Minutes of meeting
Present at meeting: Dr Jim Bonham (clinical
chemist)
Dr Richard
Bowker (fellow)
Mr Gordon
Denney (lay representative/sponsor)
Miss Susie
Hewitt (general ED)
Dr Monica
Lakhanpaul (guideline
methodologist)
Sr Sue
Shipston (emergency
department practitioner)
Prof Terence
Stephenson (chair)
Dr William
Whitehouse (paed. neurologist)
Apologies from: Dr Maria Atkinson (fellow)
Dr David
Bond (general
paediatrician)
Dr Mandy
Hampshire (primary care)
Dr Ian
Maconochie (paed. ED)
Dr Stephanie
Smith (paed. ED)
Dr Harish
Vyas (PICU)
Dr John
Walter (metabolic
medicine)
AGENDA
1.
Minutes of
last meeting
The minutes of the last meeting
2.
Overview of
the
The
GDG discussed all the statements which had reached consensus and those which
had not reached consensus in rounds one and two. The GDG decided some
statements, which had already reached consensus, should be altered for clarity
and put back to the panel in round three. Some new statements were suggested
for round three. Some statements which did not reach consensus should be
altered and put back to the panel in round three. Some statements which did not
reach consensus should be omitted from the guideline. And finally, some
statements which did not reach consensus should be left to local policy decisions.
Statements
already reaching consensus
Original
statement:
“Children
with a reduced conscious level should have the following observations made:
heart rate; respiratory rate; oxygen saturation level; blood pressure; continuous
cardiac monitoring; temperature.”
Change
to statement suggested as some of these are continuously monitored whilst
others are recorded as isolated observations.
Original
statement:
“In
children with a reduced conscious level, a capillary glucose of <2.6 mmol/l
is low and should be investigated further and corrected.”
A
discussion as to whether this should apply to children less than 4 weeks old
(who may have a low cap. glucose due to feeding difficulties) concluded that
the safe approach to take was to correct the hypoglycaemia with a bolus of
dextrose plus infusion. A trial feed for an infant with a reduced conscious
level could not be recommended by the guideline, but individual practitioners
could deviate from the guideline on a case-by-case basis. No change to
statement was made.
New
statements for round three
A
statement clarifying that a child needs to be roused from normal sleep before a
Glasgow coma scale of less than 15 is documented was proposed by Dr Whitehouse.
A
statement about the clinical clues for the suspected diagnosis of bacterial
meningitis when neck stiffness is not present needs to be put to the panel (the
evidence is only available for children who have neck stiffness).
A
statement for acyl carnitines to be measured in hypoglycaemia cases and “cause
unknown” was requested by Dr Bonham as this is a very easy test to perform and
faster than urine organic acids in many centres.
Statements
not reaching consensus in round two changed for round three
Original statement:
“In children with a reduced
conscious level, a capillary glucose of 2.6-3.5 is borderline low and should be
repeated within 10 minutes”
The feedback from the panel suggests
that the timing of repeating the test is debatable and that the type of repeat
test required is debatable.
Round three statement:
This will be divided into two
separate statements, allowing a range of timings and reaffirming that the core
investigations should be sent (which include a true glucose).
Original statement:
“Children with a reduced conscious
level should be considered for intubation if their oxygen saturations are less
than 92% despite high flow oxygen therapy”
Feedback from the panel suggest that
further treatments need to be instigated.
Round three statement:
“Children with a reduced conscious
level should be considered for intubation if their oxygen saturations are less
than 92% despite high flow oxygen therapy and airway opening manoeuvres”
Original
statement:
“Children with a reduced conscious level
should be considered for intubation if they have signs of shock despite initial
fluid resuscitation therapy”
Feedback suggested more clarity
about the initial therapy.
Round three statement:
“Children with a reduced conscious
level should be considered for intubation if they have signs of shock despite
fluid resuscitation of 40ml/kg or more”
Original statement:
“Herpes simplex encephalitis should
be suspected clinically in a child with a reduced conscious level if the child
has had a prolonged convulsion with no other known precipitating cause, the
child has focal neurological signs, the child has had a fluctuating conscious
level for 6 hours or more.”
Most of the statements nearly
reached consensus. The statements will be fed back to the panel unchanged, with
additional statements combining the symptoms.
Original statement:
“A child with a reduced conscious
level and no obvious clinical sign pointing towards the cause should have the
core investigations reviewed and the following additional tests should be
requested: urine amino acids, an urgent EEG, serology for mycoplasma, ESR,
thyroid function test”
The round 3 statements will confirm
that the core tests have been reviewed without shedding light on the diagnosis,
that these tests should be “considered” and the time frame of “urgent” for EEG.
Note acyl carnitine will be added to the list for round three.
Statements not put forward to
round 3
CT scan for sepsis, bacterial
meningitis, prolonged convulsion or herpes simplex encephalitis. (
Statements where consensus will
not be reached
Fluid therapy in raised ICP was
split down the middle 70% v 100% maintenance. A statement in the final
guideline document will acknowledge this as an area for local discussion.
The dose of mannitol could not be
agreed upon ranging from 0.25 g/kg – 1 g/kg. Again this will be acknowledged in
the final guideline.
3.
This
will start shortly and hopefully be completed by the beginning of April 2005.
4.
Audit points
for the guideline
The
GDG were asked to think about what can be audited and what would be the suggested
audit topics which the guideline can put forward as part of the implementation
package.
Suggested
points included:
·
The standard
of capillary glucose being measured within 15 minutes of arrival
·
The standard
of an experienced paediatrician reviewing a child with a reduced level of
consciousness and suspected sepsis within one hour of arrival
·
The standard
of the core investigations being performed for children with reduced conscious
level within the first hour of presentation, especially whether a plasma
ammonia is being requested.
·
The standard
of the observations recommended being documented by the nursing/medical staff.
Further
audit points will be discussed at the next GDG meeting, so please continue to
think about what can be audited and what should be audited.
5.
The
Trustees/Stakeholder meeting will take place on Friday October 7th
at
As well as the listed
stakeholder groups (see website) invitations will be sent to the Delphi
panellists, the NPSA, CHAI, Clinical directors group of RCPCH, the RCPCH
representative for Dept. of Health, Patient representative groups, NHS risk
managers forum, and the chair of Q.P.C. for the RCPCH.
Please
note:
Next
GDG meeting is on Wednesday June 15th,
at 11.00 in the PGEC at QMC.
