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PED-EM-L  January 2009

PED-EM-L January 2009

Subject:

Re: ketamine for septic w/u

From:

David Herd <[log in to unmask]>

Reply-To:

David Herd <[log in to unmask]>

Date:

Wed, 28 Jan 2009 15:38:30 +1100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (359 lines)

An interesting discussion about ketamine sedation for LP.
I have attached my personal plan that is partly evidence based, partly  
just obvious.
Approach based on integrating procedure, psychology and pharmacology.
Always happy for suggestions or modifications.

Regards,

Dr David Herd BSc MBChB FRACP
Paediatric Emergency Medicine Specialist
Mater Children's Hospital (from April)
Brisbane, Queensland, Australia



Procedure
Ensure it is indicated. Best way to reduce the distress is not to do  
the procedure.
A neonate that you cannot restrain sounds sounds fairly well - but no  
doubt there was a reason.
Ensure you have maximised the technical aspects. Best person, best  
environment, best equipment.
How trainees learn the procedure then becomes an issue. Mentored  
training or simulation. Best practice guidelines?
Usually done lying on side but occasionally baby is happiest sitting.
Sitting position is actually easier to get CSF due to a 'head of  
pressure'. Cannot measure the pressure in this position.
I do not flex the neck, it does not add much to intervertebral space  
and adds much discomfort.
Biggest mistake I believe is not getting the saggital plane correct  
(or parasaggital).
Textbooks talk about having babies back orthogonal to the floor. This  
is technically hard.
Often I have baby propped on oblique angle to present back more toward  
me.
Then I have to physically check that I am on the correct approach.
I prefer sitting for LPs using a chair with wheels.
The chair is so I can swing down the end of the bed to check my  
approach angle.
Would use a 25G short Quincke needle as that is what I learnt with. 22  
in older child.
Would make sure the needle cutting edge is inserted in a parallel  
plane to the fascial fibres.
Taking the troca (stylet) out once through the skin and posterior  
fascia helps increase success.
Replace the stylet before removing reduces LP headache in adults. No  
evidence in children but I do this.
Could use up to 22G but no larger. Once again adult evidence but makes  
sense in children.
Pencil tip in adults reduceds post-LP headache but I have not used a  
lot, so stick with what I know.
I don't rely on the 'pop' at this age group instead using an advance a  
little and see approach. Pop is a bonus.
When I think I am in the right spot but no CSF comes forward,  
carefully rotating the bevel 90 degrees cephalic helps.
Remember the skin has pain receptors as does periostium and the dura.

Psychology
I would tell the parents this is no more technically difficult than IV  
and can be done with little pain and some distress due to holding.
A fully informed supportive family present often makes procedure go  
better.
Key points of information for family; "the fluid around the brain goes  
down the spine and back up again;"
"the spinal cord finishes around the belly button and the fluid goes  
down a bit lower";
"getting this fluid is the only absolute way we can exclude infection  
in this fluid"
Rarely parents may not wish to be present or worsen the situation.
I believe parents that sit outside imagine the procedure to be much  
worse than the reality.
(in fact several parents who were 'not allowed in' for previous  
procedures tell me this)
Parental presence (or a surrogate) is essential for baby. This is  
obvious.
Swaddling, cuddling in a neonate is the best positioning but hard for  
LP.
Many babies like been wrapped, some don't. Have done sitting cuddling  
LPs.
Neonates don't have a lot of cognitive coping skills.
Remember their vision has reduced range and colour discrimination at  
this age.
For older infants we can use distraction, older child visualisation  
and pre-teen/teen self-hyponosis.

Pharmacology
Sucrose is effective and low risk. No specific LP study but should be  
given. Minimum 24%, I use up to 66% 0.5ml titrating to effect.
(the pharmacodynamic effect is that they smack their lips then look a  
bit stoned).
Effect can be present within 30 seconds but most trials are based with  
procedure 1-2 minutes later.
Topical anaesthetic I would use is amethocaine if there is time (30-45  
minutes).
Alternative is liposomal lignocaine (20-30 minutes).
I would not use EMLA as it takes longer and risk Met-Hb in neonate  
(low risk but better alternatives).
Optimally I would use warmed buffered lignocaine but I must admit I  
find this practically difficult.
(also warming too much and overbuffering can cause precipitation of  
local)
I tend to reserve buffering for the anxious older child - evidence is  
a bit mixed but personal experience is positive.
I used to be in the camp that believed that lignocaine injection added  
more distress than it relieved.
This may be true if you are technically excellent and don't hit bone.  
I teach trainees to use local now.
Lignocaine also increased chance of successful tap (probably by  
reducing movement).
I would not use ketamine at this age - I suspect because all the above  
makes it unnecessary. Likewise midazolam.
I wonder if one does use these drugs whether we should tell parents  
about the neuronal apoptosis theoretical risk.
Another possibility for infants is chloral hydrate.
My choice for anxious older child would be midazolam (+analgesics) and  
I have used nitrous successfully as well.
I think intranasal fentanyl could be considered, although I have yet  
to use it in this situation.
I am a little wary of the 3 to 12 month infant airway.
In a child above one, in whom all the above fail, then ketamine is a  
great choice with very low risk.




On 27/01/2009, at 2:23 PM, Fergus Thornton wrote:

> Let me clarify my position lest I be thought an ogre.  I am very  
> aggressive in treating pain in kids; I often use narcotics where  
> most of my collegues use NSAIDS.  [My "record" was 14 mg of MS in a  
> 3 yo with a Fx femur.]  I don't usually use lido in an LP because  
> that's two sticks instead of one.  Most of the pain is going thru  
> the skin.  I've also found that once they feel the first stick, they  
> start to struggle much more making the LP more difficult.  It's the  
> same reasoning I don't use lido with a small scalp lac which I can  
> staple; I can get 2-4 staples in before the child needs to be  
> restrained.  I think that's more humane than strapping the child  
> down, sticking with the painful lido 3-4 time, and then suturing.  
> BTW, the "one-stick" LP was taught to me by an experienced pediatric  
> collegue; I didn't think of it on my own.
>
>
> -----Original Message-----
>> From: William Zempsky <[log in to unmask]>
>> Sent: Jan 27, 2009 6:52 AM
>> To: [log in to unmask]
>> Subject: Re: ketamine for septic w/u
>>
>> I am disappointed and  dismayed at the numbers of members of this  
>> listserv who continue to discount the importance of pain management  
>> whether in neonates or children with sickle cell disease.  Despite  
>> years of accumulating evidence on the negative impact of pain and  
>> the benefits of pain management, there are still those who feel it  
>> is not necessary in many scenarios.  I am not sure what "a normal"  
>> procedure is, or what the evolutionary benefit of the pain from  
>> lumbar puncture might be that would suggest we don't do something  
>> to control it.  I would ask those naysayers in the group to tell  
>> us...how do we change your mind?  If evidence based approaches  
>> don't work what does?  At St. Louis children's they instituted IV  
>> practicums for nurses and residents so they could compare the pain  
>> of IVs with and without anesthesia.  Perhaps a similar approach  
>> would work for LP's.  Any volunteers to have an LP without  
>> anesthesia?......
>>
>> Bill
>>
>> William T. Zempsky, MD
>> Associate Director, Pain Relief Program
>> Medical Director, Clinical Trials
>> Connnecticut Children's Medical Center
>> 282 Washington Street
>> Hartford, CT 06106
>> 860-545-9041
>> Fax 860-545-9969
>> [log in to unmask]
>>
>>
>>>>> Fergus Thornton <[log in to unmask]> 1/26/2009 2:57 AM >>>
>> 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
>>>
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>>>
>>>
>>>
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>>
>>
>> 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
>>
>> 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

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

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