CSF Part of septic workup. While this could be a “simple febrile convulsion” with another source of sepsis LP is mandatory in this setting culture Sepsis workup A lumbar puncture is performed: CSF white cell count Neutrophils 120 (nil) Lymphocytes 25 (<5) CSF red cell 200 CSF Protein 1.2 (< 0.4 g/L) CSF glucose 0.4 (> 2.5 mmol/L) b. Interpret these results. Highly suggestive of bacterial meningitis. Likely a tap” but ratio of RBC:WBC “traumatic still indicates too many WBCs c. List and justify the medications you use to treat this child. Medication Justification Dose Cefotaxime Could choose ceftriaxone though 50mg/kg 6th hourly under 3 months usually cefotaxime (hepatic immaturity) (ceftriaxone 100mg/kg 12th hourly) Ben Penicillin To cover listeria 60mg/kg 4th hourly Vancomycin For resistant S pneu 30 mg/kg 12th hourly – practice varies depends on – local prevalence. Some wait for CSF gram stain or antigen studies Dexamethasone Give before or with antibiotics. 0.15 mg/kg Reduce hearing loss in Hib meningitis (JAMA 1997). Decrease poor outcomes (GOS) & death (NEJM 2002) Paracetamol For 15mg/kg d. A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to with the JMO”. The doctor says he only wanted to take some as “deal prophylaxis against possible meningococcus. What key principles should you consider in your discussion with the JMO? Non-judgemental, non-confrontational, confidential, document discussion. drugs is potentially serious disciplinary/employment ramifications “Stealing” – Doctor needs counselling - ?apology etc Concern about infection not entirely unreasonable though prophylaxis only indictaed if meningococcus confirmed & close exposure (e.g. suctioning, intubation)
CSF Part of septic workup. While this could be a “simple febrile convulsion” with another source of sepsis LP is mandatory in this setting culture Sepsis workup A lumbar puncture is performed: CSF white cell count Neutrophils 120 (nil) Lymphocytes 25 (<5) CSF red cell 200 CSF Protein 1.2 (< 0.4 g/L) CSF glucose 0.4 (> 2.5 mmol/L) b. Interpret these results. Highly suggestive of bacterial meningitis. Likely a “traumatic tap” but ratio of RBC:WBC still indicates too many WBCs c. List and justify the medications you use to treat this child. Medication Justification Dose Cefotaxime Could choose ceftriaxone though under 3 months usually cefotaxime (hepatic immaturity) 50mg/kg 6th hourly (ceftriaxone 100mg/kg 12th hourly) Ben Penicillin To cover listeria 60mg/kg 4th hourly Vancomycin For resistant S pneu – practice varies – depends on local prevalence. Some wait for CSF gram stain or antigen studies 30 mg/kg 12th hourly Dexamethasone Give before or with antibiotics. Reduce hearing loss in Hib meningitis (JAMA 1997). Decrease poor outcomes (GOS) & death (NEJM 2002) 0.15 mg/kg Paracetamol For 15mg/kg d. A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to “deal with the JMO”. The doctor says he only wanted to take some as prophylaxis against possible meningococcus. What key principles should you consider in your discussion with the JMO? Non-judgemental, non-confrontational, confidential, document discussion. “Stealing” drugs is potentially serious – disciplinary/employment ramifications Doctor needs counselling - ?apology etc Concern about infection not entirely unreasonable though prophylaxis only indictaed if meningococcus confirmed & close exposure (e.g. suctioning, intubation)
paeds_w_answers.docx