I'm also a huge fan of ketamine and use it frequently. However, I have not had as positive an experience with ketamine and extra glottic airways. They do vomit. I have not found ondansetron helpful and think the vomiting is move from direct stimulation by the device rather than central from the ketamine (the vomiting occurs more frequently as the ketamine wears off rather than during sedation and I do think benzodiazepines or antiemetics may help with this). Not sure what to think about the gag reflex blunting with ondansetron but my practice now with extra glottic devices placed with sedation only (and ketamine is my DOC) once I am sure I can ventilate through the ILMA I will paralyze the patient and then intubate through it either blind or using the bronchoscope. Great discussion, Darren. L
Love this episode! Still can't use propofol at my hospital and have been using low dose etomidate for procedural sedation. Have not had a problem with myoclonus, but as an avid EMRAP listener have been waiting for it. This myoclonus prophylaxis is what I am going to do going forward to further lengthen my luck streak. Thanks!
That was a nice lecture. Dan Berg wants to say hi. He listens to EMRAP with me. We met at the other Gallup hospital, IHS! He was pleasantly surprised to hear you, Oscar.
I found this approach bizarre to say the least. We have moved away from sedation only intubation and gained the ability to use paralytics. There is no reason to go back. If you are going to use a extraglottic airway anyway, there is no reason not to use a paralytic to facilitate placement and prevent aspiration. DSI is another option with crych as a backup. It seems like a backwards step to use sedation only.
I certainly understand your position Derek. I have been a very vocal advocate against a sedation-only approach but ketamine is a unique agent. Just as ketamine for procedural sedation does not fall cleanly into moderate or deep sedation categories it is possible that it does not fall clearly into "sedation-only" intubation as we have always known it when using etomidate or benzos alone. I do believe that we have become so comfortable with RSI that it occasionally gets used in circumstances that are fraught with danger and I have certainly seen bad outcomes as a result. We definitely need some other tools in the tool box for predicted difficult airways. Whether or not ketamine-facilitated intubation is one of them remains to be seen. Thanks for the comment.
Ketamine at 200mg/kg is definitely not sedation only. It renders many people nearly motionless (except for breathing) and deeply dissociated and anesthetized ( not sensing pain). No other single agent that we use can accomplish this. I have used ketamine followed by rocuronium and an ILMA with a Bougie several times and that has worked well. No one questions RSI as the optimal technique for most intubations, however we should develop other techniques for those infrequent situations in which RSI may be be the riskier way to go.
Shout out to Dan Berg; good to hear from you Michelle. Oscar Palomo
James K. - November 6, 2013 1:50 PM
Why not use DSI with ketamine and sux? Paralytic not shown to decrease LES tone.
Leslie S. - November 6, 2013 2:17 PM
I'm also a huge fan of ketamine and use it frequently. However, I have not had as positive an experience with ketamine and extra glottic airways. They do vomit. I have not found ondansetron helpful and think the vomiting is move from direct stimulation by the device rather than central from the ketamine (the vomiting occurs more frequently as the ketamine wears off rather than during sedation and I do think benzodiazepines or antiemetics may help with this). Not sure what to think about the gag reflex blunting with ondansetron but my practice now with extra glottic devices placed with sedation only (and ketamine is my DOC) once I am sure I can ventilate through the ILMA I will paralyze the patient and then intubate through it either blind or using the bronchoscope. Great discussion, Darren. L
brendan c. - November 7, 2013 7:06 AM
Love this episode!
Still can't use propofol at my hospital and have been using low dose
etomidate for procedural sedation. Have not had a problem with myoclonus, but as an avid EMRAP listener have been waiting for it. This
myoclonus prophylaxis is what I am going to do going forward to further lengthen my luck streak. Thanks!
Michelle O. - November 13, 2013 10:52 AM
That was a nice lecture. Dan Berg wants to say hi. He listens to EMRAP with me. We met at the other Gallup hospital, IHS! He was pleasantly surprised to hear you, Oscar.
Derek I., M.D. - November 14, 2013 9:52 PM
I found this approach bizarre to say the least. We have moved away from sedation only intubation and gained the ability to use paralytics. There is no reason to go back. If you are going to use a extraglottic airway anyway, there is no reason not to use a paralytic to facilitate placement and prevent aspiration. DSI is another option with crych as a backup. It seems like a backwards step to use sedation only.
Darren B. - December 30, 2013 12:39 PM
I certainly understand your position Derek. I have been a very vocal advocate against a sedation-only approach but ketamine is a unique agent. Just as ketamine for procedural sedation does not fall cleanly into moderate or deep sedation categories it is possible that it does not fall clearly into "sedation-only" intubation as we have always known it when using etomidate or benzos alone. I do believe that we have become so comfortable with RSI that it occasionally gets used in circumstances that are fraught with danger and I have certainly seen bad outcomes as a result. We definitely need some other tools in the tool box for predicted difficult airways. Whether or not ketamine-facilitated intubation is one of them remains to be seen. Thanks for the comment.
Oscar P. - January 3, 2014 10:27 AM
Ketamine at 200mg/kg is definitely not sedation only. It renders many people nearly motionless (except for breathing) and deeply dissociated and anesthetized ( not sensing pain). No other single agent that we use can accomplish this. I have used ketamine followed by rocuronium and an ILMA with a Bougie several times and that has worked well.
No one questions RSI as the optimal technique for most intubations, however we should develop other techniques for those infrequent situations in which RSI may be be the riskier way to go.
Shout out to Dan Berg; good to hear from you Michelle. Oscar Palomo
Oscar P. - January 5, 2014 6:55 AM
Oops, I meant Ketamine at 2mg/kg ( not 200mg/kg) or roughly 200mg is definitely not sedation only. Oscar Palomo MD
Charles W. - January 16, 2014 5:30 PM
Great to hear from you Alan & Oscar. I enjoyed your segment and miss working with you.