Minutes of meeting
Present at meeting: Dr David Bond (general
paediatrician)
Dr Richard
Bowker (fellow)
Miss Susie
Hewitt (general ED)
Dr Monica
Lakhanpaul (guideline
methodologist)
Dr Stephanie
Smith (paed. ED)
Prof Terence
Stephenson (chair)
Dr Harish
Vyas (PICU)
Apologies from: Dr Maria Atkinson (fellow)
Dr Jim
Bonham (clinical
chemist)
Mr Gordon
Denney (lay representative/sponsor)
Dr Mandy
Hampshire (primary care)
Dr Ian
Maconochie (paed. ED)
Sr Sue
Shipston (emergency
department practitioner)
Dr John
Walter (metabolic
medicine)
Dr William
Whitehouse (paed. neurologist)
AGENDA
1.
Minutes of last meeting
The minutes
of the last meeting
- Overview of the final
The results of the third and final round
of the
(i) Bacterial meningitis: 2 statements
reached consensus on how to suspect bacterial meningitis in the absence of neck
stiffness:
a) Children
with reduced conscious level but no neck stiffness should be suspected of having bacterial meningitis clinically
if they have fever and two of the following:
rash
irritability
bulging fontanelle (75%
agreement)
b) Consider bacterial meningitis in
children with a reduced conscious level without neck stiffness if they have a
fever, a rash, a bulging fontanelle and or they are irritable. (83%
agreement)
The
GDG agreed that statement (a) was preferable as it gave clear instructions as
to when to “suspect” bacterial meningitis. The GDG felt that the wording of
statement (b) should have led to 100% agreement as bacterial meningitis should
always be “considered” in these patients.
(ii) Herpes simplex encephalitis: after
two rounds the
“Herpes
simplex encephalitis should be suspected clinically in a child with a reduced
conscious level (and therefore aciclovir
started) if:”
a) the child has focal neurological signs (84%
agreement)
b) the child has had a fluctuating conscious level for 6
hours or more (79% agreement)
c) the child has had two or more of the following:
a prolonged convulsion with no obvious
precipitating cause
focal neurological signs, including a focal
convulsion
a fluctuating conscious level for 6 hours or
more (92%
agreement)
d) the child has had all of the following:
a prolonged convulsion with no obvious
precipitating cause
focal neurological signs, including a focal
convulsion
a fluctuating conscious level for 6 hours or
more (96% agreement)
e) the
child has or has been in contact with herpetic lesions (84% agreement in round
2)
f) A child with a reduced consciousness and no obvious
clinical signs pointing towards the cause should be started on acyclovir(81.8% agreement
in round 1)
The
GDG decided that statements (a) and (b) included more patients than (c) or (d)
and it is sensible to encourage clinicians to suspect HSE in more children than
less. The statement about “prolonged convulsion with no obvious precipitating
cause” in (c) and (d) is covered by statement (f), i.e. if the cause of the
convulsion is not known then the cause of the reduced conscious level is not
known and the child will be suspected of having HSE. The final statement will
read:
“Herpes
simplex encephalitis should be suspected clinically in a child with a reduced
conscious level if one or more of the following 4 :
the child has focal neurological signs
the
child has had a fluctuating conscious level for 6 hours or more
the
child has or has been in contact with herpetic lesions
the
child has no obvious clinical signs pointing towards the cause”
- Stakeholder comments
The stakeholder groups were
asked to comment on the draft guideline recommendations and algorithm. Their
input needs to be incorporated into the guideline without undermining the
(i)
Hypertensive encephalopathy
Hypertension had not been
mentioned in the guideline due to the risk of confusing hypertension of raised
ICP from hypertension of hypertensive encephalopathy. However, this was pointed
out by a number of stakeholders to be a flaw in the guideline. The GDG reviewed
the comments made by the stakeholders and decided that guidance on hypertension
is required in the algorithm and therefore is part of the scope of the
guideline. If there is no evidence available to guide detection or management
of hypertensive encephalopathy then the statements from the stakeholders will
be used to form a consensus statement from the GDG.
(ii)
Pharmacy comments
The National paediatric
pharmacy group commented that the doses and infusions should be clearly stated
on the algorithm. A separate page will therefore be devoted to the calculations
of infusions which have been mentioned in the guideline and are not readily
available in an “off the shelf” preparation.
(iii)
PICs / APEM comments
They felt that oxygen should
be given to all children. The
(iv)
APEM / RCPath comments
The recognition of shock does not include
tachycardia. The
“Shock can be recognised
clinically if one or more of the following signs are present in a child with
reduced conscious level:
Capillary refill time > 2 seconds
Mottled cool extremities
Diminished peripheral pulses
Systolic blood pressure is less than 5th percentile
for age
Decreased urine output <1ml/kg/hour”
The GDG agreed that
tachycardia is a sign of shock and an early sign. However, the other signs of a
compromised circulation are included in the
(v)
GDG comments
The recommendation to collect a
urine sample on admission by urine bag would not be appropriate for older
children. The statement has been changed from:
“As a non-sterile urine sample is required
for these tests [the core investigations], a urine
bag should be in situ as soon as the patient has had monitors attached”
to: “As a non-sterile urine sample is required for
the core investigations, a technique for collecting urine should be in place as
soon as the patient has had
monitors attached, e.g. urine bag, clean catch collecting device, catheter”
- Audit criteria
The list of audit criteria drawn up at the
last meeting was discussed along with further suggestions from the GDG members.
The final recommended audit criteria are:
|
Criterion |
Exception |
Definition
of terms |
|
Percentage
of children with a reduced conscious level having a plasma ammonia sent |
Children
within one hour post convulsion. Children
with trauma not related to a medical collapse. |
Plasma
ammonia result should be available in the notes or on the hospital results
system |
|
Percentage
of children with a reduced conscious level having a sample of urine sent to
clinical pathology to be saved for later use |
Children
within one hour post convulsion. Children
with trauma not related to a medical collapse |
Saved
urine sample sent should be documented in the notes or on the hospital
results system |
|
Percentage
of children with a reduced conscious level who have their respiratory rate
from admission documented in the notes |
|
|
|
Percentage
of children with a reduced conscious level who have their blood pressure from
admission documented in the notes |
|
|
|
Percentage
of children with a reduced conscious level who have their GCS from admission
documented in the notes |
|
|
|
Percentage
of children with suspected bacterial meningitis who were treated with
intravenous dexamethasone before or with the first dose of antibiotics. |
|
Suspected
bacterial meningitis is defined by a score of 8.5 or more using the clinical
diagnostic decision rule below if the child has neck stiffness: Symptom/sign Score If GCS
< 9 = 8 Neck
stiffness present = 7.5 Duration
of symptoms = 1 /each 24 hrs Vomiting = 2 Cyanosis = 6.5 Petechiae = 4 Serum CRP = CRP value (g/dl) divided by 100 or if the
child does not have neck stiffness but has fever and two or more of the
following: rash irritability bulging
fontanelle |
These audit criteria were
selected as they were readily measurable and important markers of good
practice. The criterion for dexamethasone given in suspected bacterial meningitis
is based on level 1a evidence. These audit criteria were also selected as the
GDG felt performance could be improved in these areas (personal experience).
- Implementation strategies
These will be further
discussed at the next meeting.
- GDG comments on the algorithm
The new algorithm was
discussed and several alterations have been suggested which will add to the
clarity of the document. Recommendations based on level 1 evidence will be
highlighted on the algorithm in such a way as to not affect the ease of use of
the algorithm. Dr Bowker will make the necessary changes and pilot the
algorithm in the next few weeks to highlight further adaptations.
The
next GDG meeting is to be on the 26th
August at
Minutes written by Dr Richard Bowker 15th
June, 2005
