Time Is Brain: Improving Early Access to Antiseizure Medications During Status Epilepticus in the Pediatric Population

Abstract number : 3.229
Submission category : 4. Clinical Epilepsy / 4C. Clinical Treatments
Year : 2022
Submission ID : 2204981
Source : www.aesnet.org
Presentation date : 12/5/2022 12:00:00 PM
Published date : Nov 22, 2022, 05:27 AM

Authors :
Lauren Morris, DO – Duke University Hospital; Mahmoud Elkhooly, MD – Wayne State University; Jennifer Frakes, PharmD – Duke University Hospital; Kayli Maney, MD – Duke University Hospital; Emily Sterrett, MD – Duke University Hospital; Muhammad Zafar, MD – Duke University Hospital

Rationale: Status epilepticus represents a common medical emergency which has a high mortality rate. Several factors affect the outcome and prognosis such as cause and seizure semiology. One of the most important factors is early treatment initiation. Over the years, intravenous (IV) benzodiazepines have been the mainstay first line treatment. However, the time used in IV access placement is associated with delayed treatment initiation. After benzodiazepines, fosphenytoin is widely used as the standard of care first line agent in many institutions including ours. However, there is also additional delay in getting fosphenytoin to the patient._x000D_
At our institution, two problems were identified: the time it took to administer medications to treat status epilepticus and a lack of IV access contributing to the delay. In previous studies, different routes of administration such as intranasal (IN) and intramuscular (IM) were determined as safe as IV. In a study done by Kay et al., they concluded that IN midazolam may act as a first line therapy for status epilepticus instead of a buccal, IV or IM routes. In another large multicenter study, it was concluded that 50% of patients with status epilepticus respond to higher doses of levetiracetam, fosphenytoin, or valproate with no significant safety differences. _x000D_
This study focuses on a simplified approach to treating status epilepticus in children that focuses on addressing the problems regarding time to administration of medications and the route of administration. Our goal is to decrease the time it takes to treat status epilepticus at our institution.

Methods: PDSA quality improvement methodology was used for this project. Multiple pediatric departments within Duke University Hospital are involved in this project including pharmacy, inpatient, emergency department, pediatric intensive care unit, pediatric cardiac intensive care unit, epilepsy monitoring unit, and nursing. Prior to the adjustments made to our status pathway, a survey was performed within our department. This survey compared the use of fosphenytoin vs. levetiracetam as first line after benzodiazepines for the treatment of status epilepticus in children. After the survey, a simplified status algorithm adding IN midazolam and including levetiracetam as first line was created. An orderset was then developed in EPIC that includes all medications listed in the algorithm with doses preset. The algorithm and orderset were made available May 1, 2022.

Results: The results of the initial survey among the department of pediatric neurology showed that initially 54% would chose fosphenytoin vs. 46% levetiracetam for the treatment of status epilepticus in children. After presenting the study by Chamberlain et al, 11% chose fosphenytoin and 89% levetiracetam. Future results include how many times the orderset was used, the total time it takes for medication administration and the number of times IN midazolam is used between May 1, 2022, and 6 months later on November 1, 2022. Data collection will begin next month (July 1, 2022). 

Conclusions: With the usage of a simplified algorithm and order set for medications, we hope to decrease the time to treat status epilepticus at our institution.

Funding: Not applicable
Clinical Epilepsy