Management of JE
Management of JE

Management of JE is only symptomatic. The proposal of treatment is to maintain fluid eletrolyte balance, control temperature, convulsions and reduce intracranial pressure.

  • Fluid Elecrolyte balance

  • Temperature

  • Convulsions

  • Intracranial pressure

Fluid Elecrolyte balance

  • Intravenous fluids-Isolyte P-2/3rd to 3/4th of the maintenance with allowance of temperature, hyperventilation, and urine output.

  • For every 10oC above basal body temperature, increase maintenance by 12%.

  • For hyperventilation, add 50-60 ml/100 kcal of energy used.

  • If the urine output is more than 50% of the total input, then add the excess fluid to the maintenance.

Temperature

  • Tepid sponging

  • Enteral paracetamol-60mg/kg/d-divided doses every 4-6 hourly

Convulsions

  • sedation with diazepam 0.1-0.3 mg/kg/dose

  • PHENYTOIN: Loading dose 15-20 mg/kg to be isfused at a rate of 0.5-1.5 mg/kg/min.
    Maintenance dose - 5-8 mg/kg/d. If the seizures persist, then another loading dose of phenobarbitone 10mg/kg can be given.

  • DIAZEPAM INFUSION: If the seizures still persists, then diazepam infusion to be started at a rate of not more than 5 mg/min followed by infusion at rate of 0.1-0.4 mg/kg/hr. Diluents to be used - sterile water, normal saline. If the seizures are yet to be controlled, then any of the following options can be tried.

  • MIDAZOLAM INFUSION: loading dose of 0.05-0.2 mg/kg stat followed by infusion at a rate of 1-5 g/kg/min.

Intracranial pressure

  • MANNITOL:Initial bolus to be given over 30 min, after stabilizing the vital signs.
    DOSE: 2.5-ml/kg of 20% solution (0.5-1 g/kg)
    Repeat mannitol to be given only if serum osmolality is <=300 mOm/kg.
    Repeat doses of mannitol can be given every 4-6 hourly, at a dose of 2.5ml/kg, given over 30 minutes.

  • FUROSEMIDE: The ICP to be reassessed about 30 min after giving mannitol. If the intracranial hypertension persists, inj. furosemide 1mg/kg/dose every 12th hrly can be given (potassium levels & blood pressure to be monitored while giving diuretics.

  • HYPERVENTILATION: can be done with bag and mask ventilation or after intubation. To decrease further rise in ICPduring intubation either 4% lignocaine as local spray or intravenous lignocaine at 1 mg/kg/dose slow IV can be used. When hyperventilation is used for the management of raised ICP, then aim is to achieve a Paco2 of 25mmhg.
    The level of PCO2 should ne raised to 30-35 mm hg after 1 hr.

  • THIOPENTONE: To be used when the above measures fail, but can be combined with hyperventilation. Dosage: loading dose of 5 mg/kg given over 30 - 60 min with a maintenance dose of 1 mg/kg/hr as infusion. Maximum maintenance dose is 5 mg/kg/hr. Whenever the maintenance dose is increased by 1 mg/kg/hr, a loading dose of 5 mg/kg to be given.

MONITORING                                                   

  • Blood pressure-hourly-maintain at 0.5 ml/hr

  • Urine output every 4 hourly - maintain at 0.5 ml/kg/hr

  • Serum osmolality - every 24 hourly (preferably every 12 hrly)
    Formula for calculation of serum osmolality S.osmolality (mOsm/kg)
    =
  • Hourly SpO2 Central venous pressure for severe coma, whenever possible.
Last Updated on : 20/01/2014