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Whereas I don't argue to value of pain prevention for procedures, I would not use ketamine in this situation. 

Ketamine has an excellent safety profile in otherwise healthy pediatric patients.  I am not aware of studies looking at the safety of using ketamine for procedural sedation in potentially septic patients.  Add to this a potentially compromised airway and in this instance I'm not sure I want to take that risk - or defend a possible sedation complication. With use of local anesthesia I don't think the pain is unreasonable.  If it was my potentially septic child, I would say hold the ketamine and hold my child. 

Jesse




________________________________
From: William Zempsky <[log in to unmask]>
To: [log in to unmask]
Sent: Monday, January 26, 2009 1:52:14 PM
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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Fergus Thornton
read my blog @ http://docdownunder.wordpress.com 

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