Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus

Objective: To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). Methods: We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining four phases during status epilepticus management: 1) baseline characteristics, 2) acute treatment, 3) 20-minute neurologic recovery, and 4) 60-minute recovery, including seizure cessation and improving responsiveness. Results: Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4-32% at pediatric sites and 19-39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve (AUC) .63). However, treatment at sites with an intubation rate in the highest (versus lowest) quartile strongly predicted endotracheal intubation independent of other treatment variables (adjusted OR (aOR) 8.12, 95% CI 3.08, 21.4; model AUC .70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjusting for 20-minute (aOR 23.4; 95% CI 6.99, 78.3; model AUC .88) and 60-minute neurologic recovery (aOR 14.7; 95% CI 3.20, 67.5; model AUC .98). Conclusions: Endotracheal intubation following established status epilepticus is strongly associated with site-specific practice pattern variation, independent of baseline characteristics. and early neurologic recovery, and should not alone serve as a clinical trial endpoint in established status epilepticus.