management of convulsive status epilepticus in children: an adapted clinical practice guideline

DR. MUDDATHIR HAMADS. REGI STRAR / FELLOW, PEDIATRI C NEUROLOGYMEMB ER, PEDI ATRI CS C PGS D EPT. C OMMI T TEE

PEDI ATRI CS D EPARTMENT

DR. YASSER S. AMERGENERAL PEDI ATRIC IAN

CPG METHODOLOGI ST, C PG STEERI NG COMMI T TEE, QUALITY MANAGEMENT DEPARTMENT

Management of convulsive status epilepticus in children: an adapted clinical practice

guideline

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بســـــم الله الرحمـــــن الرحـــــيم

In the name of Allah. Most Gracious, Most Merciful

Tuesday, November 29, 2016Childhood Convulsive SE CPG for Residents of Pediatrics

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Statement of disclosure

Tuesday, November 29, 2016

Dr. Muddathir H. HamadMD, ABP

Dr. Yasser S. AmerMBBCh, MPedia, MHCI, CPHQ, FISQua

We have no actual or potential, commercial or academic conflict of interest to declare

in relation to this presentation/ project

Childhood Convulsive SE CPG for Residents of Pediatrics

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The EBM Triad


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Clinical Practice Guidelines

“Statements that include Recommendations intended to optimize patient care that are informed by a Systematic Review of evidence and an assessment of the benefits and harms of alternative care options”

(IOM-AHRQ 2011)


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Rationale for CPGs

Worldwide concerns about:- ▫ Unexplained variation/ variability in practice!▫ Rising healthcare costs!▫ Exponential growth of health information!

Aim of CPGs:-▫ To facilitate more consistent, effective and

efficient practice and improve health outcomes for patients



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What makes a trustworthy CPG?


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Standards for high quality CPGsIOM 2011 – G-I-N 2012 – AGREE 2013



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Why Status Epilepticus (SE)?

SE is a common and serious neurological problem

SE is more common in children esp. in children less than 2 years old.

life- threatening condition that needs abrupt recognition and early intervention to prevent significant neurological sequelae.


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Status Epilepticus in children has been identified as one of the high priority health topics in King Saud University Medical City based on the University hospital records.


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Stats of Pediatrics Department


Children with seizure disorders are recorded as the fifth commonest cause of admissions to the Pediatrics wards (after bronchiolitis, bronchial asthma, pneumonia and sickle cell anemia) according to the Pediatrics wards records between 2011 and 2012.


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In PICU, the total number of children with SE accounts for 10.7% (n=50) of the total number of admissions (n=467) in 2013 according to the PICU Disease index.


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Definition


Formerly, SE was defined as a seizure lasting longer than 30 minutes or two or more seizures within 30 minutes without a return to the baseline consciousness level between seizures.

Recently, the definition evolved to be a seizure longer than 5 minutes or two or more seizures without a return of consciousness between seizures (Abend 2009, NICE 2012).



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Timeline of progression of Status Epilepticus


Jessica J, J. Clin. Med. 2016, 5, 49

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Scope and purpose (PIPOH)


Patient population (P): children aged 1 month - 14 years with convulsive status epilepticus (Exclusion: Neonatal seizures and NCSE)

Intervention (I): Dx and RxProfessionals (P): physicians, nurses and clinical

pharmacists in pediatrics, pediatric EM, PICU, pharm., lab., and nursing.

Outcomes (O): seizure control and decrease morbidity and mortality.

Healthcare settings (H): KSUMC … & … 1ry, 2ry and 3ry HC setting in all sectors especially pediatric inpatient wards, PICU and emergency services that care for similar patients.Childhood Convulsive SE CPG for Residents of Pediatrics

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Inclusion/ exclusion selection criteria


Methods of Development: Evidence-based CPGs with a detailed development methodology section or document (NOT consensus/ expert-based only)

Author(s): Organization/ Specialized Society NOT single authors.

Country: International and national CPGs.Date of Publication: last 5 years (2009-2013)Language: English onlyStatus: Original source CPG (de novo

developed) NOT adapted CPGs.Childhood Convulsive SE CPG for Residents of Pediatrics


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Search and screen


4 databases: NGC, G-I-N, EBSCO-DynaMed, MEDLINE PubMed.

Keywords: SE in children, CSE, CCSEPIPOH, eligibility criteria filtered: 15 source

CPGs to three for further assessment.Quality assessment of three source CPGs:-

Neurocritical Care Society (NCS_2012) Texas Children’s Hospital (AAP/Texas_2009) National Institute for Health and Care Excellence

(NICE_2012) [PLUS] American Epilepsy Society (AES_2016)

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Comparative quality assessment of source CPGs for CCSE (AGREE II

Instrument)


[Source CPGs]AGREE-II Domains

Scores (%)Texas

2009NICE 2012

NCS 2012

AES 2016

D1: Scope & Purpose 92 100 78 100D2: Stakeholder Involvement 47 100 41

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D3: Rigour of Development 56 98 68 69

D4: Clarity & Presentation 100 97 80 92

D5: Applicability 48 85 10 21D6: Editorial Independence

50 88 19 38

Overall Assessment 85 100 57 75Recommendation for CPG use

Yes - 0, Yes withmodifications - 2,

No - 0

Yes - 1, Yes withmodifications - 1, No

- 0

Yes - 0, Yes with modifications - 1, No - 1

Yes - 0, Yes with modifications - 2, No - 0

This table uses the AGREE II Domain score colour coding proposed by Dr Lubna Al-Ansary (< 40% Red - >41-70% Yellow - >71% Green)


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Case scenario


You are the senior on call in pediatric emergency and you have been called by a triage nurse to see a 2 years old child with abnormal movements that started at home.

What questions you want to ask to parents ?

How do you manage this patient ? Childhood Convulsive SE CPG for Residents of Pediatrics

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The first step is to confirm clinically that it is epileptic seizure and to R/O seizure mimickers.


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Check and maintain ABC (airway, breathing and circulation)

Give high flow oxygen Check blood glucose level. Establish IV access.Consider CBC, renal function test, serum

electrolytes, blood culture and toxicology screening if appropriate.

Consider anti-epileptic drug (AED) level.

Stabilization phase (0-5 minutes)


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Early SE , seizure 5-30 minutes


Benzodiazepine: IV Lorazepam 0.1 mg/kg (max: 4 mg) slowly

over 2-5 minutesIV Diazepam 0.15-0.2 mg/kg (max: 10 mg)If no IV line, consider: Buccal Midazolam 0.5 mg/kg (max: 10 mg) OR PR Diazepam 0.5 mg/kg (max: 20 mg)OR IM Midazolam 0.2 mg/kg (max: 10 mg) Don’t give more than 2 doses of Benzodiazepines Childhood Convulsive SE CPG for Residents of Pediatrics

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Established SE, seizure > 30 minutes


IV Phenytoin 20 mg/kg (max 1000 mg) Infusion over 20 minutes with cardiac monitoring IF NOT ON REGULAR PHENYTOIN.


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If seizure continues:IV Phenobarbitone 20 mg/kg (max: 1000 mg)

Infusion over 20 minutes.Alternative medications: IV Levetiracetam 20-60 mg (max 2500 mg)

Infusion over 20 minutes. IV Valproic acid 20-40 mg/kg (max 3000 mg)

over 20 minutes.


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Refractory SE , seizure > 60 minutes


Admit to PICURapid sequence intubation IV Midazolam 0.15 mg/kg loading dose (max:

8 mg) over 2-3 min then start continuous infusion by 2 mcg/kg/min and titrate to maximum of 24 mcg/kg/min.

OR IV Thiopental Sodium Bolus dose 3 mg/Kg, Titration instructions: 3 mg/Kg (max 500 mg) over 10 minutes, followed by continuous IV infusion of 3 mg/Kg/hour. Titrate to effect


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Admission/ Discharge criteria


All children with established SE should be admitted for observation.

Children who required 3rd line therapy AND/OR have respiratory distress should be admitted to the PICU.

Discharge Criteria:Seizure cessationAppropriate mental status; return to baseline

mental status


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Follow Up Care:All children admitted with SE should have a

follow up appointment in the Pediatric Neurology Clinic after discharge



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Clinical algorithm for CCSE



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Medication table for CCSE



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CCSE CPG Audit data collection tool


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Saudi Pediatric Association (SPA) endorsement for KSUMC Pediatric

CPGs


Endorsement by the Saudi Neurology Society and Saudi Epilepsy Society is in progress.



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Desktop Icon


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With or without Clinical Decision Support (CDS)


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CPOE with Order Sets in eSiHi are called “POWERPLANS”

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6 PowerPlans from Pediatrics CPGs

1. PED Diabetic ketoacidosis CPG2. PED Severe sepsis/ septic

shock CPG3. PED acute asthma CPG4. PED acute bronchiolitis CPG5. PED Fever of known cause in

infants 60 days or less CPG6. NICU Neonatal Hyperbilirubinemia

CPG7. PED Status Epilepticus CPGTuesday, November 29, 2016Childhood Convulsive SE CPG for Residents of

Pediatrics

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41PED SE CPG, Phase 1


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PED SE CPG, Phase 2 (cont’d)



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PED SE CPG, Phase 4


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PED SE CPG, Phase 5


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Acknowledgments


Pediatric Neurology Unit, Pediatrics Department.

Pediatrics CPGs Departmental Committee.

Pediatrics Department Quality Team.KSUMC CPG Steering Committee.Research Chair for Evidence-Based

Health Care and Knowledge Translation.

Quality Management Department.

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What is your role as a HCP in CPGs? “spread the word”

1) CPG implementers/users:“Your continuous feedback!”

2) CPG developers/adapters.3) Improvement research

projects.


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Questions?
