Variation in Anticonvulsant Selection and Electroencephalographic Monitoring Following Severe Traumatic Brain Injury in Children—Understanding Resource Availability in Sites Participating in a Comparative Effectiveness Study

Abstract

Objective Early post-traumatic seizures (PTS) may contribute to worsened outcomes after traumatic brain injury (TBI). Evidence to guide the evaluation and management of early PTS in children is limited. We undertook a survey of current practices of continuous electroencephalographic monitoring (cEEG), seizure prophylaxis and the management of early PTS to provide essential information for trial design and the development of PTS management pathways. Design Surveys were sent to site principal investigators at all 43 sites participating in the ADAPT (Approaches and Decisions in Acute Pediatric TBI) trial at the time of the survey. Surveys consisted of 12 questions addressing strategies to (i) implement cEEG monitoring, (ii) PTS prophylaxis, (iii) treat acute PTS, (iv) treat status epilepticus (SE) and refractory status epilepticus (RSE) and (v) monitor anti-seizure drug levels. Setting Institutions comprised a mixture of free-standing children’s hospitals and university medical centers across the United States and Europe. Measurements and Main Results cEEG monitoring was available in the pediatric intensive care unit in the overwhelming majority of clinical sites (98%); however, the plans to operationalize such monitoring for children varied considerably. A similar majority of sites report that administration of prophylactic anti-seizure medications is anticipated in children (93%), yet a minority reports that a specified protocol for treatment of PTS is in place (43%). Reported medication choices varied substantially between sites, but the majority of sites reported pentobarbital for RSE (81%). Presence of an treatment protocols for seizure prophylaxis, early PTS, post-traumatic SE and RSE was associated with decreased reported medications (all p < 0.05). Conclusions This study reports the current management practices for early PTS in select academic centers after pediatric severe TBI. The substantial variation in cEEG implementation, choice of seizure prophylaxis medications, and management of early PTS across institutions was reported, signifying areas of clinical uncertainty that will help provide for focused design of clinical trials. While sites with treatment protocols reported decreased number of medications for the scenarios described, completion of the ADAPT Trial will be able to determine if these protocols lead to decreased variability in medication administration in children at the clinical sites.

EEG Monitoring and Antiepileptic Drugs in Children with Severe TBI

“…That manuscript reported that 40% of North American and 42% of European centers state that they routinely provide EEG monitoring for children with severe TBI. (10) Children in our study with known risk factors for PTS(6, 26, 31–33) including young age, abusive injury mechanism, and SDH, were more likely to receive EEG monitoring. Young children and those who suffered child abuse tended to receive EEG monitoring earlier in the hospitalization.…”

“…(10) Overall, 16.5% of all patients received NMB after day 0 (NMB use on day 0 is more likely be procedure-related and temporary). Those patients received a median of 2.0 (1.0, 3.0) days of NMB beyond day 0.…”

“…(10) This lack of congruence between stated and actual clinical practice could be related to within-center variation, as a minority of ADAPT sites stated that they have standardized clinical pathways for the administration of AEDs in severe TBI. (10) Alternatively, the survey may not have captured the level of detail needed to explore this question. It will be important to compare the results of the ADAPT survey(10), this study, and the ADAPT observational data when they are available.…”

“…(10) Alternatively, the survey may not have captured the level of detail needed to explore this question. It will be important to compare the results of the ADAPT survey(10), this study, and the ADAPT observational data when they are available.…”

“…(9) In a survey of 43 sites participating in a large observational cohort study, 90% of sites reported seizure prophylaxis with AEDs in children with severe TBI. (10) The same survey also reported wide center variation in approach to EEG monitoring. Other aspects of the care of children with severe TBI are known to vary widely.…”