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**"If you object to a 23 hour admission for rehydration and
pain control in the appropriate setting then I don't understand why you
would keep them in the ED for 6 hours for a repeat tap in cases where there
is initially a PMN pleocytosis.  What is your plan if there is then a
conversion to predominate lymphocytes (as is usually the case)?  Keep the
patient in observation for 2 to 3 days IN THE ED? Send them home? And if
ther latter, how do you reconcile this decision with your observation that
23 hours is too short a time interval to discharge them but 6 hours is not.
 
You have missed the point Harvey. I do not object to rehdration and pain
management if you read my original posting on criteria for discharge. Yes,
indeed I would send them home if they have a spontaneous
mononuclear/lymphocytic response. That is the idea. This is not the same as
getting a response after antibiotics are on board. All I am saying is that
23 hours of observation after initiating antibiotics and getting improvement
is not the same as giving only IVF!!! Your clinical response could then be
related to a bacterial meningitis that has improved. In the latter case 23
hours of treatment of potential meningitis is certainly NOT standard of
care.
 
I will also add that treating ALL kids with antibiotics for fever, neck
stiffness and any level of CSF pleiocytosis as you do is not shared by all
in the PEM community.
 
        ** " It is also a reflection of the
        fact that there is a diversity of opinion about this matter and the
decision is more one of personal preference than hard scientific evidence"
 
You hit the nail on the head here. Our discussion here is testimony to
that. There is no one way or the other. It is what level of risk, comfort,
experience and setting/resources of practice one has with this situation.
Discussion of risk benefit with the parents is also part of the equation.
 
Jay Pershad
 
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