ongoing monitoring for complications
The main dangers once treatment has started are
- cerebral oedema
- look for sign and symptoms suggestive of cerebral oedema
- headache & slowing of heart rate
- change in neurological status (restlessness, irritability, increased drowsiness, incontinence)
- specific neurological signs (eg. cranial nerve palsies)
- rising BP, decreased O2 saturation
- abnormal posturing
- dramatic changes such as convulsions, papilloedema, respiratory arrest are late signs
- associated with extremely poor prognosis
- if cerebral oedema is suspected inform senior staff immediately and arrange transfer to PICU
- exclude hypoglycaemia as a possible cause of any behaviour change
- give hypertonic (2.7%) saline (5mls/kg over 5-10 mins) or Mannitol 0.5 - 1.0 g/kg stat (= 2.5 - 5 ml/kg Mannitol 20% over 20 minutes). This needs to be given as soon as possible if warning signs occur (eg headache or pulse slowing).
- restrict IV fluids to 1/2 maintenance and replace deficit over 72 rather than 48 hours
- discuss with PICU consultant. Do not intubate and ventilate until an experienced doctor is available
- once the child is stable, exclude other diagnoses by CT scan - other intracerebral events may occur (thrombosis, haemorrhage or infarction) and present similarly
- a repeated dose of Mannitol may be required after 2 hours if no response
- document all events (with dates and times) very carefully in medical records
- hypoglycaemia &hypokalaemia
- avoid by careful monitoring and adjustment of infusion rates
- consideration should be given to adding more glucose if BG falling quickly even if still above 4 mmol/l (1).
Serum urea and electrolytes should be repeated two hours after starting treatment and thereafter as required; the blood glucose should be measured every two hours. Regular blood gas analysis can give a good indicator of improvement.
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