LISTSERV mailing list manager LISTSERV 16.5

Help for PED-EM-L Archives


PED-EM-L Archives

PED-EM-L Archives


PED-EM-L@LISTSERV.BROWN.EDU


View:

Message:

[

First

|

Previous

|

Next

|

Last

]

By Topic:

[

First

|

Previous

|

Next

|

Last

]

By Author:

[

First

|

Previous

|

Next

|

Last

]

Font:

Proportional Font

LISTSERV Archives

LISTSERV Archives

PED-EM-L Home

PED-EM-L Home

PED-EM-L  January 2009

PED-EM-L January 2009

Subject:

Re: ketamine for septic w/u

From:

Jeffrey Proudfoot <[log in to unmask]>

Reply-To:

Jeffrey Proudfoot <[log in to unmask]>

Date:

Mon, 26 Jan 2009 18:12:29 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (335 lines)

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

Top of Message | Previous Page | Permalink

Advanced Options


Options

Log In

Log In

Get Password

Get Password


Search Archives

Search Archives


Subscribe or Unsubscribe

Subscribe or Unsubscribe


Archives

May 2019
April 2019
March 2019
February 2019
January 2019
December 2018
November 2018
October 2018
September 2018
August 2018
July 2018
June 2018
May 2018
April 2018
March 2018
February 2018
January 2018
December 2017
November 2017
October 2017
September 2017
August 2017
July 2017
June 2017
May 2017
April 2017
March 2017
February 2017
January 2017
December 2016
November 2016
October 2016
September 2016
August 2016
July 2016
June 2016
May 2016
April 2016
March 2016
February 2016
January 2016
December 2015
November 2015
October 2015
September 2015
August 2015
July 2015
June 2015
May 2015
April 2015
March 2015
February 2015
January 2015
December 2014
November 2014
October 2014
September 2014
August 2014
July 2014
June 2014
May 2014
April 2014
March 2014
February 2014
January 2014
December 2013
November 2013
October 2013
September 2013
August 2013
July 2013
June 2013
May 2013
April 2013
March 2013
February 2013
January 2013
December 2012
November 2012
October 2012
September 2012
August 2012
July 2012
June 2012
May 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September 2011
August 2011
July 2011
June 2011
May 2011
April 2011
March 2011
February 2011
January 2011
December 2010
November 2010
October 2010
September 2010
August 2010
July 2010
June 2010
May 2010
April 2010
March 2010
February 2010
January 2010
December 2009
November 2009
October 2009
September 2009
August 2009
July 2009
June 2009
May 2009
April 2009
March 2009
February 2009
January 2009
December 2008
November 2008
October 2008
September 2008
August 2008
July 2008
June 2008
May 2008
April 2008
March 2008
February 2008
January 2008
December 2007
November 2007
October 2007
September 2007
August 2007
July 2007
June 2007
May 2007
April 2007
March 2007
February 2007
January 2007
December 2006
November 2006
October 2006
September 2006
August 2006
July 2006
June 2006
May 2006
April 2006
March 2006
February 2006
January 2006
December 2005
November 2005
October 2005
September 2005
August 2005
July 2005
June 2005
May 2005
April 2005
March 2005
February 2005
January 2005
December 2004
November 2004
October 2004
September 2004
August 2004
July 2004
June 2004
May 2004
April 2004
March 2004
February 2004
January 2004
December 2003
November 2003
October 2003
September 2003
August 2003
July 2003
June 2003
May 2003
April 2003
March 2003
February 2003
January 2003
December 2002
November 2002
October 2002
September 2002
August 2002
July 2002
June 2002
May 2002
April 2002
March 2002
February 2002
January 2002
December 2001
November 2001
October 2001
September 2001
August 2001
July 2001
June 2001
May 2001
April 2001
March 2001
February 2001
January 2001
December 2000
November 2000
October 2000
September 2000
August 2000
July 2000
June 2000
May 2000
April 2000
March 2000
February 2000
January 2000
December 1999
November 1999
October 1999
September 1999
August 1999
July 1999
June 1999
May 1999
April 1999
March 1999
February 1999
January 1999
December 1998
November 1998
October 1998
September 1998
August 1998
July 1998
June 1998
May 1998
April 1998
March 1998
February 1998
January 1998
December 1997
November 1997
October 1997
September 1997
August 1997
July 1997
June 1997
May 1997
April 1997
March 1997
February 1997
January 1997
December 1996
November 1996
October 1996
September 1996
August 1996
July 1996
June 1996
May 1996
April 1996
March 1996
February 1996
January 1996
December 1995
November 1995
October 1995
September 1995
August 1995
July 1995
June 1995
May 1995
April 1995
March 1995
February 1995
January 1995
December 1994
November 1994
October 1994
September 1994

ATOM RSS1 RSS2



LISTSERV.BROWN.EDU

CataList Email List Search Powered by the LISTSERV Email List Manager