Management of Status Epilepticus by Different Pediatric Departments: Neurology, Intensive Care, and Emergency Medicine

Abstract

<b><i>Introduction:</i></b> The aim of this study was to explore the differences in status epilepticus (SE) management among pediatric neurology, emergency medicine, and intensive care specialists in Turkey. <b><i>Methods:</i></b> A 22-item questionnaire regarding first-, second-, and third-line management strategies of SE including demographic characteristics and common etiologies according to the specialty of participants was mailed to 370 specialists working in Turkey. <b><i>Results:</i></b> A total of 334 participants (response rate 90%) comprising 136 pediatric neurologists, 102 pediatric emergency medicine specialists, and 96 pediatric intensive care specialists completed the survey. While intensive care specialists frequently managed SE due to metabolic and autoimmune reasons, the most common etiologies encountered by emergency medicine specialists were epilepsy and infections. More than half of the intensive care specialists (64.6%) reported using non-BZD antiseizure medications in the 5th minute of the seizure. Most of the neurologists (76.4%) preferred to administer intravenous (IV) levetiracetam infusion as a second-line agent. About half of intensive care specialists and neurologists tried immunomodulatory therapies in super-refractory SE. Intensive care and emergency medicine specialists were less likely to favor ketogenic diet and pyridoxine therapy for the treatment of super-refractory SE. The rate of requesting EEG monitoring to recognize nonconvulsive SE (NCSE) was found to be very low except for neurologists. <b><i>Conclusion:</i></b> There was no consensus among neurologists, intensive care specialists, and emergency medicine specialists in the management of SE in Turkey. Familiarity with particular antiseizure medications and the etiologies they manage seem to be the most important factors influencing the attitudes.

Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey)

“…Until recently phenytoin was commonly used second-line ASM. 3 , 5 , 13 , 14 However, two recent large randomized controlled trials (RCTs) compared the efficacy of levetiracetam and phenytoin as second-line ASM in PSE and noted that levetiracetam is equally effective and safe second-line ASM. 7 , 8 However, due to safety profile and comparative ease of administration, it was suggested that levetiracetam could be an appropriate alternative to phenytoin as second-line ASM in PSE.…”

“…For the treatment of SRSE, about half of intensive care specialists and neurologists preferred to use immunomodulation and 60% neurologists preferred ketogenic diet. 14 Another survey from Argentina (252 participants; 77% pediatricians and 16% intensive care specialists) demonstrated that most participants preferred midazolam infusion as third-line ASM (63%) and only 17% preferred thiopentone infusions. 13 The preference in use of midazolam infusion as third-line ASM in literature as well as in the index eSurvey is possibly due to lack of evidence for this stage of treatment, easily availability, and better adverse effect profile.…”

“…[3][4][5] However, there is wide variability in management of PSE and poor compliance to guidelines. [3][4][5][13][14][15][16][17] Regarding the first-line ASM, midazolam was the most preferred agent and most respondents use 2 doses. Until recently phenytoin was commonly used second-line ASM.…”

“…17 Few other surveys also demonstrated preference toward levetiracetam as second-line ASM. 14,15 Considering the recent evidence about the efficacy of levetiracetam, [7][8][9] ready to use preparation, ease and speed of administration, and better safety profile, many clinicians have already incorporated levetiracetam as an alternative second-line ASM in their practice awaiting changes in national and international guidelines. 14,15,17 In index eSurvey, we also noted a trend towards preference in using levetiracetam as second-line ASM (51.2% respondents).…”

“…[3][4][5] However, several studies and surveys demonstrated that there is wide variability in treatment modalities among treating physicians and poor adherence to PSE management guidelines, particularly in time-dependent decisions. [13][14][15][16] The information about variability in treatment practices and adherence to PSE management guidelines is limited from India. Therefore, we planned this survey in India to assess current treatment practices and adherence to PSE management guidelines among healthcare providers.…”