Abstracts

Rationale: Recent guidelines recommend critically ill children undergo EEG monitoring to identify and manage electrographic seizures (ES). Reducing ES exposure could decrease secondary brain injury and improve neurobehavioral outcomes. However, only limited data are available regarding the safety of anti-seizure medication (ASM) administration for ES treatment in critically ill children. We aimed to determine ASM utilization patterns, the incidence and types of adverse events associated with ASM administration, and which children were at increased risk for experiencing adverse events. Methods: We performed a single-center prospective observational study of consecutive critically ill children undergoing EEG monitoring. We evaluated clinical and EEG features, seizure characteristics, ASM utilization and impact, and ASM adverse events within 12 hours of ES management. Results: We enrolled 472 consecutive critically ill children who underwent clinically indicated EEG monitoring. ES occurred in 131 children (28%), and clinicians administered ASM to 108 children with ES (82%). ES management involved one ASM in 47 patients (44%), two ASM in 24 patients (22%), three ASM in 22 patients (20%), and four or more ASM in 15 patients (14%). ES terminated after the initial ASM in 41 of 108 patients (38%) who received one ASM, after the second ASM in 22 of 62 (35%) patients who received two ASM, after the third ASM in 19 of 38 (50%) patients who received three ASM, and after the fourth ASM in 8 of 15 (53%) patients who received four ASM. Thirty patients (28%) received pharmacologic coma for management of ES. There were no differences in ASM efficacy between patients with epilepsy and acute symptomatic etiologies. Adverse events occurred in 18 patients (17%), were readily managed by intensivists, and all resolved. Adverse events were rare in patients with acute symptomatic seizures requiring management with 1 to 2 ASM for ES but were more common in children with epilepsy, with more complex EEG patterns (ESE or ictal-interictal continuum), or requiring more extensive ASM management with midazolam infusion. Conclusions: Most patients with ES require multiple ASM, but ES ceased after administration of two ASM in 73% of subjects. Thus, management of ES is often accomplished with readily available management strategies, although approaches to optimize multi-step ES management regimens might be beneficial. Adverse events were rare and readily managed by intensivists among children with acute symptomatic seizures requiring relatively simple management. Funding: NINDS K02NS096058