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Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) 12. MANAGE COAGULOPATHY IF PRESENT HAEMATOLOGY CONSULTATION REQUIRED 13. IF MENINGOCOCCAL INFECTION SUSPECTED OBTAIN THROAT SWAB and/or PERNASAL SWAB 14. CONSIDER FURTHER CONSULTATION 15. CONSIDER RENAL REPLACEMENT THERAPY Review coagulation screening results: • If PT and/or APPT > 2ULN (upper limit of normal) – give Octoplas ® , 10 – 20 ml/kg • If Fibrinogen < 1.5g/L correct with fibrinogen concentrate (Riastap/ Haemocomplettan). It should be given at a dose of 70 mg/kg and the fibrinogen level rechecked 1 hour following completion of the infusion • Reserve platelet transfusion for those with active bleeding or if platelet count < 20 x 10 9 /L and severe consumptive coagulopathy. If indicated transfuse with 20 mls/kg of platelets for children and 1 bag (pool) for adults The order in which blood products and anticoagulants are optimally used can vary from patient to patient and may significantly affect outcome. It is critical that guidance from a haematologist experienced in the management of meningococcal coagulopathy be obtained OCTOPLAS® is the plasma replacement used to correct consumptive coagulopathy in bleeding patients, as it contains a wide selection of coagulant and anticoagulant factors. For epidemiological purposes- Important as may be only site to yield isolate, especially, if antibiotics have been given Throat swab – a full sweep of the pharyngeal wall and tonsils, from all patients. If not possible, obtain a pernasal swab rotated on the posterior pharyngeal wall. Microbiology, haematology, nephrology, infectious diseases and infection control input may be helpful Continuous renal replacement therapy (CRRT) - Veno-venous haemofiltration, haemodiafiltration and plasmapharesis are all used in the management of severe sepsis Aggressive correction of coagulation defects is essential to optimise outcome Maintain: • Hb 7.0 – 9.0g/L (according to co-morbidity) • PT and APPT 1.5g/L • Platelets > 20 x 10 9 /L • ACT of 150 – 200 Monitor epidemiology of bacterial sepsis and meningitis. Of critical importance in era of introduction of ‘meningitis vaccines’ Early rather than delayed CRRT may be beneficial 16. NOTIFY PUBLIC HEALTH and INFECTION CONTROL as soon as possible Ensure contact chemoprophylaxis and information as per agreed protocol if necessary (See Chapter 7,8,9,Appendix 4) Under the statutory Infectious Diseases Regulations 1981, amended 2003, cases or suspect cases of bacterial meningitis or meningococcal septicaemia must be notified immediately to the relevant department of public health (medical officer of health). Telephone notification should be used initially and this is the responsibility of the admitting team. This should be done as a matter of urgency. All telephone notifications must be followed by written notification. -32-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Reference normal vital signs - values The abnormal vital signs by age groups are demonstrated in Table 3.1 Table 3.1. Age specific abnormal vital signs – cut-offs Age group Heart rate, beats/minute Tachypnoea Hypotension Tachycardia Bradycardia (breaths/min) (mm Hg) 0 days - 1 wk >180 50 180 40 180 34 140 NA >22 130 NA >18 110 NA >14
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