Results from the UK national audit
Paediatric convulsive status epilepticus is a time-critical neurological emergency with potential progression to refractory and super-refractory status epilepticus, carrying substantial morbidity and mortality. Current APLS and national guidelines appropriately focus on timely seizure termination and escalation of care, recommending preparation for intubation once second-line antiepileptic agents have been administered.
While the indications for intubation are well described, there is a notable absence of evidence to guide decisions after airway control has been achieved. In particular, data on extubation practices in children intubated during emergency management of status epilepticus are scarce. The authors sought to address this gap through a nationwide audit of UK paediatric critical care transport services, examining extubation practices, outcomes, and predictors of successful local extubation.
Knight P, Norman V, Gully R, et al. Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis. Arch Dis Child. 2024;109(6):476-481. Published 2024 May 17. doi:10.1136/archdischild-2023-326320
Methods
This is a retrospective audit involving case record review and case-control analysis. It took place over 2 years, from 1 September 2018 to 1 September 2020. They collected data on all children aged over 1month of age, intubated during seizure management and referred to 1 of 10 UK paediatric critical care transport teams (PCCTs).
Participating centres contributed to the collection of demographic data and outcome measures, including 24-hour follow-up.
Results
Out of 1622 paediatric SE referrals, 1136 children were intubated and included in the study.
| Attempted extubation at DGH | 396 (34.9%) |
| Successful extubation | 377 (33.2%) |
| Re-intubation | 19 (4.8%) |
| PICU Transfer | 759 (66.8%) |
Out of 759 intubated children transported to PICU, 71 (9.5%) were extubated < 6hours, 91 (12.3%) at 6-12 hours, 155 (20.8%) at 12-24 hours, 204 (27.4%) children over 24 hours. The timing of extubation was unknown in 238 (29.9%).
The study found an inverse relationship between local extubation rates and the timing of extubation for those children who were transferred to PICU.
The children transferred by regions with high local success rates were more likely to require prolonged care, with 60% remaining intubated for over 24 hours after PICU arrival, potentially indicating the severity of critical illness.
| Region Type | Local Extubation Rate (Avoiding Transfer) | PICU Extubation Rate <12 hrs (Short Stay) | PICU Extubation Rate >24 hrs (Long Stay) |
| High Local extubation | 74% | 14% | 60% |
| Low Local extubation | 2.2% | 45% | 23% |
The overall risk of reintubation following local attempts at extubation was low, estimated at less than 1 in 20. The risk of re-intubation specifically due to recurring seizures is even lower, at 1 in 50 or less. However, failures were often linked to “avoidable” factors, such as attempting extubation when the child still had a low Glasgow Coma Scale (GCS) score or requiring high levels of respiratory support.
The multivariable logistic regression analysis identified several independent factors that significantly predict whether a child can be successfully extubated at a local hospital or if they will require transfer to a critical care unit.
The key predictors include:
- Maintenance Sedation Type: This was one of the strongest predictors. The use of Propofol for continuous sedation post-intubation was significantly associated with successful local extubation (OR 6.67). Conversely, Midazolam infusions were strongly associated with the need for transfer to a PICU.
- Contributing Diagnosis: Children with no identified acute primary contributing factor had the highest odds of successful local extubation. In contrast, a diagnosis of infection (OR 0.51) or metabolic derangement (OR 0.12) significantly increased the likelihood of requiring transfer to intensive care.
- Acute CT Brain Findings: The absence of acute changes on a CT head scan was a significant predictor of success. If acute changes were present, the odds of successful local extubation dropped significantly (OR 0.17).
- Preceding Encephalopathy: Children who did not exhibit neurological symptoms suggesting encephalopathy prior to the seizure were much more likely to be successfully extubated locally. The presence of preceding encephalopathy was a strong predictor for transfer (OR 0.12).
- Medication Burden (Second-tier AEDs): The number of second-tier anti-epileptic drugs (AEDs) administered was an inverse predictor. Requiring fewer drugs increased the chance of success; as the number of AEDs increased (from 1 to 3), the odds of successful local extubation decreased (OR 0.55 down to 0.17).
- Region and Transport Team: The specific geographical region and the transport team involved were significant independent variables. Success rates ranged from 2% to 74%, with the highest success found in regions with established, detailed extubation guidelines. The team that achieved the highest rate (74%) regularly conducted annual status epilepticus audits and provided feedback to local teams on guideline adherence and complications.
Interestingly, the multivariable analysis found that factors such as the choice of induction agents, the reason for intubation, and the number of benzodiazepine doses did not significantly influence whether a child could be successfully extubated locally.
The authors identified the following themes based on existing guidance.
Limitations
The study’s primary limitations include its retrospective design and the potential for bias resulting from one of the eleven UK transport teams at time of data collection failing to submit data. Furthermore, the analysis lacked precise extubation timings and relied on subjective diagnostic categories that required interpretation by the recording clinical teams.
How good is the study – the CASP checklist
Q1 – Did the study address a clearly focused issue?
Yes.
The study focused on a specific population (children >1 month intubated for SE referred to UK transport teams), risk factors, and a specific outcome (successful local extubation versus transfer).
Q2 – Did the authors use an appropriate method to answer their question?
Yes.
A case-control analysis is appropriate for identifying factors associated with a specific outcome (successful local extubation) within a retrospective cohort.
Q3 – Were the cases recruited in an acceptable way?
Yes.
All cases (intubated during seizure management of status epilepticus) were precisely defined and representative of the UK population, as they were recruited through 10 UK transport teams over a two-year period. Trauma and neurosurgical cases were excluded.
Q4 – Were the controls selected in an acceptable way?
Yes.
The controls were the 759 children who were transferred to a PICU intubated. They were recruited from the same referral population and time frame as the cases, minimising selection bias.
Q5 – Was the exposure accurately measured to minimise bias?
Yes.
Clinical data were recorded by transport teams during the initial referral and management. The temporal relationship is correct: the clinical factors (exposure) occurred before the outcome (successful extubation or transfer).
Q6 – Have the authors taken account of confounding factors?
Yes.
The researchers used multivariable logistic regression to identify independent predictors and to adjust for potential confounders, including age, diagnosis, and geographic region.
Q7- Was the treatment effect large?
Yes.
Strong associations were found.
Q8 – Was the estimate of the treatment effect precise?
Yes.
The study provided 95% Confidence Intervals for all major predictors
Q9. Do you believe the results?
Yes.
The results are based on a large, national dataset of 1,136 children. The findings are biologically plausible; for instance, children with infections or metabolic issues (who may be more unstable) were more likely to require transfer.
Q10 – Can the results be applied to your local population?
Yes.
Since the study covered nearly all of the UK (10 out of 12 transport teams), the results are highly applicable to UK district general hospitals and similar healthcare systems that utilise tertiary transport models.
Q11 – Do the results fit with other available evidence?
Yes.
While the authors state this is the first paper to report these specific predictors for early extubation in SE, the findings regarding the safety of de-escalation are consistent with the goal of reducing unnecessary critical care transfers.
Reflection and next steps:
The study had a large multicentre sample, identified clear clinical predictors, and demonstrated a low reintubation rate (4.8%), supporting the safety of extubation at local hospitals.
The region and transport team remained significant independent predictors even after adjustment for clinical factors.
The regions achieving the highest extubation rates were those with the most detailed agreed extubation criteria and, in the case of the highest-performing team, a programme of annual SE audit with feedback to local DGHs.
This implies that robust regular audits of individual PCCTs and supporting local DGHs with strong evidence-based guidelines combined with feedback could help reduce incidence of PICU admissions.
A prospective design would allow researchers to measure the actual burden to local hospitals when care is de-escalated early.
References
National Institute for Health and Care Excellence (NICE) (2022) Epilepsies in children, young people and adults: Treating status epilepticus, repeated or cluster seizures, and prolonged seizures (NG217). Available at: https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures (Accessed: 1 February 2026).
Critical Appraisal Skills Programme (CASP) (2024) CASP checklist: Case control study. Available at: https://casp-uk.net/checklists/ (Accessed: 1 February 2026).
Behjati, S., Jamieson, K., Montgomery, M., et al. (2012) ‘Do paediatric high dependency units in district general hospitals improve patient care? A local review of children presenting with seizures’, Archives of Disease in Childhood, 97, p. 582.
