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Intravenous Versus Nonintravenous Benzodiazepines for the Cessation of Seizures: A Systematic Review and Meta‐analysis of Randomized Controlled Trials
Author(s) -
Alshehri Abdussalam,
Abulaban Ahmad,
Bokhari Rakan,
Kojan Suleiman,
Alsalamah Majid,
Ferwana Mazen,
Murad Mohammad Hassan
Publication year - 2017
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.13190
Subject(s) - medicine , randomized controlled trial , confidence interval , meta analysis , medline , cochrane library , relative risk , anesthesia , political science , law
Abstract Background The acquisition of intravenous ( IV ) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine ( BDZ ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity. Objective The objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non‐ IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes). Methods A systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi‐randomized controlled trials directly comparing IV to non‐ IV (buccal, rectal, intranasal, or intramuscular) BDZ were included. Results Our search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non‐ IV BDZ was superior to IV BDZ (odd ratio [ OR ] = 0.72; 95% confidence interval [ CI ] = 0.56–0.92). However, no significant difference was found between the two treatments in the pediatric subgroup ( OR = 1.16; 95% CI = 0.74–1.81). Non‐ IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69–5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52–0.95 minutes). Respiratory complications requiring intervention were similar between non‐ IV BDZ and IV BDZ , regardless of administration route (risk difference = 0.00; 95% CI = –0.02 to 0.01). Conclusion Non‐ IV BDZ , compared to IV BDZ , terminate seizures faster and have a superior efficacy and side effect profile. Higher‐quality studies and further evaluation in different age groups are warranted.