Variability in preferred management of electrographic seizures in neonatal hypoxic Ischemic encephalopathy

Melanie A. McNally, MD, Adam L. Hartman, MD.  Variability in Preferred Management of Electrographic Seizures in Neonatal Hypoxic Ischemic Encephalopathy.  Pediatric Neurology.  In press.

Abstract

Objective

Seizures occur commonly in neonates and growing evidence suggests they may cause added harm in neonates with hypoxic ischemic encephalopathy (HIE). However, specific recommendations about when and how to treat seizures in this context are lacking. The objective of this study was to determine the scope of practice nationally regarding management of non-status epilepticus electrographic-only seizures (ESzs) in neonates with HIE.

Study Design

A case-based survey was distributed to members of the Child Neurology Society. Providers were asked about their preferred management strategy for sequential clinical scenarios.

Results

177 child neurologists responded to the survey. 77% of providers would treat 20 seconds or less of electrographic seizure activity. In a neonate with mild HIE and an ESz, there was no agreement among providers regarding whether to start maintenance therapy in addition to a one-time anti-seizure drug (ASD) load. In a neonate with moderate HIE on phenobarbital (PB) for early electro-clinical seizures, the majority of providers would escalate treatment for ongoing ESzs and would do so by increasing PB dosing. In a neonate with severe HIE complicated by status epilepticus on PB who subsequently develops recurrent ESzs, providers varied significantly in their management preferences. For all three cases, 75-85% of providers would not change their management preferences based on the presence or absence of a clinical correlate with the electrographic seizure.

Conclusions

We found marked variability among providers regarding preferred management of non-status epilepticus ESzs after HIE. Our results identified specific aspects of ESz management in neonatal HIE where there is limited consensus. These discrepancies may serve as opportunities for future investigation.

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This study was meant to determine the scope of practice nationally about management of non–status epilepticus electrographic–only seizures (ESzs) in neonates with hypoxic ischemic encephalopathy (HIE). Among providers regarding preferred management of non–status epilepticus ESzs, the physicians found marked variability after HIE. The outcomes recognized specific aspects of ESz management in neonatal HIE where there is the limited consensus. For the future investigation, these discrepancies probably served as opportunities.

Methods

The authors distributed a case-based survey to members of the Child Neurology Society.

They asked providers about their preferred management strategy for sequential clinical scenarios.

Results

A total of 177 child neurologists responded to the survey and 77% of providers would treat 20 seconds or less of electrographic seizure activity.

There was no agreement among providers regarding whether to start maintenance therapy in addition to a one-time anti-seizure drug (ASD) load in a neonate with mild HIE and an ESz.

The majority of providers would escalate treatment for ongoing ESzs and would do so by increasing PB dosing in a neonate with moderate HIE on phenobarbital (PB) for early electro-clinical seizures.

In their management preferences, providers varied significantly in a neonate with severe HIE complicated by status epilepticus on PB who subsequently develops recurrent ESzs.

Based on the presence or absence of a clinical correlate with the electrographic seizure, 75-85% of providers would not change their management preferences for all 3 cases.

Courtesy of:  https://www.mdlinx.com/neurology/medical-news-article/2017/06/23/neonatal-seizures-phenobarbital-levetiracetam-phenytoin-survey/7219482/?category=latest&page_id=1