Minutes of
meeting
Present at meeting: Dr
Jim Bonham (clinical
chemist)
Dr Richard Bowker (fellow)
Gordon Denney (lay representative/sponsor)
Miss Susie Hewitt (general A+E)
Sr Sue Shipston (nurse practitioner A+E)
Dr Stephanie Smith (paed. A+E)
Prof Terence Stephenson (chair)
Apologies from: Dr
Maria Atkinson (fellow)
Dr
David Bond (general
paediatrician)
Dr
Mandy Hampshire (primary care)
Dr Monica Lakhanpaul (guideline methodologist)
Dr
Ian Maconochie (paed. A+E)
Dr
Harish Vyas (PICU)
Dr
John Walter (metabolic
medicine)
Dr William Whitehouse (paed. neurologist)
AGENDA
1
Minutes of previous meeting
The minutes of the last
meeting
2
Update on progress
The searches which are
now completed include the topics of shock, sepsis, trauma, meningitis, herpes
simplex encephalitis, hyperammonaemia and hyperglycaemia.
Searches remain to be
completed in the topics of raised intracranial pressure, convulsions,
hypoglycaemia, and catabolic state (re-named “non-hyperglycaemic
ketoacidosis”).
The first round of the
3
Statements from round
one had previously been defined as reaching consensus if >75% of responses
ticked
The following courses of actions
were agreed by the guideline development group:
a) Those statements which reached consensus in agreement with the
statement would be included in the guideline, unless there were significant
comments made by the
b) Those statements which reached consensus in disagreement with
the statement would be excluded from the guideline.
c) Those statements which did not reach consensus, should be fed
back to the panel in round two with a clarification of the same statement, with
the statistical analysis of the level of agreement, with comments from the
panel, and / or changes to the wording or substance of the statement.
The statements
which fell into category (a) were:
Stem: “Children with a reduced conscious level should be
intubated if: …”
Several of the options
were agreed upon (e.g. “their
Change for
round 2 :
“In children with a reduced conscious level, consider intubation if: “
Stem: “Contraindications for lumbar puncture include:…”
Several of the options
were agreed upon but some which were felt to be clear cut contraindications
were not including “a
Change for
round 2:
“A lumbar puncture should not be
performed as part of the initial acute
management if:…”
Stem: “Children with a reduced conscious level and shock which
has been unresponsive to 40ml per kg should be monitored on an intensive care
unit.”
Comments indicated that
High dependency Units would be locally available and capable of monitoring
these cases.
Change for
round 2:
“Children with a reduced conscious level and shock which has been unresponsive
to 40ml per kg should be monitored on an intensive care unit or high dependency unit.”
Stem: “If the microscopy of a cerebrospinal fluid sample is
abnormal, request a Zeihl-Neelsen stain”
Comments suggested a
definition of abnormal should be included.
Change for
round 2:
To be discussed with microbiology stakeholder group.
Stem: “The emergency treatment of hypoglycaemia in a child with a
reduced conscious level is a bolus of 5ml/kg of 10% dextrose solution”
Comments from the
metabolic medicine panellists recommend only using 2ml/kg to reduce the risk of triggering further insulin release
in hyperinsulinaemic patients.
The Guideline development group could not quantify the risk of triggering
insulin release with this dose of glucose and what the evidence is for this. As
APLS guidance is currently 5ml/kg and is well established in the training
package a decision was made to check with the authors of the new APLS manual to
determine that this is still going to be their advice.
Change for
round 2:
To be decided after further look at the evidence.
Stem: A child with
a reduced conscious level, a capillary/venous pH < 7.3 and ketones in the
urine is in a catabolic state.
The guideline
development group felt that this term was not useful as a “catabolic state”
does not necessarily imply a pathological condition which needs special
attention. The background to the statement is the need for some patients to be
treated with insulin and dextrose to switch catabolism to anabolism (especially
for excessive muscle / glycogen
breakdown which can occur in metabolic conditions). The term
“non-hyperglycaemic ketoacidosis” was agreed to be a better descriptive term.
Change for
round 2:
Any statement with the term “catabolic state” should be changed to “non-hyperglycaemic ketoacidosis”.
The statements
which fell into category (c) were:
Stem: In a child 3
months of age or over with a reduced conscious level, a capillary glucose level
of less than 3.5 mmol/l is low and should be investigated and corrected.
Comments ranged from 3.5
mmol/l being too high a cut off level to the reliability
of various methods of performing a capillary bedside glucose test (BM stix are known to be unreliable at the lower
range but electronic testing kits are more reliable
but not as reliable as laboratory tests). The guideline development group agreed that the level of 3.5 mmol/l was
too high (3rd centile for children) and that treatment need not be started until a reading of < 2.6
mmol/l was obtained. However,
re-testing a capillary glucose within 10 minutes if the initial result was 2.6 – 3.5 mmol/l would be reasonable. As
the child has a reduced conscious level, the core
investigations will be sent (agreed by the
Changes for
round 2:
In all children with reduced conscious level, a capillary glucose of less than 2.6 mmol/l is low and
should be investigated further and corrected.
In
children with a reduced conscious level, a capillary glucose of 2.6 – 3.5 mmol/l is borderline low and should be
repeated within 10 minutes.
Stem: During the first
hour of the post-convulsion state, it may be appropriate to observe the child
without initiating any tests or treatments.
Comments suggested that
at least a capillary glucose should be performed in this circumstance.
Change
for round 2: During the first hour of the post-convulsion state, it may be
appropriate to observe the child without initiating any tests or treatments if the capillary glucose is normal.
Stem: All children
with reduced consciousness (except those patients within one hour post convulsion,
who are clinically stable) should be investigated with the following tests at
presentation: Plasma ammonia,
Plasma lactate,
1 – 2 ml of plain serum
saved for later analysis,
urine for organic acids
CT scan,
LP (if not
contraindicated)
Comments indicated that
these tests were not sent as first line samples or further indications were required before automatically requesting
the tests. The guideline development group discussed ammonia as one of the key
investigations which has to be sent fresh (ie cannot be requested later from
the other samples), is a treatable
condition, and the test is available (audit of northern NHS labs) – for round 2
the statement will be sent back to the panel with clarification of these
points. Plasma lactate can be requested from the blood glucose sample agreed
upon, urine for organic acids can be requested from the urine saved sample
agreed upon – for round 2 these statements will not be included. 1-2ml of plain
serum could be useful for serology tests and this point will be clarified in
round 2. The CT scan and LP comments indicated that the panel wanted more
details before requesting - for round 2 the panel will be asked for indications
to perform these procedures.
Stem: (Regarding shock) If more than 40 ml per kg of fluid has
been given, the child should be intubated and ventilated to prevent
uncontrolled pulmonary oedema developing.
Comments indicated that
this statement was too strong.
Change for
round 2:
If more than 40 ml per kg of fluid has been given, consider intubating and ventilating the child to prevent
uncontrolled pulmonary oedema developing.
Stem: (Regarding
shock) If more than 40 ml per kg of fluid has been given with little clinical
response, inotropic support should be initiated.
Comments indicated that
this statement was too strong and that the term “inotropes” is not a collective
term (eg some may prefer to use vasopressor agents).
Change for
round 2:
If more than 40 ml per kg of fluid has been given with little clinical
response, drug treatment to support the circulation should be considered.
Stem: If raised intracranial pressure is suspected, then the
child should undergo the following treatments:
sedate, intubate and ventilate the
patient to maintain the PaCO2 between 4.0 and 5.0
kPa
Administer a dose of 1g/kg of
intravenous mannitol
Maintenance fluid should be
administered at 70% / 100% of normal
Maintenance fluid should be 0.9%
saline
Comments indicated that
more than a suspicion of raised intracranial pressure was required for
intubation and mannitol. In round 2 the panel will be asked for indications for
these treatments which are available in the first hour. The volume of
maintenance fluids provoked a split in the group: 100% maintenance runs the
risk of worsening cerebral oedema while the 70% maintenance runs the risk of
reducing the cerebral perfusion pressure. A continuous scale for fluid volume
was suggested for round 2, with the mean value being the consensus figure. The type
of fluid was not agreed upon therefore the comments will be fed back to the
group in round 2.
Stem: Patients with
suspected raised intracranial pressure should have invasive intracranial
pressure monitoring performed if…
Comments reflected the
opinion that there was little evidence in this field and case by case
assessment was required. The guideline development group decided that these
statements were outside the scope of the guideline and so have been excluded
from the guideline.
Stem: Herpes simplex encephalitis should be clinically suspected
if two or more of the following are present: fever, convulsions, headache,
vomiting, focal neurological signs.
Comments indicated that
all these signs were too non-specific. The panel did agree to give aciclovir if
there were no clinical clues to the cause of the reduced conscious level, but
not if there were non-specific features of HSE. The guideline development group
discussed this point and felt that advice on when to suspect HSE should be
provided by the guideline and in its current form HSE is a diagnosis of
exclusion rather than inclusion. The guideline development group wanted to find
out if there were any validated algorithms available to put to the panel for
round 2.
Change for
round 2:
To be decided after consultation with stakeholder groups.
Stem: A child with
a reduced conscious level who is in a catabolic state needs treating by the
following algorithm…
Comments indicated that
the algorithm was too aggressive and the panel was not familiar with this form
of treatment. The guideline development group agreed to change “catabolic
state” to “non-hyperglycaemic ketoacidosis”.
Change for
round 2:
A child with a reduced conscious level who has non-hyperglycaemic ketoacidosis
may benefit from an insulin infusion with a high dose dextrose infusion.
4
Round two will begin as
soon as possible, so the results can be discussed at the next guideline
development group meeting.
5
Any other business
A time line for the
investigations was proposed as a helpful tool for the guideline and this will
be developed along with the algorithm.
The input from parents
was acknowledged and thanked. Their contributions have been very important to the
guideline project and have confirmed the need for a guideline of this nature.
Their contributions continue to be welcomed.
A meeting with the
trustees of the National Reye’s Syndrome Foundation was suggested for September
2005, towards the end of the guideline project. Stakeholder groups would be
invited to attend and comment on the guideline at this stage before the final
draft version is produced.
The
next meeting will be at
Minutes
written by Richard Bowker 18th November, 2004
