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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
>>>>
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>>>>
>>>>
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>>>
>>>
>>> Fergus Thornton
>>> read my blog @ http://docdownunder.wordpress.com
>>>
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>>>
>>
>>
>> --
>> Try not. Do or do not, there is no try...
>>                                             YODA
>>
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>
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>



-- 
Try not. Do or do not, there is no try...
                                              YODA

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