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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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DELPHI PROCESS
Round two
9. Sepsis
9b) (iii) A child with a clinical diagnosis of sepsis should be considered for the following additional investigations:
(a) chest X-ray
|
Position |
Comment |
|
Paed |
a chest xray only if there is a resp symptoms or a pulmonary focus of the sepsis is considered |
|
Metab |
– clue to various diagnoses incl NAI, TB, primary CVS prob with sec brain comlications |
Agreed |
Neither agree nor disagree |
Disagreed |
|
90% |
10% |
0 |
(b) throat swab
|
Position |
Comment |
|
Micro |
Useful to pick up carriage of Neisseria meningitides if PCR etc negative or serogroup not determined, unlike other investigations likely to be affected by antibiotics and therefore cannot be reliably repeated later in course of illness, also non-invasive investigation. On the down side carriage does not equal disease. |
|
Endo |
?viral or bacterial, preferably both |
Agreed |
Neither agree nor disagree |
Disagreed |
|
86% |
14% |
0 |
(c) urine culture, if urinalysis positive for leucocytes and / or nitrites
Agreed |
Neither agree nor disagree |
Disagreed |
|
100% |
|
|
(d) lumbar puncture
|
Position |
Comment |
|
Neuro |
If impaired level of conscious or other features suggestive of CNS infection |
|
Paed |
Should be considered in the absence of agreed complications and patient must be stable |
|
Paed |
Not while unconscious |
|
Micro |
Only reliable way to exclude meningitis, may be useful in conforming diagnosis or showing other alternative causes of infection such as TB meningitis or HSE not picked up clinically |
|
Endo |
haven’t we covered this? depends on contraindications and timing is important |
|
Metab |
– as long as no CI |
Agreed |
Neither agree nor disagree |
Disagreed |
|
78% |
15% |
7% |
(e) PCR from blood for meningococcus and pneumococcus
|
Position |
Comment |
|
Renal |
Is this routinely available? |
|
Micro |
PCR for meningococcus is useful I am less convinced about pneumococcal PCR on blood as false positives in healthy children are well documented, PCR on CSF for both meningococcus and pneumococcus is helpful |
Agreed |
Neither agree nor disagree |
Disagreed |
|
100% |
|
|
(g) skin swab, if areas of inflammation are present
|
Position |
Comment |
|
Renal |
Better is microscopy of skin scrapings |
|
Renal |
What do you mean by inflammation? |
Agreed |
Neither agree nor disagree |
Disagreed |
|
89% |
7% |
4% |
(h) joint aspiration, if signs of septic arthritis are present
|
Position |
Comment |
|
Paed |
Child should be fully assessed with appropaiate imaging and clinical evaluation |
|
Renal |
Most paediatricians would not be competent to do this |
|
Micro |
PCR on joint fluid sometimes helpful too |
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
0 |
4% |
(i) a thick and thin film for malarial parasites if foreign travel to endemic area
|
Position |
Comment |
|
Micro |
This is a mandatory investigation, may need to give a time interval as the above statement would suggest any travel to an endemic area. There are a long list of other neurological, conditions which could affect children (although less likely than adults as I assume they would go less off the beaten track) I think such cases should be discussed with a microbiologist or paediatric/adult ID unit or one of the Schools of Tropical Medicine, I would hope each would be aware of the limitations of their expertise in this area. |
Agreed |
Neither agree nor disagree |
Disagreed |
|
100% |
|
|
(j) intracranial imaging, if no other source of infection determined
|
Position |
Comment |
|
Radiol |
Not unless cranial signs – CT is a poor tool as a ‘fishing’ investigation |
|
Radiol |
intracranial imaging in these cases should only be undertaken after discussion with a consultant radiologist about the next appropriate imaging investigation given the results of all other investigations and the childs clinical state. |
|
Paed |
In earlier section I indicated that this should be done even if if other source identified. |
|
Micro |
Important to exclude Brain Abscess |
Agreed |
Neither agree nor disagree |
Disagreed |
|
90% |
4% |
6% |