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Arch Dis Child 2001 Volume 85 No 1
Where are we kinder, Boston Mass. or Boston Lincs.?
As a young paediatrician I cheerfully conducted marrow aspirations and lumbar punctures, using such potentially dangerous drugs as rectal barbiturates, intravenous benzodiazepines, and ketamine. The advantages were that procedures could be done quickly, on the ward, without the tedium of negotiating with anaesthetists and booking a theatre (operating room). The disadvantage was the innocent disregard of proper safety standards for a potentially unconscious patient. The anaesthetist's union has, in the UK at least, largely put a stop to such amateur fumblings but what to do for the best is still a question. Last year we published, under our heading “Controversy”, a debate about the safety of deep sedation when performing magnetic resonance imaging.1
This month we take the debate a stage further. Hain and Campbell (page12) have compared how invasive techniques are carried out in oncology centres in the UK, Europe, and the USA. The authors believe North American patients may be deprived of appropriate deep sedation or anaesthesia because of a misperception of the hazards involved. We offered a right of reply to a group from Boston, Mass. courtesy of our US editor Howard Bauchner. They point out differing definitions across the Atlantic of “deep sedation”, and deny Hain and Campbell's assertion. Readers may find the references appended to the two contributions useful in helping them decide what to do in their own wards.
Outcome of meningitis and sepsis—mixed news
We have also revisited a subject dealt with last year, namely the long term outcome of severe sepsis. This cohort, from Melbourne Australia, dealt with survivors of all types of bacterial meningitis and disclosed that 8% had major impairments and 29% minor impairments including IQ 70–80, deafness and educational and behavioural problems.1-2
In September 2000 we reported—briefly—results from the Oxford pneumococcal surveillance group, including 39 cases of meningitis with this organism reported between 1991 and 1996.1-3
Two subsequently required long term anticonvulsants and one has a persisting hemiparesis. Five children have sensorineural deafness.
This month's report deals with the outcome from meningococcal disease suffered by children in Merseyside, UK from 1988–90 (page 6). Four of 115 survivors have a major impairment, 15.7% had moderate problems (as did 4.3% of controls), and 22 cases and 14 controls had minor impairments. The authors call for caution, speculating that recent improvements in survival might prove to be at the expense of an increase in amputations and other major sequelae.
BPSU defines risk of cerebral oedema in DKA
Another life threatening condition we deal with this month is diabetic ketoacidosis (DKA). Edge and colleagues report on the results of the British Paediatric Surveillance Unit study of cerebral oedema in DKA, conducted nationwide between 1995 and 1998 (page 16). The 34 cases found represent a risk of 6.8 per 1000 episodes of DKA, considerably higher in newly diagnosed diabetics, so non-specialists may never see a case. Mortality and morbidity were high.
This study did not set out to investigate aetiology or management, but the authors usefully refer to the different US and UK practices in regard to using crystalloid or colloid and are reassured by the similar risk in the two countries. They remind us that for maximum effect mannitol has to be given within 5 or 10 minutes of deterioration in neurological function. A case control study has started looking at what factors may be associated with developing cerebral oedema.
A little gem
Another critical illness to avoid during public holidays is acute decompensation of congenital adrenal hyperplasia (CAH).3-4But at least once the condition is recognised, emergency treatment is well established. Or is it? Charmandari and colleagues from London investigated serum cortisol levels in patients with 21-hydroxylase deficiency after a standard dose of IV hydrocortisone, comparing them with the levels achieved by endogenous secretion during critical illness in children without CAH (page 26). The latter had been admitted to a paediatric intensive care unit with acute severe illness and had a mean cortisol on admission of 727 nmol/l (SD 426.1), a maximum concentration of 1700 nmol/l and a level after 24h of 515 nmol/l (SD 264.1). Much higher levels were achieved in CAH patients with 15 mg/m2 of hydrocortisone but the level remained over 450 nmol/l for only 2.5h. The authors of this neat and tidy paper neatly and tidily calculate the dose frequency of hydrocortisone likely to be necessary in treating an unwell child with CAH. If you are working in an acute unit, please place this paper in your ward guidelines book, but read the authors' last sentence.
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