학술논문
Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States.
Document Type
Academic Journal
Author
Guterman EL; Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA. Electronic address: Elan.Guterman@ucsf.edu.; Sporer KA; Department of Emergency Medicine, University of California, San Francisco, CA.; Newman TB; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA.; Crowe RP; ESO, Inc. Kaiser Permanente, Northern California, San Francisco, CA.; Lowenstein DH; Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA.; Josephson SA; Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA.; Betjemann JP; Department of Neurology, Kaiser Permanente, Northern California, San Francisco, CA.; Burke JF; Department of Neurology, Ohio State Wexner Medical Center, Columbus, OH; Department of Neurology, University of Michigan, Ann Arbor, MI.
Source
Publisher: Mosby Country of Publication: United States NLM ID: 8002646 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1097-6760 (Electronic) Linking ISSN: 01960644 NLM ISO Abbreviation: Ann Emerg Med Subsets: MEDLINE
Subject
Language
English
Abstract
Study Objective: Guidelines recommend 10-mg intramuscular midazolam as the first-line treatment option for status epilepticus. However, in real-world practice, it is frequently administered intranasally or intravenously and is dosed lower. Therefore, we used conventional and instrumental variable approaches to examine the effectiveness of midazolam in a national out-of-hospital cohort.
Methods: This retrospective cohort study of adults with status epilepticus used the ESO Data Collaborative research dataset (January 1, 2019, to December 31, 2019). The exposures were the route and dose of midazolam. We performed hierarchical logistic regression and 2-stage least squares regression using agency treatment patterns as an instrument to examine our outcomes, rescue therapy, and ventilatory support.
Results: There were 7,634 out-of-hospital encounters from 657 EMS agencies. Midazolam was administered intranasally in 20%, intravenously in 46%, and intramuscularly in 35% of the encounters. Compared with intramuscular administration, intranasal midazolam increased (risk difference [RD], 6.5%; 95% confidence interval [CI], 2.4% to 10.5%) and intravenous midazolam decreased (RD, -11.1%; 95% CI, -14.7% to -7.5%) the risk of rescue therapy. The differences in ventilatory support were not statistically significant (intranasal RD, -1.5%; 95% CI, -3.2% to 0.3%; intravenous RD, -0.3%; 95% CI, -1.9% to 1.2%). Higher doses were associated with a lower risk of rescue therapy (RD, -2.6%; 95% CI, -3.3% to -1.9%) and increased ventilatory support (RD, 0.4%; 95% CI, 0.1% to 0.7%). The instrumental variable analysis yielded similar results, except that dose was not associated with ventilatory support.
Conclusion: The route and dose of midazolam affect clinical outcomes. Compared with intramuscular administration, intranasal administration may be less effective and intravenous administration more effective in terminating status epilepticus, although the differences between these and previous results may reflect the nature of real-world data as opposed to randomized data.
(Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)
Methods: This retrospective cohort study of adults with status epilepticus used the ESO Data Collaborative research dataset (January 1, 2019, to December 31, 2019). The exposures were the route and dose of midazolam. We performed hierarchical logistic regression and 2-stage least squares regression using agency treatment patterns as an instrument to examine our outcomes, rescue therapy, and ventilatory support.
Results: There were 7,634 out-of-hospital encounters from 657 EMS agencies. Midazolam was administered intranasally in 20%, intravenously in 46%, and intramuscularly in 35% of the encounters. Compared with intramuscular administration, intranasal midazolam increased (risk difference [RD], 6.5%; 95% confidence interval [CI], 2.4% to 10.5%) and intravenous midazolam decreased (RD, -11.1%; 95% CI, -14.7% to -7.5%) the risk of rescue therapy. The differences in ventilatory support were not statistically significant (intranasal RD, -1.5%; 95% CI, -3.2% to 0.3%; intravenous RD, -0.3%; 95% CI, -1.9% to 1.2%). Higher doses were associated with a lower risk of rescue therapy (RD, -2.6%; 95% CI, -3.3% to -1.9%) and increased ventilatory support (RD, 0.4%; 95% CI, 0.1% to 0.7%). The instrumental variable analysis yielded similar results, except that dose was not associated with ventilatory support.
Conclusion: The route and dose of midazolam affect clinical outcomes. Compared with intramuscular administration, intranasal administration may be less effective and intravenous administration more effective in terminating status epilepticus, although the differences between these and previous results may reflect the nature of real-world data as opposed to randomized data.
(Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)