The objective of this paper is to provide a critical review of the article Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review) by Riviello et al. The objective of the article is to evaluate current clinical evidence which concerns the value of different types of diagnostic testing of children with status epilepticus. The main issue regarding physical assessment and diagnosis of children with status epilepticus is the fact that the research of this topic is limited.
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The main strength and the limitation of this systematic review are limited data due to the lack of a large body of research and strict selection criteria. The researchers achieved their objective and recommended considering AED levels, toxicology testing, and the use of EEG to make appropriate diagnostic or treatment decisions. The information provided in the article is clinically relevant and could be implemented into my day-to-day activities as a nurse through guidelines for diagnostic assessment.
The article, Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review), by Riviello, J. et al. seeks to address the issue of diagnostic assessment of children with status epilepticus, a well-recognized neurological emergency. Researchers evaluate the current evidence on the value of diagnostic testing in children suffering from status epilepticus and include their own recommendations based on the data available.
Status epilepticus is an increasingly recognized medical emergency that causes 42,000 annual deaths in the US alone (Sirven, 2003, par. 1). Although there were guidelines concerning the treatment of patients with status epilepticus, there were no evidence-based pediatric guidelines for its diagnostic assessment. The researchers at the American Academy of Neurology (AAN) aimed to analyze the available data and use it to formulate clinically relevant guidelines for diagnostic testing of children with status epilepticus.
Specifically, the researchers reviewed the evidence in support of different diagnostic tests, such as blood cultures, toxicology testing, metabolic and genetic testing, EEG, etc., to answer the question of whether they should be routinely performed in the assessment of children with status epilepticus. The review was founded by AAN, which “seeks to develop scientifically sound, clinically relevant Practice Parameters for the practice of neurology” (Riviello, et al., 2006, p. 1548).
There are the following elements to this review:
- Description of the process;
- Analysis of the evidence;
- Future research;
- Mission statement;
- Conflict of interest statement.
The researchers used the following process to gather evidence: they chose articles in the library of the University of Minnesota and MEDLINE which included relevant keywords (Riviello, et al., 2006, p. 1544). Only English-language articles that described case studies of a minimum of 20 participants were accepted; other search parameters included publishing date between 1970 and 2005 and patient age limit of 19 years. In addition, the team at AAN included relevant position papers from professional organizations (Riviello, et al., 2006, p. 1544). In order to evaluate the yield of diagnostic tests, the Quality Standards Subcommittee of the ANN created a proprietary evidence classification scheme (Riviello, et al., 2006, p. 1549).
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The final results of this systematic review are as follows. There was insufficient data to support or refute blood cultures and LP inclusion in regular diagnostic testing. The data supports the need to consider AED levels in routine testing of children with epilepsy on AED prophylaxis. The researchers claim that toxicology testing may also be considered in regular diagnostic testing. No sufficient data was found to support the need for routine testing for inborn errors of metabolism, but such testing might be considered if the first evaluation reveals no etiology. The same applies to neuroimage, which should be done only if the seizure activity is under control.
The evidence supports the use of EEG to determine abnormalities in children with status epilepticus which can help the health care professional to make appropriate diagnostic or treatment decisions. The researchers conclude that further research is needed for evidence-based pediatric guidelines to be complete. In particular, controlled prospective blinded studies are required to determine the yield of neuroimaging, the role of laboratory investigation, and to determine the timing for EEG testing in children with status epilepticus (Riviello, et al., 2006, p. 1548). The researchers claim that additional prospective studies are needed to evaluate the prognostic significance of non-convulsive status epilepticus (Riviello, et al., 2006, p. 1548).
The biggest strength of this systematic review is the strict approach toward data collection. Since irrelevant articles with small samples or unusual pathologic findings were excluded, the results of the systematic review were scientifically valid, which is a strong point of this review. The strict approach toward data sourcing means that conclusions made by the researchers are based on valid clinical information.
Another strong point of this review is the classification scheme, developed by respectable scientists who are a part of QSS at AAN. However, strict criteria also mean that the sample size was quite small, with only 25 articles out of over 1600 publications corresponding to the necessary requirements. This fact also highlighted the lack of substantial evidence for certain diagnostic tests; although, this might be a general problem of insubstantial research efforts in this direction. Nonetheless, the team at AAN did achieve its objective of analyzing the available data and using it to formulate clinically relevant recommendations, albeit their work is not finished and is the first step towards future research of the value of different diagnostic tests for children with status epilepticus.
In my opinion, the evidence-based approach is essential for both health services research as well as for making appropriate treatment or diagnostic decisions. This approach means using the best available clinical evidence such as clinical trials to make informed decisions (Romana, 2006). In order to provide better quality diagnosis and treatment for children with status epilepticus, medical professionals in charge of their care have to consult the current best evidence to improve the quality of health services. All nurses are committed to further advancing medical science by conducting research and implementing research evidence in their work (LoBiondo-Wood, & Haber, 2014, p. 7).
This fact means that as a nurse I must be a knowledgeable consumer of research and use it in evidence-based practice. The information from Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review) is clinically relevant and could be implemented into my day-to-day activities as a nurse through guidelines for diagnostic assessment. The information provided in the review helped me better understand the effectiveness of particular tests for the evaluation of the child with status epilepticus. The systematic review also helps raise awareness on the issues of status epilepticus diagnostic assessment and the need to conduct additional research on this topic.
The report was done by the researchers at AAN successfully used the best available data to evaluate the current clinical practice of status epilepticus diagnostic assessment and provided specific recommendations on which ones should be included in pediatric guidelines.
LoBiondo-Wood, G., & Haber, J. (2014). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. Amsterdam, Netherlands: Elsevier Health Sciences.
Riviello, J., Ashwal, S., Hirtz, D., Glauser, T., Ballaban-Gil, K., Kelley, K.,…& Shinnar, S. (2006). Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review). Neurology, 67, 1542-1550.
Romana, H. (2006). Is Evidence-Based Medicine Patient-Centered and Is Patient-Centered Care Evidence-Based? Health Services Research Journal, 41(1), 1-8. Web.
Sirven, J. (2003). Management of status epilepticus. Web.