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Seizure management in children requiring palliative care: a review of current practice
  1. Nicola Harris1,
  2. Megumi Baba2,
  3. Charlotte Mellor3,
  4. Rebekah Rogers4,
  5. Kirsty Taylor5,
  6. Antonia Beringer6 and
  7. Peta Sharples7
  1. 1Centre for Health and Clinical Research, University of the West of England, Bristol, UK
  2. 2Medical Director, Children’s Hospice South West, nr Bristol, UK
  3. 3Paediatric Palliative Medicine, United Hospitals Bristol NHS Foundation Trust, Bristol, UK
  4. 4Paediatric Pharmacy, United Hospitals Bristol NHS Foundation Trust, Bristol, UK
  5. 5Community Children's Nursing Team, Devon VirginCare, Dartington, UK
  6. 6Faculty of Health and Allied Sciences, University of the West of England, Bristol, UK
  7. 7Paediatric Neurology, United Hospitals Bristol NHS Foundation Trust, Bristol, UK
  1. Correspondence to Dr Nicola Harris, Orchard Cottage, Nailsbourne, Taunton, Somerset TA2 8AG, UK; nicky.harris{at}nhs.net

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.

  • seizures
  • midazolam
  • terminal care
  • hospice care
  • paediatric
  • Received 13 April 2017.
  • Revision received 5 June 2017.
  • Accepted 7 June 2017.

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  • Received 13 April 2017.
  • Revision received 5 June 2017.
  • Accepted 7 June 2017.
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Footnotes

  • Contributors NH, PS, CM, MB and KT were involved in the design of the project and securing funding. NH, CM, KT and MB sourced data. All authors were involved in data analysis and interpretation, and in drafting this paper.

  • Funding Funding for this project was obtained from Health Education England, as part of an initiative from the South West Strategic Clinical Network to improve End of Life Care.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Original project data is held by NH. This includes full analysis of results of the survey of professionals, and anonymised data from audited case notes. Data will be stored securely at UWE for 7 years and then destroyed. For further information please contact nicky.harris@uwe.ac.uk.

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