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• Ceftriaxone drug alert - no longer for first line use in meningococcal sepsis
  Saul N. Faust
  Published on: 13 November 2007
• Valuation of low blood pressure in children
  Egidio Barbi
  Published on: 10 April 2007
• Emergency management of meningococcal disease:eight years on
  Tina Newton
  Published on: 3 April 2007
• Indication for tracheal intubation in meningococcal disease and septic shock
  Martin Peter Gray
  Published on: 3 April 2007

• Published on: 13 November 2007

  Ceftriaxone drug alert - no longer for first line use in meningococcal sepsis

  • Saul N. Faust, Senior Lecturer in Paediatric Infectious Diseases
  • Other Contributors:
    • Andrew J. Pollard, Simon Nadel, Nelly Ninis, and Michael Levin

  Dear sir,

  Although UK and international high income country practice has been to recommend ceftriaxone or cefotaxime as first line therapy for the initial treatment of paediatric sepsis, the US FDA has issued an alert (1) that has led to changes in the US label for ceftriaxone (2). Due to concerns regarding the potential for calcium chelation in vivo, ceftriaxone must no longer be administered within 48 hours o...

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  Dear sir,

  Although UK and international high income country practice has been to recommend ceftriaxone or cefotaxime as first line therapy for the initial treatment of paediatric sepsis, the US FDA has issued an alert (1) that has led to changes in the US label for ceftriaxone (2). Due to concerns regarding the potential for calcium chelation in vivo, ceftriaxone must no longer be administered within 48 hours of the completion of infusions of calcium-containing solutions, including parenteral nutrition, regardless of whether the drugs are administered by different infusion catheters (1,2). In the UK, the current Drug Safety bulletin (3) states that ceftriaxone must not be given simultaneously with calcium-containing infusions.

  We would therefore like to update the antibiotic recommendation made in our meningococcal therapy guideline update published in the April 2007 edition of ADC (4) as follows: “Cefotaxime should be used as the first line antibiotic in meningococcal sepsis due to the high incidence of calcium replacement requirement in severe disease. However, ceftriaxone may still be considered as first line therapy in children with clinical meningitis, and for continuation of sepsis therapy after the acute phase when calcium infusions are no longer required. Where children are admitted for observation following cefotaxime for suspected sepsis and are subsequently assessed as being well enough for discharge on ambulatory intravenous antibiotics, the antibiotic may be changed to ceftriaxone (where the once/day dose regimen may be of benefit) and the first dose administered 8 hours following the last dose of cefotaxime given, assuming no calcium containing infusions have been used or are planned.” The Meningitis Research Foundation will be making appropriate changes to their educational literature.

  Yours faithfully, Saul N. Faust, Andrew J. Pollard, Simon Nadel, Nelly Ninis and Michael Levin

  (1 http://www.fda.gov/cder/drug/InfoSheets/HCP/ceftriaxone.htm (2) http://www.rocheusa.com/products/rocephin/rocephin-hcp-letter.pdf (3) http://www.nelm.nhs.uk/Record%20Viewing/viewRecord.aspx?id=587080 (4) Pollard AJ, Nadel S, Ninis N, Faust SN, Levin M. Archives of Disease in Childhood 2007;92:283-286

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  Conflict of Interest:
  None declared.

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• Published on: 10 April 2007

  Valuation of low blood pressure in children

  • Egidio Barbi, Medical Doctor
  • Other Contributors:
    • Laura Badina and Alessandro Ventura

  Dear Editor,

  We greatly appreciated the review by Pollard AJ. and colleagues about emergency management of meningococcal disease(1). Even though we found a questionable issue on figure 1, which report the algorithm for early management of meningococcal disease in children. In the algorithm the normal systolic blood pressure is supposed to be 80 + (age in years x 2). According to the PALS guidelines, the third...

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  Dear Editor,

  We greatly appreciated the review by Pollard AJ. and colleagues about emergency management of meningococcal disease(1). Even though we found a questionable issue on figure 1, which report the algorithm for early management of meningococcal disease in children. In the algorithm the normal systolic blood pressure is supposed to be 80 + (age in years x 2). According to the PALS guidelines, the third centile for systolic blood pressure should be 70 + (age in years x 2)(2). We believe that referring simply to “normal” blood pressure can be misleading and that the PALS definition is more precise and universally accepted. We are well aware that hypotension is a very late sign of shock in children and therefore an higher cut-off could be more useful in this setting for practical purposes to alert physicians. Nevertheless we believe that a proper standard definition remains mandatory in the setting of an official guideline, especially when this one has been disseminated in several emergency, paediatric and intensive care units and appeared in numerous articles, book chapters and a handbook for junior doctors.

  No competing interest.

  References:

  1) Polland AJ, Nadel Simon, Ninis Nelly, Faust SN, Levin M. Emergency managment of meningococcal disease: eight years on. Arch Dis Child 2007;92:283-286.

  2) Andavanced Life Support Group and Kevin Mackway-Jones ed. Advanced Paediatric Life Support. The pratical approach. BMJ Books, fourth edition;2005.

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  Conflict of Interest:
  None declared.

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• Published on: 3 April 2007

  Emergency management of meningococcal disease:eight years on

  • Tina Newton, Consultant paediatrician

  Dear Editor,

  I read with interest the article on emergency management of meningococcal disease and welcome the publication of the revised algorithm. However I note that in the section on use of inotropes it states that adrenaline infusions must only be given by central venous route. Whilst central venous access is the gold standard, placing of a central line in paediatric patients requires skills which may not b...

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  Dear Editor,

  I read with interest the article on emergency management of meningococcal disease and welcome the publication of the revised algorithm. However I note that in the section on use of inotropes it states that adrenaline infusions must only be given by central venous route. Whilst central venous access is the gold standard, placing of a central line in paediatric patients requires skills which may not be readily available. As an alternative I would remind practitioners that any inotropes (including adrenaline infusions) can be given via the intraosseous route. The advent of the bone injection gun has made it possible to place IO needles in patients of all ages (including adults). Whilst most doctors working in emergency medicine will be familiar with the use of IO needles in the immediate resuscitation setting, all doctors need to be aware of the usefulness of the technique for advanced life support.

  No competing interests

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  Conflict of Interest:
  None declared.

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• Published on: 3 April 2007

  Indication for tracheal intubation in meningococcal disease and septic shock

  • Martin Peter Gray, Consultant Paediatric Intensivist
  • Other Contributors:
    • Anami Gour, Caroline Davison, Jonathan Round and Linda Murdoch

  Dear Editor,

  We read with interest the recently published update to an algorithm for the early recognition and treatment of meningococcal disease in children (1). Of note there is a change to the recommended trigger point for tracheal intubation. The previously recommended trigger point has moved from after 40mls/kg of fluid resuscitation in the face of persistent shock to after 60mls/kg of fluid resuscitation. This...

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  Dear Editor,

  We read with interest the recently published update to an algorithm for the early recognition and treatment of meningococcal disease in children (1). Of note there is a change to the recommended trigger point for tracheal intubation. The previously recommended trigger point has moved from after 40mls/kg of fluid resuscitation in the face of persistent shock to after 60mls/kg of fluid resuscitation. This is following consideration of the work of Joseph Carcillo who recommends that up to 200 mls/kg (average 40-60mls/kg) of fluid resuscitation may be required in the first hour of resuscitation in septic shock (2). This is based on level II evidence. Although early intubation in fluid refractory septic shock is desirable, the trigger for tracheal intubation should not be based solely on the volume of resuscitation fluid administered. The trigger should be based on clinical need. Indeed, Carcillo himself recommends that the decision to intubate and ventilate in septic shock should be based on the presence of the clinical findings of increased work of breathing, hypoventilation, impaired mental status or presence of a moribund state. The current algorithm as published may result in patients being intubated unnecessarily; as this is not without considerable risk in this cohort of patients this presents a significant patient safety issue.

  The time course over which fluid is administered is also very important. 60 mls/kg given over minutes will precipitate a very different physiological response to 60 mls/kg given over several hours. The optimal time course of rapid volume expansion is within the first hour of resuscitation; however this time course is often delayed. The resultant redistribution of fluid over time may negate the need for tracheal intubation in some cases; this should be reflected in the algorithm.

  If we examine the adult data of Emmanuel Rivers looking at early goal directed therapy in septic shock we find that early and generous fluid resuscitation reduced the number of shocked patients who required tracheal intubation and ventilation (3). If this data is extrapolated to the paediatric population it suggests that early, aggressive fluid resuscitation may reverse the progression of septic shock and circumvent the need for tracheal intubation.

  This algorithm has contributed to more effective resuscitation of patients with meningococcal septicaemia and septic shock in general; however without more robust evidence we believe that the indication for tracheal intubation in septic shock should be based on clinical criteria and not the volume of fluid infused during initial resuscitation.

  References:

  1. Pollard AJ, Nadel S, Ninis N, Faust SN, Levin M. Emergency management of meningococcal disease: eight years on. Arch Dis Child 2007;92(4):283-6.

  2. Carcillo JA, Fields AI, American College of Critical Care Medicine Task Force Committee M. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock.[comment]. Critical Care Medicine 2002;30(6):1365-78.

  3. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345(19):1368-77.

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  Conflict of Interest:
  None declared.

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