Minutes of meeting
Present at meeting: Dr
Maria Atkinson (fellow)
Dr
David Bond (general paediatrician)
Dr Jim Bonham (clinical chemist)
Dr Richard Bowker (fellow)
Gordon
Denney (lay
representative/sponsor)
Sr Sue Shipston (nurse practitioner A+E)
Prof. Terence Stephenson (chair)
Dr William Whitehouse (paed. neurologist)
Apologies from: Dr
Mandy Hampshire (primary care)
Miss Susie Hewitt (general A+E)
Dr Monica Lakhanpaul (guideline methodologist)
Dr
Ian Maconochie (paed.
A+E)
Dr
Stephanie Smith (paed.
A+E)
Dr
Harish Vyas (PICU)
Dr
John Walter (metabolic medicine)
1. Minutes of last meeting
The minutes were passed from
2. Clinical questions to be
answered by the guideline
Before the clinical questions were discussed, the final
algorithm layout was commented upon. Comments were made about the overlap of
clinical features (e.g. vomiting, seizures, headache) for many of the different
diagnoses. Would it be possible to determine different treatments based on
initial clinical features alone or would several different treatments need to
be started and then stopped as the diagnosis became more certain? The example
of acyclovir was cited. Currently, the use of acyclovir for potential herpes
encephalitis is used by some clinicians in some circumstances in addition to
antibiotics to treat meningitis. The decision to start acyclovir is often made
on instinctive grounds rather than firm clinical features. If there is no
evidence suggesting easy ways to determine who should or should not require
acyclovir then it will be left up to the Delphi panel to provide clearer
guidance than instinct (e.g. choose a level of consciousness or a period of
decreased consciousness at which point treatments or tests should be
triggered). The view of Dr Bowker was that until the
evidence search was complete it would be difficult to comment on whether
children presenting with an altered level of consciousness could be divided
into different treatment groups based on their clinical features alone.
The
discussion moved on to the proposed clinical questions, which had been
circulated and placed on the web-site prior to the meeting. It was explained
that the terms “rapid” and “delayed” bedside tests referred to the time period
they take to come back from the laboratory, not the time they should be sent.
Ideally, the smaller the number of separate venepunctures
required the better, but the results of some tests will trigger the need to
send further tests (e.g. the finding of hypoglycaemia will trigger a long list
of metabolic / endocrine tests). The term “special” test was applied to a test
which required discussion with another department and could not be performed at
the bedside. This distinction was made for the purpose of guideline development
and will be unlikely to feature in the final algorithm.
Clinical parameters of pulse, pulse oximetry
and blood pressure were added to the list of presenting features to help
differentiate sub-groups of children who can be treated differently.
The systematic search should also address the need for
clotting studies, paracetamol and salicylate
levels to be sent in a sub-population of children on presentation.
Saved
samples of serum (rapidly spun down by the lab) and urine at the time of
admission should be taken, so that they can be used later when further results
are available. This point will go to the
The
need for a chest radiograph in children with altered consciousness was
questioned by Sr Shipston.
The evidence search would help to determine the proportion of patients with
altered conscious level without respiratory signs who had pneumonia, thereby
allowing a judgement to be made as to whether a chest xray
should be taken.
The
need for creatinine kinase
to be sent initially was questioned by Dr Bonham as it would not be helpful in
directing treatments or further tests in the first hour. Creatinine
kinase will not be reviewed by the guideline as a
necessary test to be performed at first presentation. Similarly, urinary
sulphites and urinary dinitrophenylhydrazine are
redundant tests in the face of urine profiles of amino and organic acids.
Testing for urinary reducing substances is not as accurate as performing a
Gal-1-PUT assay, and it was explained by Dr Bonham that liver transaminases would be raised in galactossaemia.
Liver function tests could therefore be used as a decision tool for sending a
Gal-1-PUT rather than performing urinary reducing substances.
The
importance of obtaining a urine sample for metabolic tests was agreed by all.
The method of obtaining urine from small children was raised by Prof.
Stephenson. Was it worth performing a suprapubic
aspirate or catheter sample if the patient had not passed urine early after
admission? This point and the time frame of waiting before collecting urine
invasively will be left to the
The
“special” tests to be reviewed will also include thyroid function and thyroid
antibodies to rule out Hashimotos encephalopathy, and
an autoimmune screen to rule out Lupus encephalopathy. The time line for
performing these tests may be after the initial presentation. The “special”
tests are likely to be directed by the results of previous tests rather than
all patients having all the tests performed. As neuroimaging
should be thought about early in the management of altered conscious level and
CT is much more readily available than MRI, it was agreed that CT and MRI will
be looked at separately.
Treatments
to be reviewed for raised intracranial pressure should also include
ventilation, hypothermia, paralysis, ventricular drainage valve, and subtemporal decompression as well as those already listed.
Considering
Biotin and B12 treatments should be reviewed by the guideline, as a trial of
these can be given whilst awaiting test results without causing harm.
Therapies
such as carnitine and arginine
are currently not given blindly, and therefore probably come outside the scope
of the guideline. Similarly, NTBC therapy for Tyrosinaemia
type II would be indicated once the diagnosis had been secured.
3.
A brief discussion took place regarding the nature of the
The
guideline development group has not completed the discussions about the
4. Other business
The first module of the guideline will have to address
all those who present with altered conscious level. The second module of the
guideline will include the patients for whom, after initial investigation
results are back, the diagnosis and treatment plan remains unclear. Prof.
Stephenson felt that signposting to other guidelines for
meningitis/encephalitis, raised intracranial pressure and sepsis would be
necessary to reduce the breadth of the guideline.
Contraindications to performing a lumbar puncture should
be addressed.
A method of encouraging the medical teams to continue to
use the guideline after the initial presentation may be to produce a care
pathway.
The patient representatives have now been identified and
will be interviewed to gauge their views on the guideline and help with a
patient / parent information leaflet. They do not wish to attend the guideline
development group meetings, but will be able to have their voice heard through
Dr Bowker.
5. Next guideline
development meeting will be on
