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Peds Intensivist chiming in...

There is a bigger picture here.  This kid is going to be admitted, and will receive antibiotics pending the results of blood, urine, and (once it's obtained) CSF cultures.  Without an IV, the infant will have to endure painful IM antibiotics at least every 6-8 hours, depending on the antibiotic choice.  Also, this great looking kid can crash on you - or worse, on the floor, where management without an IV is tricky at best.

Although I would probably give intranasal midazolam, I don't think it's unreasonable to use ketamine, especially with its favorable hemodynamic and respiratory profile.  I've seen it cause myoclonus, so it's not a great choice for patients who require immobility, and IM may not be as effective at inducing brief anesthesia as IV ketamine is.  I'd rather see it given in the ED, where you are equipped to handle potential complications, than see the infant sent to the floor without IV access, and have multiple more unsuccessful attempts, or miss antibiotic doses, or undergo sedation for IV placement with floor staff who may not be as well trained in cardiopulmonary emergencies as your ED staff is.

My take on this is that using ketamine in the ED to obtain good IV access (with or without an LP) may be preferable to sending the infant to the floor, where he probably won't get an IV for many, many hours (especially since the NICU nurses couldn't get one).

Michael J. Verive, MD, FAAP
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