Seizure management in children requiring palliative care: A review of current practice

Harris, Nicola; Baba, Megumi; Mellor, Charlotte; Rogers, Rebekah; Taylor, Kirsty; Beringer, Antonia; Sharples, Peta

Abstract

OBJECTIVES: Controlling seizures in children approaching death can be difficult, and there is a limited evidence base to guide best practice. We compared current practice against the guidance for seizure management produced by the Association of Paediatric Palliative Medicine (APPM). METHODS: Retrospective case note review of episodes of challenging seizure management in children receiving end-of-life care over a 10-year period (2006-2015) in the south-west region of England. RESULTS: We reviewed 19 admissions, in 18 individuals. Six (33%) had a malignancy, nine (50%) had a progressive neurodegenerative condition and three (17%) had a static neurological condition with associated epilepsy. Thirteen (72%) died in their local hospice, four (22%) at home, and one (6%) in hospital. Seventeen of 19 episodes involved the use of subcutaneous or intravenous midazolam infusion, for a mean of 11 days (range 3-27). There was a wide range of starting doses of midazolam, and 9/17 (53%) received final doses in excess of current dose recommendations. Six individuals received subcutaneous phenobarbital infusions, with four of these (67%) receiving final doses in excess of current dose recommendations. Plans for adjustments of infusion rates, maximal doses or alternative approaches should treatment fail were inconsistent or absent. In 16/18 (88%) cases seizures were successfully controlled prior to the day of the child's death. Staff found the experience of managing seizures at end of life challenging and stressful. CONCLUSIONS: Pharmacological approaches to seizure management in end-of-life care are variable, often exceeding APPM dose recommendations. Despite this, safe and effective seizure control was possible in all settings.

• Journal Article Type: Article
• Acceptance Date: Jun 7, 2017
• Online Publication Date: Jul 7, 2017
• Publication Date: Aug 19, 2020
• Deposit Date: Jul 17, 2018
• Publicly Available Date: Jul 17, 2018
• Journal: BMJ supportive & palliative care
• Print ISSN: 2045-435X
• Electronic ISSN: 2045-4368
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 10
• Issue: e22
• DOI: https://doi.org/10.1136/bmjspcare-2017-001366
• Public URL: https://uwe-repository.worktribe.com/output/885223
• Publisher URL: http://dx.doi.org/10.1136/bmjspcare-2017-001366
• Additional Information: Additional Information : This is the author's accepted manuscript. The final published version is available here: http://dx.doi.org/10.1136/bmjspcare-2017-001366.
• Contract Date: Jul 17, 2018