|
PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
|||||||||
DELPHI PROCESS
Round two
11. Raised
intracranial pressure
11c) Children with a clinical diagnosis of raised intracranial pressure should have the following treatments to prevent coning:
(iii) Sedate, intubate and ventilate the patient to maintain the PaCO2 between 4.0 and 4.5 kPa
|
Position |
Comment |
|
Neuro |
Hyperventialtion may give rise to ischaemia – I think it is more important to prevent it rising above 4.5 kPa |
|
PICU |
ALTHOUGH THAT IS MILD HYPOCARBIA-CURRENT RECOMMENDATIONS ARE NORMOCARBIA (4.5-5.2) |
|
Metab |
Only uncertainty is the PaCO2 aim. Too low is harmful. What is the evidence base for kPa 4-4.5 in non traumatic raised ICP? |
|
Paed ED |
PCO2 to normality |
Agreed |
Neither agree nor disagree |
Disagreed |
|
100% |
|
|
(vi) Administer a dose of 1g / kg of intravenous mannitol
|
Position |
Comment |
|
Paed |
Would use 0.5 g/kg |
|
Metab |
Answer reflects more on my practice, than evidence base for its effectiveness |
|
Paed ED |
after D/W neurosurgeon |
|
Paed |
I am a little uneasy about this dose and would if possible discuss with neurosurgeons |
|
PICU |
0.25 g/kg is enough. |
|
Paed |
Only after DW neurosurgeons |
|
Metab |
– in addition to iii) might be crucial also to infuse this – see vii) also |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
56% |
19% |
25% |
(vii) Administer a dose of 1g / kg of intravenous mannitol with furosemide 1mg / kg
|
Position |
Comment |
|
Paed |
Don’t know of any evidence that furosemide adds anything when used with such a powerful diuretic |
|
PICU |
0.25 g/kg is enough. |
|
Neuro S |
This combination of frusemide with mannitol risks dehydration unless give fluid bolus with it |
|
ED |
Have never used furosemide in raised ICP |
|
PICU |
Both not required initially |
|
Metab |
in more critical situations, use this as an alternative to vi); vi) & vii) may be used where features of coning have begun, or are progressing inspite of management shown at iii) |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
21% |
29% |
50% |
(vi) Administer a dose of 0.5 g / kg of intravenous mannitol
|
Position |
Comment |
|
Neuro |
0.25 g/kg may also work |
|
Paed ED |
After D/W neurosurgeon |
|
PICU |
0.25 g/kg is enough. |
|
Neuro S |
Not enough |
|
Paed |
I’d look the dose up |
|
PICU |
1g/kg first |
|
Metab |
APLS favours 0.5-1.0 g/ kg. There may be concern re too large a dose (ie 1.0g/ kg), but our main concern should be for the brain not the kidneys. |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
59% |
35% |
6% |
(vii) Administer a dose of 0.5 g / kg of intravenous mannitol with furosemide 1 mg / kg
|
Position |
Comment |
|
Paed |
Again, ? evidence for furosemide adding anything |
|
PICU |
0.25 g/kg is enough. |
|
Neuro S |
Not enough |
|
ED |
Have never used furosemide in raised ICP |
|
PICU |
Just stick to 1g/kg |
|
Metab |
APLS favours 0.5-1.0 g/ kg. There may be concern re too large a dose (ie 1.0g/ kg), but our main concern should be for the brain not the kidneys. |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
23% |
46% |
31% |
(ix) Maintenance fluid should be titrated to the clinical condition of the patient aiming to administer at 100% of normal
|
Position |
Comment |
|
Neuro |
It is important to ensure adequate blood pressure and cerebral perfusion pressure. I would only reduce fluids if there are signs of herniation, |
|
PICU |
SHOULD BE NORMAL SALINE |
|
Neuro |
Available evidence suggests better to resuscitate and then treat oedema |
|
Paed |
I’m in the 70% camp on this one as it feels like a safer starting point for the inexperienced and reminds them to think about cerebral oedema carefully |
|
PICU |
What is normal when the ADH is high – there is quite a literature on this topic from the Toronto group. |
|
Endo |
Depends also on cause doesn’t it? In sepsis increased leaky vessels and oedema, but need to support circulation therefore not sure you can do a simple statement |
|
Metab |
in spite a large exp with RS years ago, I am unsure of the correct/ better view here; as you say the comparison has not been tested. The US specialists favour 100%, whereas we in UK 70-75 %. If a child is shocked or dehydrated these must be corrected & this is obvious. Thereafter it is essential to avoid over-infusion, and each and every source of fluid being given to the patient must be thought of and quantitated. Perhaps a compromise is valid today with a more aggressive approach to management, with earlier and better imaging, etc. This is an aspect that requires expert input and ought not to be/ is not delegated to juniors! |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
40% |
40% |
20% |
(x) Maintenance fluid should be titrated to the clinical condition of the patient aiming to restrict to 70% of normal
|
Position |
Comment |
|
Paed |
I prefer the wording in (xi) below |
|
Neuro S |
This is ARCHAIC! and risks compromising cerebral perfusion |
|
PICU |
Start at 70%, wait for 1-2 hours, get chemistry, monitor urine output, send osmols, paired monitor CVP then decide |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
40% |
35% |
25% |
(xi) Maintenance fluid should be titrated to the clinical condition
of the patient but generally is administered at X % of normal
|
50 |
55 |
60 |
65 |
70 |
75 |
80 |
85 |
90 |
95 |
100 |
|
|
|
|
2 |
8 |
2 |
1 |
1 |
|
|
7 |
AVERAGE = 81 %
|
Position |
Comment |
|
Paed |
This
wording is better, ? could be strengthened further by changing to ‘generally
is ‘commenced’ at 70% normal. This reinforces the idea that later titration might
be necessary. Consider adding further detail explaining the conflict between
70% and 100% in the narrative of the final guideline |