Doc in the Bay - Ketamine

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Paul W. -

Its a skate - not a hockey "boot", eh?
Paul Wilson
Canada

Randal R., MD -

Ever use the 321 formula for rsi with Succinylcholine@1.5mg/kg.instead or Roc ? Any issues? This dinosaur prefers the former.

Howard M. -

I've very rarely used Sux in the formula, but when I have, it's been closer to 1mg/kg (rounding up). There is no issue with it.

Jeff -

Our paramedics use ketamine and succs. Not because I think succs has any real benefit but because I couldn't get roc. Damn national backorders.

Great discussion, Howie.

David H., M.D. (@BritFltDoc) -

Great segment, thanks.
So this has me wondering about Ketofol for procedural sedation. If it is better with Ketamine to either use "a little" (0.1-0.2mg/kg) for analgesia, or "a lot" (1mg/kg) for full dissocation, then I wonder if the traditional 0.5mg/kg cited at the Ketofol dose can be refined. Perhaps the ideal combination would be usual Propofol dose of 1mg/kg and then a pain dose of Ketamine with it (0.1-2mg/kg). No need for Fentanyl. Probably better analgesia than fentanyl, and a low dose of Ketamine that avoids any emergence problems. After listening to your talk, I wonder if this might be the ideal combination and ratio ? Any thoughts ?

Howard M. -

David, sorry for the delayed response. I agree, the analgesic properties of ketamine make it an ideal agent to combine with propofol. I've always used 0.75 mg/kg of both agents when I've used Ketofol. As far as a lower dose, my concern would be the rapid metabolism of the ketamine not offering a lasting analgesia. That is why I've always leaned toward higher dose if I'm dissociating the patient anyway.

Alex F. -

Howard and David, I was also wondering about Ketamine's dose in Ketofol. In traditional dosing of 1 mg/kg Ketofol, the patient would get 0.5 mg/kg of ketamine, putting them in the partial dissociation dose. And your increased dosing of 0.75 mg/kg of both ketamine and propofol would also fall under partial dissociation. In this case, is the propofol acting almost like the midazolam-rescue in preventing partial dissociation effects?
Thanks for the discussion on the beauty that is Ketamine.
[I don't have as much experience with Ketofol or ketamine in adults, but will be graduating residency in a couple weeks and will finally have free reign over sedation choice!]

Mitchell L. -

I second this question! The pharmacologic basis of this doesn't make much sense. 1mg/kg of each might make a little more sense to me if you want to get a full dose of each and counter one another's side effects.. not sure what to think

drmtv -

Dr Mel...Question any literature on the use of Ketamine to sedate patients suffering from delirium from FLAKKA?

Jennifer M. -

great seeing you at smacc :)
Thanks for the ketamine tips. I understand when you give for procedural sedation, it is a very slow push. When used for RSI, how fast can you push the ketamine? Thanks.

Howard M. -

Hi Guys!

Drmtv - I don't know of any literature specifically to FLAKKA. However, Dr.Keseg's study of prehospital ketamine did include drug induced delirium. http://www.ncbi.nlm.nih.gov/pubmed/25153713

Jennifer M. - I don't push Ketamine slowly in any setting. If you have premedicated the patient and prepared them well, I've not seen problems with speed of the push. In RSI, I do push it "quickly"...

A. Terry -

For analgesia dosed ketamine, our hospital pharmacy has started mixing the ketamine with 50 mL NS and then running it into the pt over 20-30 minutes. Haven't seen anybody start getting to the recreational level since starting to do this.

Gar -

I hear these dose ranges for anlagesia, recreational, partial dissociation & full dissociation cited very commonly but I can't figure out where they come from? Do you have a reference?

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