I think more to the point is to avoid bringing our own biases into care to the pt's detriment. There are plenty of data to show efficacy of both oral sucrose and topical analgesia for painful procedures, with next-to-no side effects. Witholding that because a procedure is short or out of some fear of coddling infants seems just plain silly. I have two things to add.
1. Although infants do find the positioning for LP to be distressing, being stuck w the needle is w/o question more painful, and my own research on 70 infants undergoing LP shows a bell-type curve for pain w positioning, needle-stick and recovery. This can be observed w simple observation, don't you find babies cry when you stick them?
2. Anyone who doubts the harm of repeated painful stimuli for neonates should check out the neonatology literature about NICU survivors. There are increased rates of chronic pain diseases such as migraines, and hyperesthesia to standardized stimuli, changes in the cortisol axis, etc.
I would recommend Dr. Ray Pitetti's editorial in CMAJ regarding our ethical responsiblities to provide pain control when we can.
The above being said, I would never sedate an infant for LP, I stick w the basics like topical or injected lidocaine and oral sucrose.
Finally, we probably do a better job than general pediatricians, most of whom provide no anesthesia/analgesia of any kind for routine vaccinations!
James Reingold, M.D.> Date: Mon, 26 Jan 2009 18:48:04 -0800> From: [log in to unmask]> Subject: Re: ketamine for septic w/u> To: [log in to unmask]> > Sorry, didn't mean to sound dogmatic. As far as EBM references, a > number of great ones have been cited in this thread already. There > are a few good reviews in neonates appropriate to this discussion:> > "Effectiveness of sucrose analgesia in newborns undergoing painful > medical procedures." - Taddio et al. CMAJ Canadian Medical > Association Journal. 179(1):37-43, 2008 Jul 1.> > Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn > infants undergoing painful procedures. Cochrane Database of> Systematic Reviews 2004, Issue 3. Art. No.: CD001069. DOI> > Pain Reduction During Pediatric Immunizations:> Evidence-Based Review and Recommendations> Neil L. Schechter, MDa,b,c, William T. Zempsky, MDb,c, Lindsey L. > Cohen, PhDd, Patrick J. McGrath, PhDe,f, C. Meghan McMurtry, BAe,f,> Nancy S. Bright, BSNa,c> Pediatrics. www.pediatrics.org/cgi/doi/10.1542/> peds.2006-1107> > As far as matching sedation with appropriate procedures, I think > another specific procedure in which various PSA protocols have been > compared head-to-head with fairly good evidence is for fracture > reduction in which ketamine seems to be the most appropriate choice > (has been studied against fentanyl/versed, propofol, and hematoma > blocks among others).> > I would love to hear from others on the list as to some of the > convincing data that have informed specific choices for PSA in your > daily practice....> > Garth Meckler, MD, MSHS> > > > > > > On Jan 26, 2009, at 5:12 PM, Jeffrey Proudfoot wrote:> > > No argument about pain- it is real and the response is very > > measurable....the majical thinking comes in rationalizing a > > medication or procedureal sedation based on the unproven intuition > > that neonatal pain creates permanent psychological damage that > > apparently creates a subpopulation of fearful and traumatized > > children and adults lasting a lifetime with resultant psychiatric > > illness (ref- animal studies and limited human studies). Since it is > > so clear (" there is no debate or interpretation") please enlighten > > me with the correct sedation matched with the appropriate painful > > procedure supported by EBM RCT trials and then I will rest more > > comfortably that I am practicing to the "standard of care" here.> >> > Jeffrey Proudfoot, DO, FACEP> >> > On Mon, Jan 26, 2009 at 5:01 PM, Garth Meckler <[log in to unmask]> > > wrote:> > This has been a very interesting discussion, with quite a bit of > > emotion and opinion on both sides of the debate, so I will add some > > more...> > PSA should be a rational, thoughtful, and evidence-based undertaking.> > It is not a debate as to whether infants feel pain. Just because we > > cannot "communicate with them" does not make it "magical thinking" > > or a "group of adults sitting around a table 'deciding' what's right."> > Not only do we know the neuro-anatomy and physiology of pain and the > > fact that these pathways are in place and functional in neonates, > > but studies of behavioral response, sleep-wake cycles, feeding > > patterns, subsequent behavioral response to procedures, anticipatory > > fear, as well as catacholamine and stress steroid responses have all > > been demonstrated in response to painful procedures in neonates and > > infants. This is not a matter of debate or interpretation any more > > than it is a question of whether non-verbal adults feel pain when we > > perform invasive procedures.> > Furthermore, as several on this list-serve have pointed out, there > > are RCTs that have demonstrated analgesic efficacy (with a wide > > range of outcome measures) using sucrose analgesia.> > I would add, as well, that two studies have found local / topical > > anesthetic to independently correlate with LP success in infants, so > > there is one more reason to use it.> > It really concerns me to hear the rationalizations used to justify > > shortcuts.> > It is certainly true that we are capable of tipping the risk-benefit > > balance if we are not equally fastidious in our choice of PSA and we > > must always way the risks and benefits.> > The pre-test probability of meningitis, even in the febrile neonate, > > is less than 1-3%, so of course, we must consider the need for many > > of the painful procedures we routinely perform in the ED (a bunch of > > adults 'deciding' how we should treat patients in order to protect > > ourselves legally).> > On the other hand, what are the down-sides to topical analgesics or > > sweeties?> > We, as PEM providers, have taken on the responsibility of advocating > > for children; while I recognize that only a small fraction of the > > medicine we practice is evidence based or even logical, I think we > > should apply the principles of EBM where they exist, and PSA is one > > of the few areas of our specialty in which there is a wealth of > > quality basic and applied research.> >> > Garth Meckler, MD, MSHS> > Fellowship Director & Assistant Section Chief> > Oregon Health & Science University> >> >> > On Jan 26, 2009, at 2:03 PM, Jeffrey Proudfoot wrote:> >> > I would agree with Dr Thornton....there has to be some common sense > > involved> > in> > terms balancing invasiness vs benefit in given clinical situations. > > In a> > pediatric ED with> > experienced peds nurses it's a snap to place an iv and sedate if > > necessary.> > Too often> > I have seen the same neonate undergo 4 attempts at iv placement in > > order to> > use PSA> > for an LP in other settings. In the right hands, a two minute LP > > without> > sedation seems to be far less painful than multiple unsuccessful > > attempts at> > an IV. Likewise if it is taking multiple attempts to get an LP --- > > maybe the> > problem is the operator? And the fact is the majority of these > > workups are> > done in non pediatric EDs. As far as the psyche of newborns is > > concerned,> > until we are able to communicate with them its all majical thinking-- > > I would> > defer to the clinician with common sense before I would to a group > > of adults> > sitting around a table "deciding" what is right.> >> > "Life is pain, highness. Anyone who tells you differently is selling> > something."> > *William Goldman*> > **> >> > Jeffrey Proudfoot, DO, FACEP> > Maricopa Medical Center> > Pediatric Emergency Dept> > Phoenix, AZ> >> >> > **> >> > On Mon, Jan 26, 2009 at 12:57 AM, Fergus Thornton <[log in to unmask] > > >wrote:> >> > I'm not sure pain has much to do with this. What bothers the baby > > is being> > held down and doubled up to expose the back. Not only would I not > > use PS> > (risk vs benefit) but I don't use local. If held well, the > > procedure is> > over in one to two minutes or less. I think the pendulum has swung > > too far> > to the "be nice" extreme. It's time to recognize that those of us who> > experienced painful/normal procedures/experiences haven't grown up > > with any> > particular psyche disorders. I use PS to enable me to care for > > people, not> > to protect them from a 2 minute painful procedure. [BTW, the > > "holder" is> > much more important than the "needler" in an LP; done well, it > > shouldn't> > take more than a minute.]> >> > -----Original Message-----> > From: "Chamberlain, Jim" <[log in to unmask]>> > Sent: Jan 20, 2009 10:36 AM> > To: [log in to unmask]> > Subject: Re: ketamine for septic w/u> >> > I am watching this post with fascination.> >> > We have moved from the use of "Brutane" for even the most painful> > procedures to a much more compassionate, patient-centered approach > > to pain> > management. This is great.> >> > However, we really need to ask ourselves whether the known and unknown> > risks of procedural sedation are worth it for a procedure that is only> > painful for about 15 seconds of lidocaine injection. Even this pain > > can be> > minimized by use of a topical anesthetic and by buffering the > > lidocaine.> >> > Nigovic LE et al showed that NON-use of local anesthetic is > > independently> > associated with traumatic lumbar punctures (Ann Emerg Med > > 2007;49:762). This> > echoes a previous study by Carraccio C et al (Arch Dis Pediatr Adol > > Med> > 1996:150;1044.> >> > Animal studies suggest that the young mammalian brain is especially> > susceptible to neuronal apoptosis from some anesthetic agents. > > Ketamine does> > this as well. Benzodiazepines potentiate the effect.> >> > Please review Steve Green's article on ketamine (reference posted here> > earlier this week).> >> > Adequate local anesthesia should provide you with a non-squirming > > infant> > for an LP, without the risks of procedural sedation.> >> >> > James Chamberlain, MD> > Division Chief, Emergency Medicine> > Children's National Medical Center> > 111 Michigan Avenue, NW> > Washington, DC 20010> >> > 202.476.3253 (O)> > 202.476.3573 (F)> > 202.476.5433 (Emergency Access)> >> > -----Original Message-----> > From: Pediatric Emergency Medicine Discussion List [mailto:> > [log in to unmask]] On Behalf Of timothy hall> > Sent: Tuesday, January 20, 2009 5:55 AM> > To: [log in to unmask]> > Subject: Re: ketamine for septic w/u> >> > At what age would you give a child , who needs a full septic work up,> >> >> > At what age would you give a child , who needs a full septic work > > up, a> > single shot of im ketamine,to get the job done (lp etc) ,i start at 6> > months.> > Tim H> >> >> > ________________________________> > From: Peter Antevy <[log in to unmask]>> > To: [log in to unmask]> > Sent: Tuesday, 20 January, 2009 2:56:00 AM> > Subject: Re: ketamine for septic w/u> >> > Don,> >> > Technically, obtaining an IV is a secondary issue in this well > > appearing> > child. The blood work can be obtained sterilly, the urine via cath > > and the> > LP utilizing first LMX4 then subQ lidocaine. The rocephin IM and > > either> > admit or potentially send home if all criteria are met.> >> > I personally use lidocaine on every LP no matter the age and it's > > worked> > well for me. A recent paper backs up the use for local anesthetic for> > infant LP's. Along with using "sweeties" on the pacifier you'll > > soon find> > yourself obtaining CSF on a sleeping infant. Parents appreciate it > > too.> >> > Peter> >> >> > -----Original Message-----> >> > From: don zweig <[log in to unmask]>> > Subj: ketamine for septic w/u> > Date: Sun Jan 18, 2009 8:11 pm> > Size: 823 bytes> > To: [log in to unmask]> >> > Do any of you sedate kids to get a septic wu done? I had a 4 week old> > (today he was 4weeks) with fever of 38.6 who looked quite good ,> > feeding bottle avidly, had hx cough and was rsv neg. no one could get> > iv (nicu nurses tried eight times) and i could not get lp due to xs> > squirming. It would seem to be so much easier for me and prob for kid> > to give i m ketamine, get a line (groin if needed or ej) and do the lp> > on a stationary target. Whaddya think? whaddya do? would everyone> > have done a complete work up? we got cbc,crp and ua/cxr which were> > normal and the cx was pending of course.> >> > don> >> > For more information, send mail to [log in to unmask] with > > the> > message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> > For more information, send mail to [log in to unmask] with > > the> > message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> >> >> > Stay connected to the people that matter most with a smarter inbox.> > Take a look http://au.docs.yahoo.com/mail/smarterinbox> >> > For more information, send mail to [log in to unmask] with > > the> > message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> > Confidentiality Notice: This e-mail message, including any > > attachments, is> > for the sole use of the intended> > recipient(s) and may contain confidential and privileged > > information. Any> > unauthorized review, use, disclosure or distribution is prohibited.> > If you are not the intended recipient, please contact the sender by > > reply> > e-mail and destroy all copies of the original message.> >> > For more information, send mail to [log in to unmask] with > > the> > message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> >> > Fergus Thornton> > read my blog @ http://docdownunder.wordpress.com> >> > For more information, send mail to [log in to unmask] with > > the> > message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> >> >> >> > -- > > Try not. Do or do not, there is no try...> > YODA> >> > For more information, send mail to [log in to unmask] with > > the message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> > For more information, send mail to [log in to unmask] with > > the message: info PED-EM-L> > The URL for the PED-EM-L Web Page is:> > http://listserv.brown.edu/ped-em-l.html> >> >> >> > -- > > Try not. Do or do not, there is no try...> > YODA> > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://listserv.brown.edu/ped-em-l.html
Windows Live™ Hotmail®…more than just e-mail.
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: