An Italian Survey on the Management of Pediatric Convulsive Status Epilepticus: More Than Just a Pharmacological Choice

Abstract

Background and purpose: To explore specialists' opinions on the current management of pediatric convulsive status epilepticus (CSE) in Italy and the main factors influencing the applicability of guidelines.

Methods: We conducted a national survey of child neurologists, pediatric emergency physicians, and intensivists. Within the multidisciplinary Italian Paediatric Status Epilepticus (IPSE) Group, a web-based 48-multiple-choice questionnaire was developed to explore treatment choices, use of internal protocols and guidelines, and self-perceived competencies in the treatment of CSE.

Results: Responses were received from 250 clinicians from 34 Italian hospitals (response rate 71%). Intravenous midazolam (iv-MDZ) was the preferred benzodiazepine (BDZ) when iv access was available (90%). When iv-access was unavailable, 75% of clinicians used BDZs; rectal diazepam was the most indicated (65.6%). Concerning second-line treatment, the choices were equally distributed between phenytoin (55.2%), levetiracetam (52.4%), and phenobarbital (52.4%). MDZ infusion at a dosage < 0.23 mg/kg/h was also a frequent choice (38%). A PICU in the hospital influenced this latter choice, resulting in a significantly greater use of iv-MDZ by pediatric emergency physicians working in these hospitals. Answers' variability was related to organizational aspects such as the availability of on-duty specialists and diagnostic tools in emergency settings.

Conclusions: This survey confirmed that first-line treatment of pediatric CSE relied on iv-MDZ and that the heterogeneity of therapeutic choices started from the second-line treatment in real life. The survey also highlighted the need to consider the organizational heterogeneity among settings and to involve different specialties in an integrated and feasible approach.

Keywords: intensive care unit; pediatric; status epilepticus; survey; treatment.

FIGURE 1

First‐line therapy choices. (A) Participants’ answers to the survey question “You use BDZ that do not require availability of vascular access” (a single choice was possible between “only if vascular access is not available” and “always as first option, particularly in young children”). (B) Participants’ answers to the survey question “In the absence or difficulty in finding vascular access which of the following BDZs do you prefer?” (C) Participants’ answers to the survey question “If the vascular access is available which BDZ do you preferentially administer?” BDZ = benzodiazepines.

FIGURE 2

Second‐line therapy choices. Participants’ answers are divided by specialty (emergency pediatrician, pediatric neurologist, and intensivist) and second‐line treatment choices “Which of the following drugs do you use as second line, in the treatment of SE, regardless of the ranking order?” are reported. SE = status epilepticus.

FIGURE 3

Third‐line therapy choices. Participants’ answers regarding third‐line treatment choices. (A) Overall drug choices are represented. (B and C) Drug choices of specialists are represented (respectively intensivist and pediatric neurologist).