Authors :
Presenting Author: Leena Abdelmoity, MD Candidate – Boston Children's Hospital
Fatemeh Mohmmad Alizadeh Chafjiri, MD – Boston Children's Hospital
Rajib Kanti Dey, MBBS – Boston Children's Hospital
Sahar Rostamian, MD – Boston Children's Hospital
Luisa Atunes Ortega, MD – Boston Children's Hospital
Stephanie Dailey, BA – Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
Elijah Simon, BS – Boston Children's Hospital
Agnieszka Kielian, MD – Boston Children's Hospital
Jennifer Gettings, BMBS, FRCPC – Boston Children's Hospital
Tobias Loddenkemper, MD – Boston Children's Hospital
Rationale:
Status epilepticus, a prolonged and potentially life-threatening seizure, requires timely treatment with rescue medications. Guidelines recommend first-line benzodiazepines and followed by non-benzodiazepine anti-seizure medications (ASMs) if seizures persist. In pediatric patients with refractory status epilepticus (RSE), the effectiveness of the initial benzodiazepine treatment may influence the need for additional ASMs. We aim to evaluate whether pediatric patients with RSE need additional ASMs after the initial benzodiazepine dose if the first benzodiazepine is intranasal midazolam compared to rectal diazepam, adjusting for confounders of dose, time to treatment, etiology, and seizure triggers.
Methods:
In this retrospective cohort study, we reviewed the electronic health records of patients from a tertiary care centerbetween 2013 and 2023 to identify 212 RSE cases. For patients with multiple RSE events during an admission, only the first event was included. We included patients with convulsive RSE in which either intranasal midazolam or rectal diazepam was administered at a standard dose (0.2 mg/kg to 0.5 mg/kg for both intranasal midazolam and rectal diazepam) to patients aged 28 days to 21 years. Patients were excluded if they received an inappropriate benzodiazepine or received a benzodiazepine other than intranasal midazolam or rectal diazepam. Our outcome was the number of subsequent doses of ASMs required to terminate the seizure. We compared the mean number of additional ASM doses administered between the group that received initial intranasal midazolam and the group that received rectal diazepam. We adjusted for confounders including age, sex, location of administration of the first benzodiazepine, and the dose of the first benzodiazepine.
Results:
We included 41 patients (41% female, median age of 4.63 years) with 43 admissions for RSE 32 episodes of RSE were initially treated with rectal diazepam, and 11 episodes were initially treated with intranasal midazolam. After adjusting for confounders of age, sex, location of administration of the first benzodiazepine, and the dose of the first benzodiazepine, we discovered a trend that patients who received intranasal midazolam needed, on average, 0.70 fewer subsequent ASM doses than patients who treated with rectal diazepam as their first-line rescue medication (p=0.37).
Conclusions:
In this pilot study, pediatric patients with RSE treated initially with intranasal midazolam tended to require fewer subsequent ASMs than patients treated with rectal diazepam. While this result is not statistically significant, it may suggest be a clinically meaningful difference between administering intranasal midazolam versus rectal diazepam as a first-line medication for pediatric patients experiencing RSE. Each additional ASM administered to a patient reflects a lag in seizure control and thus, potentially morbid outcomes. This trend requires confirmation through future studies with larger sample sizes, to inform clinical practice and improve the care and outcomes of patients with RSE.
Funding: This study was supported by the Epilepsy Research Fund.