PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

18. Peri-arrest management

Statement 18

(i) If a child with a decreased conscious level deteriorates rapidly or dies suddenly, the parents / guardians should be asked to consent for a skin biopsy

% Agree	% Disagree	Result
82.8%	13.8%	Included

Position	Comments
Paed	But depends on how quickly PM can be done – might be deferred for pathologist to do
Metab	Too complex a subject for a single question. Surely a PM examination if the cause unknown. Skin biopsy request is too simplistic to look for an underlying cause
ED P	Can be done at pm
Metab	Also consider muscle & liver biopsies
Renal	Can be done post-mortem
Neuro	would not be meaningful (considered, informed) in this context
Neuro S	Certainly if dies, but then that’s covered by PM guidelines below
ED	I have never done this! Interested to know if I should

(ii) If a child with a decreased conscious level deteriorates rapidly or dies suddenly, a urine sample should be collected by catheter or suprapubic aspiration

% Agree	% Disagree	Result
94.1%	0%	Included

Position	Comments
Biochem	Also collect blood if not previously taken
Metab	If no urine has been collected
ED	If consent of coroner has been obtained
	Depends on how recently routine specimens were collected
ED P	Just as easy to use catheter
Renal	Guthrie spot more important

(iii) If a child with a decreased conscious level dies without a diagnosis being made, the coroner needs to be informed and a post-mortem examination should be performed by a paediatric pathologist within 24 hours of death

% Agree	% Disagree	Result
97.1%	0%	Included

Position	Comments
Neuro	Is the guideline now telling the coroner his job?! PM is a coroner’s decision
ED	Coroner informed – strongly agree Post-mortem exam within 24 hours – Don’t know
Paed	Ideally, but 24 hours might not always be realistic
ED P	If you can find a paed pathologist
PICU	timing to depend on paed path advice

(iv) If a child with a decreased conscious level dies without a diagnosis being made, a pathologist should perform the following:

At the time of post mortem:

Full skeletal survey, X-rays to be reported by a radiologist with expertise in NAI

Snap freeze a small sample (about 1cc) of heart, kidney, liver and muscle in liquid nitrogen

Take samples of blood and bile on Guthrie cards

Take a sample of skin in tissue culture medium

Take a sample of urine from the bladder or renal pelvis

Take specimens for virology and microbiology

Take standard samples of all organs for histology

Retain the brain for neuropathological examination

% Agree	% Disagree	Result
95.8%	0%	Included

Position	Comments
Paed	With appropriate consents
Neuro	Outside scope of this guideline
Metab	Ideally, skin, muscle and liver biopsies should be taken soon after death if consent has been obtained
ED P	But these sound very sensible
Paed	ask a pathologist!
Metab	Assumes can be done via coroner in light of organs issues. This is a good outline.
Biochem	2. “… and record the time after death samples taken” 3. “…for acyl carnitine 5. “…for OAs and AAs” ? Value of [samples] stored in liquid nitrogen if time interval between death and PM >2 hours
Endo	?need to retain brain
Radiol	Full skeletal survey – depending on age
Paed	subject to consent

(v) If a child with a decreased conscious level dies without a diagnosis being made, a pathologist should perform the following:

After the post mortem

Document virology and micribiology results

Perform an oil red O stain on frozen sections of heart, kidney, liver, and muscle and examine for microvesicular fat

Blood and bile to Chemical Pathology for mass spectrometry for acylcarnitine and fatty acid oxidation

Urine to Chemical pathology for organic and orotic acid assay

Skin to Enzymology for cultured fibroblasts and storage in liquid nitrogen

Report on paraffin sections of samples for histology

Neuropathological examination of the brain after a week and samples taken for microscopy. (The brain can then be returned to the body in time for the funeral).

% Agree	% Disagree	Result
93.8%	0%	Included

Position	Comments
ED P	But these sound very sensible
Neuro	Outside scope of this guideline
	and toxicology screen
Paed	ask a pathologist!
Neuro	In N Ireland this will delay burial as most funerals take place within 3 days (a clear difference from the UK mainland)
Biochem	Why after PM? 2,4,5 at PM 3. “…acylcarnitine [profile]” and fatty acid oxidation 4 “to chemical pathology” “and amino acids” 5. “to enzymology” “…for enzymes and/or DNA” Opportunity for sampling for biochemical analysis asap after death should be considered ie before the formal PM. Tissues taken several hours after death may be difficult / impossible to interpret
Neuro S	Can useful neuropathology really be obtained at one week?
PICU	would defer to experts