Optimizing pediatric status epilepticus management: The role of early midazolam infusion and adherence to clinical practice guidelines
Year: 2025
Type: article
Study design: Observational Study
Abstract: OBJECTIVE: This study was undertaken to describe a cohort of pediatric patients with status epilepticus (SE) in Italy over the past decade, focusing on the variability of treatment protocols among centers, adherence to guidelines, and potential predictors of refractoriness. METHODS: This is a multicenter retrospective observational cohort study including patients aged 1 month to 18 years who experienced convulsive SE (CSE) between January 2010 and June 2022. Variables analyzed included age at CSE onset, etiology, and treatment. RESULTS: We included 1374 CSE episodes in 1071 patients (median age = 3.3 years); 46% occurred in the first 3 years of life. The prominent etiology was remote symptomatic (32%). Resolution was obtained only with benzodiazepine administration in 19.2% of SE episodes. Phenytoin, phenobarbital, and midazolam by infusion were the drugs most frequently used. Maximum therapeutic response occurred with low-dose (<.2 mg/kg/h) midazolam infusion administered at an early stage, following a single dose of benzodiazepine or an antiseizure medication (ASM; 59%). Midazolam effectiveness decreased to 37% when it was used after multiple ASMs, even at high doses. CSE was refractory in 39% of cases. Predictors of refractoriness included nonadherence to current guidelines, type of CSE, and etiology. SIGNIFICANCE: This study emphasizes that low-dose midazolam infusion, not requiring endotracheal intubation and administered at an early phase, appears to be effective in permanently stopping seizure and preventing the evolution toward a refractory CSE. Given its proven efficacy and widespread use in many hospitals, early midazolam infusion could be considered in the management of pediatric CSE. Adherence to treatment protocols, specific etiologies, and type of CSE are correlated with refractoriness; thus, when facing SE in infants, these factors should guide treatment protocol selection, including medication choice and timing.
Source: Epilepsia
DOI: 10.1111/epi.18455
Authors: Anna Rosati, Patrizia Bartolotta, Carla Marini, Maria Cristina Mondardini, Duccio Maria Cordelli, Anna Fetta, Luca Bergonzini, Manuela L'Erario, Giulia Cannizzaro, Emmanuele Mongelli, Clarissa Tona, Stefano Sartori, Claudia Maria Bonardi, Fabrizio Chiusolo, Federico Vigevano, Nicola Specchio, Francesca Darra, Jacopo Proietti, Paolo Biban, Elisabetta Cesaroni, Alessandro Simonini, Francesca Izzo, Massimo Mastrangelo, Sara Olivotto, Silvia Maria Pulitanò, Domenica Immacolata Battaglia, Silvia Buratti, Emanuele Giacheri, Caterina Zanus, Paola Costa, Roberta Vittorini, Alessandra Conio, Angela Amigoni, Lucia Fusco, for the Italian Pediatric Status Epilepticus Group
Institutions: Ospedale Santa Chiara, Provincia Autonoma di Trento, Meyer Children's Hospital, Azienda Ospedaliero-Universitaria delle Marche, IRCCS Azienda Ospedliero-Universitaria di Bologna Policlinico di Sant'Orsola, Istituto delle Scienze Neurologiche di Bologna, University of Bologna, University of Padua, Azienda Ospedale - Università Padova, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele, Universitair Ziekenhuis Leuven, Istituti di Ricovero e Cura a Carattere Scientifico, University of Verona, Fondazione Ospedale Salesi, Ospedale dei Bambini Vittore Buzzi, IRCCS Policlinico San Donato, Agostino Gemelli University Polyclinic, Università Cattolica del Sacro Cuore, Istituto Giannina Gaslini, IRCCS Materno Infantile Burlo Garofolo, Ospedale Regina Margherita, University of Turin
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
Funder: Ministero della Salute
OpenAlex ID: W4410423013