Background: Sickle cell disease (SCD) vaso-occlusive episodes (VOEs) are managed primarily with opioids that can lead to dependence and tachyphylaxis. Ketamine mitigates opioid tolerance and appears efficacious for all-cause pain in the adult emergency department (ED). We hypothesized that ED treatment with low-dose adjuvant ketamine (LDK) for acute VOE is safe and decreases opioid usage in children and young adults with SCD. Procedure: In this exploratory study, patients with SCD aged 10-25 years presenting to UCSF Benioff Children’s Hospital Oakland ED with VOE were eligible for a single 0.2 mg/kg IV dose of LDK, after receipt of the first IV opioid dose. Safety, tolerability, and subjective experience were assessed prospectively. Pain scores, length of stay, likelihood of discharge from the ED, time to 50% pain reduction, and morphine equivalent usage (mg/kg/h) for the intervention visits were compared to the patient’s historical data within the year prior. Results: No serious treatment emergent adverse events occurred in the 62 enrolled patient-encounters in 25 individual patients. LDK decreased morphine equivalent usage by 0.06 mg/kg/h (15%; 95% CI [2.3%, 28%], p=0.004), but did not affect pain scores on discharge, time to or likelihood of 50% pain reduction, or likelihood of discharge. Subjectively, when assessed in their first LDK encounter, the majority of patients reported faster pain relief (60%) and desired LDK in the future (68%). Conclusions: LDK for SCD VOE in the pediatric ED is safe, subjectively improves the experience of pain, and decreases opioid usage. Larger studies are needed to confirm these findings.
Patients with precursor-B-cell acute lymphoblastic leukemia (B-ALL) may initially present with a prodrome, cytopenia(s) with abnormal bone marrow cellularity, but without clonal abnormalities. Prior cases of “indolent ALL” report infections preceding B-ALL diagnosis. Here we describe our institutional experience, eight patients over a 15-year period with a prodrome (2% of B-ALL diagnoses) prior to definitive diagnosis. Patients ranged from 3-15 years of age (median 5 years), requiring a median 3.5 months from presentation to diagnosis, with a median 3 bone marrow aspirates (BMA) to reach definitive diagnosis. Practitioners must be aware that initial negative BMA does not rule out B-ALL.
Background: Management of refractory pain in pediatric sickle cell disease (SCD) and oncology is reliant on opioids though high opioid dosing increases side effects and tachyphylaxis. We introduced low dose ketamine infusion (LDKI) to our inpatient unit to determine if LDKI was safe and tolerable. We subsequently hypothesized that LDKI would improve pain scores but not decrease opioid utilization. Procedure: We retrospectively reviewed inpatients from LDKI initiation in March 2014 through October 2017, analyzing each patient’s first admission with LDKI. The day prior to LDKI initiation was compared with the day of LDKI initiation and two subsequent days in regard to cumulative daily opioid utilization, vital signs and pain scores. For patients with SCD, the LDKI admission was compared with up to three admissions in the prior year for a vaso-occlusive event. Results: Nineteen patients (12 oncology, 7 SCD) with a median age of 14.6 years received LDKI for a median of 6 days at a median initial dose of 0.06 mg/kg/h (1.1 mcg/kg/min). There was no change in pain scores, heart rate or opioid utilization when comparing the day prior to LDKI initiation with subsequent days. No patient discontinued LDKI due to intolerability. For patients with SCD, there was a median 32% reduction in cumulative pain scores when comparing the LDKI admission with prior admissions. Conclusions: LDKI is well tolerated and may be a viable option for refractory pediatric cancer- and sickle cell-related pain. Future study is required to further delineate appropriate dosing and patients most likely to benefit.
Background: The benefits of human-animal interaction in healthcare are widely accepted, and utilized to aid in stressors of illness. However, risk of zoonotic infection from animal-assisted therapy (AAT) is less well studied. Policies around AAT in pediatric hospitals, particularly with regard to immunocompromised patients, vary widely due to lack of evidence-based guidelines. Therefore, we aimed to identify zoonoses in our hematology/oncology patients who received AAT. Procedure: We retrospectively reviewed hematology/oncology patients admitted at UCSF Benioff Children’s Hospital Oakland between May 2018 and September 2019 that received AAT and compared this cohort to prior admissions starting November 2013 when AAT was not received. Clinical outcomes including length of stay, number of blood cultures, number of positive blood cultures, organisms identified, and C. difficile infection were compared for patient admissions where AAT was and was not received to determine potential zoonotic infection. Results: A total of 666 admissions occurred during the allotted time period including 310 admissions with standard and 56 admissions with strict immune precautions. There was no hospital acquired zoonotic bloodstream infection and no increase in C. difficile infection in those with standard or strict immune precautions receiving AAT compared to those admissions when not receiving AAT. Conclusion: There was no increase in zoonotic infection in immunocompromised pediatric hematology/oncology patients receiving AAT. Though further validation is required, liberalization of hospital infection control practice to allow AAT for immunocompromised pediatric patients appears safe as long as routine hygienic practice is strictly followed and patients monitored for potential increase in zoonotic infection.