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Lim KS, Khoo CS, Fong SL, Tan HJ, Fong CY, Mohamed AR, Rashid AA, Law WC, Shaikh MF, Khalid RA, Yen-Leong Tan R, Ahmad SB, Chinnasami S, Wong SW, Raymond AA. Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap. J Clin Neurosci 2023; 114:25-31. [PMID: 37279626 DOI: 10.1016/j.jocn.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Early and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia. METHODS A web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services. RESULTS A total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE. CONCLUSIONS We identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.
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Affiliation(s)
- Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Malaysia.
| | - Ching-Soong Khoo
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Si-Lei Fong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Malaysia
| | - Hui-Jan Tan
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Choong Yi Fong
- Division of Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Malaysia
| | | | | | - Wan-Chung Law
- Division of Neurology, Department of Medicine, Sarawak General Hospital, Malaysia
| | - Mohd Farooq Shaikh
- Neuropharmacology Research Laboratory, Jeffrey CheahSchool of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | - Raihanah Abdul Khalid
- School of Dentistry and Medical Sciences, Charles Sturt University, Orange, New South Wales, Australia
| | | | | | | | - Sau-Wei Wong
- Neurology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Azman Ali Raymond
- Neurology Unit, Department of Medicine, Faculty of Medicine, MARA University of Technology, Malaysia; Epilepsy Council Malaysia, Malaysian Society of Neurosciences, Malaysia
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Sheehan T, Amengual-Gual M, Vasquez A, Abend NS, Anderson A, Appavu B, Arya R, Barcia Aguilar C, Brenton JN, Carpenter JL, Chapman KE, Clark J, Farias-Moeller R, Gaillard WD, Gaínza-Lein M, Glauser TA, Goldstein JL, Goodkin HP, Guerriero RM, Huh L, Jackson M, Kapur K, Kahoud R, Lai YC, McDonough TL, Mikati MA, Morgan LA, Novotny EJ, Ostendorf AP, Payne ET, Peariso K, Piantino J, Reece L, Riviello JJ, Sands TT, Sannagowdara K, Shellhaas R, Smith G, Tasker RC, Tchapyjnikov D, Topjian AA, Wainwright MS, Wilfong A, Williams K, Zhang B, Loddenkemper T. Benzodiazepine administration patterns before escalation to second-line medications in pediatric refractory convulsive status epilepticus. Epilepsia 2021; 62:2766-2777. [PMID: 34418087 PMCID: PMC9292193 DOI: 10.1111/epi.17043] [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: 04/21/2021] [Revised: 07/21/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022]
Abstract
Objective This study was undertaken to evaluate benzodiazepine (BZD) administration patterns before transitioning to non‐BZD antiseizure medication (ASM) in pediatric patients with refractory convulsive status epilepticus (rSE). Methods This retrospective multicenter study in the United States and Canada used prospectively collected observational data from children admitted with rSE between 2011 and 2020. Outcome variables were the number of BZDs given before the first non‐BZD ASM, and the number of BZDs administered after 30 and 45 min from seizure onset and before escalating to non‐BZD ASM. Results We included 293 patients with a median (interquartile range) age of 3.8 (1.3–9.3) years. Thirty‐six percent received more than two BZDs before escalating, and the later the treatment initiation was after seizure onset, the less likely patients were to receive multiple BZD doses before transitioning (incidence rate ratio [IRR] = .998, 95% confidence interval [CI] = .997–.999 per minute, p = .01). Patients received BZDs beyond 30 and 45 min in 57.3% and 44.0% of cases, respectively. Patients with out‐of‐hospital seizure onset were more likely to receive more doses of BZDs beyond 30 min (IRR = 2.43, 95% CI = 1.73–3.46, p < .0001) and beyond 45 min (IRR = 3.75, 95% CI = 2.40–6.03, p < .0001) compared to patients with in‐hospital seizure onset. Intermittent SE was a risk factor for more BZDs administered beyond 45 min compared to continuous SE (IRR = 1.44, 95% CI = 1.01–2.06, p = .04). Forty‐seven percent of patients (n = 94) with out‐of‐hospital onset did not receive treatment before hospital arrival. Among patients with out‐of‐hospital onset who received at least two BZDs before hospital arrival (n = 54), 48.1% received additional BZDs at hospital arrival. Significance Failure to escalate from BZDs to non‐BZD ASMs occurs mainly in out‐of‐hospital rSE onset. Delays in the implementation of medical guidelines may be reduced by initiating treatment before hospital arrival and facilitating a transition to non‐BZD ASMs after two BZD doses during handoffs between prehospital and in‐hospital settings.
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Affiliation(s)
- Theodore Sheehan
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas S Abend
- Division of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Brian Appavu
- Department of Pediatrics, University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Ravindra Arya
- Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - J Nicholas Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - William D Gaillard
- Center for Neuroscience, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Faculty of Medicine, Austral University of Chile, Valdivia, Chile
| | - Tracy A Glauser
- Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Réjean M Guerriero
- Division of Pediatric and Developmental Neurology, Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Linda Huh
- Division of Neurology, Department of Paediatrics, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Michele Jackson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Kahoud
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi-Chen Lai
- Section of Pediatric Critical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tiffani L McDonough
- Division of Child Neurology, Department of Neurology, Columbia University Medical Center, Columbia University, New York, New York, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Lindsey A Morgan
- Departments of Neurology and Pediatrics, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Edward J Novotny
- Departments of Neurology and Pediatrics, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Eric T Payne
- Division of Neurology, Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Katrina Peariso
- Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Juan Piantino
- Division of Neurology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Latania Reece
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James J Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tristan T Sands
- Division of Child Neurology, Department of Neurology, Columbia University Medical Center, Columbia University, New York, New York, USA
| | - Kumar Sannagowdara
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Renee Shellhaas
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Garnett Smith
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, and Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, North Carolina, USA.,Department of Pediatrics, Montana Children's Hospital, Kalispell Regional Medical Center, Kalispell, Montana, USA
| | - Alexis A Topjian
- Critical Care and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark S Wainwright
- Departments of Neurology and Pediatrics, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Angus Wilfong
- Department of Pediatrics, University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Korwyn Williams
- Department of Pediatrics, University of Arizona College of Medicine and Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Bo Zhang
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Gilder ME, Tun NW, Carter A, Tan FFSL, Min AM, Eh H, Aye P, Carrara VI, Angkurawaranon C, McGready R. Outcomes for 298 breastfed neonates whose mothers received ketamine and diazepam for postpartum tubal ligation in a resource-limited setting. BMC Pregnancy Childbirth 2021; 21:121. [PMID: 33563234 PMCID: PMC7874624 DOI: 10.1186/s12884-021-03610-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Anesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established. Methods Medical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy. Results Of 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13–3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11–3.13, p = 0.017). Conclusions In resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.
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Affiliation(s)
- Mary Ellen Gilder
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nay Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Annabelle Carter
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | | | - Aung Myat Min
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Hsa Eh
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Pan Aye
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Verena I Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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