). CONCLUSIONS Field treatment with diazepam and seizing at the time of PED arrival are associated with the occurrence of apnea in children 0 to 5 years of age with out-of-hospital seizure. Larger studies are needed to determine what other factors may contribute to this risk.
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Henney HR, Sperling MR, Rabinowicz AL, Bream G, Carrazana EJ. Assessment of pharmacokinetics and tolerability of intranasal diazepam relative to rectal gel in healthy adults. Epilepsy Res 2014; 108:1204-11. [PMID: 24934774 DOI: 10.1016/j.eplepsyres.2014.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/21/2014] [Accepted: 04/28/2014] [Indexed: 11/27/2022]
Abstract
Diazepam rectal gel (RG) is currently the only approved rescue therapy for outpatient management of seizure clusters in the United States. There is an unmet medical need for an alternative rescue therapy for seizure clusters that is effective, and more convenient to administer with a socially acceptable method of delivery. An intranasal diazepam formulation has been developed, and this study evaluates the tolerability and bioavailability of diazepam nasal spray (NS) relative to an equivalent dose of diazepam-RG in healthy adults. Twenty-four healthy adults were enrolled in a phase 1, open-label, 3-period crossover study. Plasma diazepam and metabolite concentrations were measured by serial sampling. Dose proportionality for 5- and 20-mg intranasal doses and the bioavailability of 20mg diazepam-NS relative to 20mg diazepam-RG were assessed by maximum plasma concentration (Cmax) and systemic exposure parameters (AUC0-∞ and AUC0-24). The mean Cmax values for 20mg diazepam-NS and 20mg diazepam-RG were 378 ± 106 and 328 ± 152 ng/mL, achieved at 1.0 and 1.5h, respectively. Subjects administered intranasal and rectal gel formulations experienced nasal and rectal leakage, respectively. Diazepam absorption following intranasal administration was consistent but 3 subjects with diazepam-RG had low plasma drug levels at the earliest assessment of 5 min, due to poor retention, and were excluded from analysis. Excluding them, the treatment ratios (20mg diazepam-NS:20mg diazepam-RG) and 90% confidence intervals for diazepam Cmax and AUC0-24 were 0.98 (0.85-1.14) and 0.89 (0.80-0.98), respectively, suggesting that the bioavailability was comparable between the two formulations. Dose proportionality was observed between the lowest and highest dose-strengths of intranasal formulation. Both intranasal and rectal treatments were well tolerated with mild to moderate adverse events. Results suggest that a single-dose of 20mg diazepam-NS is tolerable and comparable in bioavailability to that of diazepam-RG. The intranasal formulation may provide caregivers and patients with a more socially acceptable and convenient alternative rescue therapy in the acute treatment of seizure clusters.
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Affiliation(s)
- Herbert R Henney
- Acorda Therapeutics, Inc., 420 Saw Mill River Road, Ardsley, NY 10502, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, USA
| | | | - Gary Bream
- Aerial BioPharma, LLC, 9001 Aerial Center Parkway, Suite 110, Morrisville, NC 27560, USA
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Bosson N, Santillanes G, Kaji AH, Fang A, Fernando T, Huang M, Lee J, Gausche-Hill M. Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure. Ann Emerg Med 2013; 63:302-8.e1. [PMID: 24120630 DOI: 10.1016/j.annemergmed.2013.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 08/22/2013] [Accepted: 09/12/2013] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. METHODS This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. RESULTS There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). CONCLUSION We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.
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Affiliation(s)
- Nichole Bosson
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Genevieve Santillanes
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Andrea Fang
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA
| | - Tasha Fernando
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Margaret Huang
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA
| | - Jumie Lee
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; School of Nursing, University of California, Los Angeles, CA
| | - Marianne Gausche-Hill
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
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Capovilla G, Beccaria F, Beghi E, Minicucci F, Sartori S, Vecchi M. Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy. Epilepsia 2013; 54 Suppl 7:23-34. [DOI: 10.1111/epi.12307] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Giuseppe Capovilla
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Francesca Beccaria
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Ettore Beghi
- Department of Neuroscience; IRCCS-Institute of Pharmacological Research “Mario Negri”; Milan Italy
| | - Fabio Minicucci
- Clinical Neurophysiology; San Raffaele Hospital; Milan Italy
| | - Stefano Sartori
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
| | - Marilena Vecchi
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
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