Ketamin for in office sedation?

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I am considering using low dose Ketamine in conjunction with Versed for sedation. It seems to me to be a great combination from a safety standpoint, especially when considering lack of respiratory depression. Also, it is unlikely the chronic pain patient would be tolerant to Ketamine as they are with Fent and Benzos like Versed. What are your thoughts? BTW, I am not an anesthesiologist.

Sometimes a very very bad trip for the patients! The hallucinations can be extreme, profuse salivation, protracted wake up time, patients feeling completely spaced out for the rest of the day, impressive tachycardia, nystagmus, and lack of any muscle relaxation are but a few of the problems. I would suggest saving it for use on the neighborhood cats....

Algos, thanks for your comments. Do you find these reactions in low ketamine doses when Versed is given concurrently?

You should ask locally. It is not the standard of care in this area (USA).
Great street value, super duper quality high. If people knew it was stocked in your office, the safe would be stolen weekly.

Not a good idea. How about fentanyl and versed. It's called 1 and 1 and you still will not get paid for administering it, but at least you get the liability of providing MAC in your office. I had to canel a procedure on an opioid naive patient when I walked in and a fellow just gave 2 and 2. We flipped her over, gave her a little narcan, and put the O2 on. Fortunately she was fine in 5 mminutes and we didn't even have to bag her.

What did you do in fellowship training?

Higher street value than Fentanyl?! I would suspect Fent would be much more desirable to the drug abusing population. "K" is more of a club drug up here in the north.

We use primarily Fentanyl and Versed at my fellowship. "2 and 2" is standard with our patients. We have almost no opioid or benzo naive patients.

Propofol is often used as well, probably 40% of the patients. Occasionally Ketamine is thrown in the mix.

I'm fine with using Versed and Fentanyl but as a non-anesthesiologist I'd much rather deal with the rare emergence phenomena from ketamine and versed than respiratory depression. In the below study 5 out of 77 patients had very mild emergence phenomena. Thats why I'm thinking this way. But of course I'm open to suggestions and thus posting here.

Intersting study: Chudnofsky et al. • MIDAZOLAM AND KETAMINE FOR PROCEDURES, ACADEMIC EMERGENCY MEDICINE • March 2000, Volume 7, Number 3

Abstract. Objective: To describe the clinical characteristics
of a combination of midazolam and ketamine
for procedural sedation and analgesia in adult
emergency department (ED) patients. Methods: This
was a prospective, observational trial, conducted in
the ED of an urban level II trauma center. Patients
$ 18 years of age requiring procedural sedation and
analgesia were eligible, and enrolled patients received
0.07 mg/kg of intravenous midazolam followed
by 2 mg/kg of intravenous ketamine. Vital signs were
recorded at regular intervals. The adequacy of sedation,
adverse effects, patient satisfaction, and time to
reach discharge alertness were determined. Descriptive
statistics were calculated using statistical analysis
software. Results: Seventy-seven patients were
enrolled. Three were excluded due to protocol violations,
three due to lack of documentation, and one
due to subcutaneous infiltration of ketamine, leaving
70 patients for analysis. The average age was 31
years, and 41 (59%) were female. Indications for procedural
sedation and analgesia included abscess incision
and drainage (66%), fracture/joint reduction
(26%), and other (8%). The mean dose of midazolam
was 5.6 6 1.4 mg and the mean dose of ketamine was
159 6 42 mg. The mean time to achieve discharge
criteria was 64 6 24 minutes. Five patients experienced
mild emergence reactions, but there were no
episodes of hallucinations, delirium, or other serious
emergence reactions. Eighteen (25%) patients recalled
dreaming while sedated; twelve (17%) were described
as pleasant, two (3%) unpleasant, three (4%)
both pleasant and unpleasant, and one (1%) neither
pleasant nor unpleasant. There were four (6%) cases
of respiratory compromise, two (3%) episodes of emesis,
and one (1%) case of myoclonia. All of these were
transient and did not result in a change in the patient’s
disposition. Only one (1%) patient indicated
that she was not satisfied with the sedation regimen.
Conclusions: The combination of midazolam and
ketamine provides effective procedural sedation and
analgesia in adult ED patients, and appears to be
safe. Key words: procedural sedation; procedural analgesia;
ketamine; midazolam. ACADEMIC EMERGENCY
MEDICINE 2000; 7:228–235

Originally Posted by lobelsteve

You should ask locally. It is not the standard of care in this area (USA).
Great street value, super duper quality high. If people knew it was stocked in your office, the safe would be stolen weekly.

Not a good idea. How about fentanyl and versed. It's called 1 and 1 and you still will not get paid for administering it, but at least you get the liability of providing MAC in your office. I had to canel a procedure on an opioid naive patient when I walked in and a fellow just gave 2 and 2. We flipped her over, gave her a little narcan, and put the O2 on. Fortunately she was fine in 5 mminutes and we didn't even have to bag her.

What did you do in fellowship training?

Ligament,


I am an anesthesiologist and have a lot of experience with ketamine. I think that it is a little extravagant for your purposes. Many of our procedures actually require little/no sedation. I give po valium. Fifty percent of my patients refuse any sedation (especially second timers). Ketamine is not a drug that I would suggest for those that have very little experience with it. Hallucinations and bad dreams still occur with benzo pre med (even at 2-4 mg of midazolam). If you need to give 2-4 mg of midazolam just to decrease the incidence of a side effect from another drug...then what are you actually doing???? In the office setting I would suggest keeping it simple...just my 2 cents....

One should be aware of all its(ketamine) properties, including its vagolytic properties (increase BP,HR), increase airway secretions, increased ICP(usually not a problem), and so forth. No anesthesia medication is fool proof.

The reason for the few reported patient experienced side effects is due to the amount of versed given in the above study. For a thin adult patient, 5mg were used and in my population, the amount would approach 10 mg. The study did not discuss wake up time nor time to discharge from what I could tell...that would be interesting since it directly impacts the operation of the clinic....
We have found propofol alone results in very rapid emergence and discharge, frequently 15 minutes after the last dose...

I'm pretty sure I came across a study comparing prop and possibly versed vs. ketamine and versed. Post op recovery and time to discharge was in fact longer in the K/M group.

Originally Posted by algosdoc

The reason for the few reported patient experienced side effects is due to the amount of versed given in the above study. For a thin adult patient, 5mg were used and in my population, the amount would approach 10 mg. The study did not discuss wake up time nor time to discharge from what I could tell...that would be interesting since it directly impacts the operation of the clinic....
We have found propofol alone results in very rapid emergence and discharge, frequently 15 minutes after the last dose...

I like your approach. In residency we sedated maybe 10% of our patients. In fellowship its about 90%. In practice, I'd like to sedate far fewer patients.

Originally Posted by mille125

Ligament,


I am an anesthesiologist and have a lot of experience with ketamine. I think that it is a little extravagant for your purposes. Many of our procedures actually require little/no sedation. I give po valium. Fifty percent of my patients refuse any sedation (especially second timers). Ketamine is not a drug that I would suggest for those that have very little experience with it. Hallucinations and bad dreams still occur with benzo pre med (even at 2-4 mg of midazolam). If you need to give 2-4 mg of midazolam just to decrease the incidence of a side effect from another drug...then what are you actually doing???? In the office setting I would suggest keeping it simple...just my 2 cents....

We use 1+1 or 2+2. About half decline any sedation. Some of the people who want IV sedation decline it after the first procedure when they see their fears were unjustified. OTOH there are some folks I have to give PO Valium just to start the IV.

Remember, your patients are also your advertisements. If they go back into the community or to the referring doc talking about what a terrible experience it was there go your referrals. It doesn't matter how well you think they did, it's how they think they did.

Can't argue with that Gorback.

Originally Posted by gorback

Remember, your patients are also your advertisements. If they go back into the community or to the referring doc talking about what a terrible experience it was there go your referrals. It doesn't matter how well you think they did, it's how they think they did.

office sedation....

when i was doing 100% of my procedures in the office we NEVER used IV sedation (except for the occasional SCS trial or the occasional IDET - and that was maybe 3 times total)... the most potent thing i would prescribe would be some po valium (primarily for intra-discal stuff or for those really anxious patients who vagal'ed in the past) on the very RARE occasion....

these are the reasons i don't use sedation at all
1) no sedation - therefore no complications with sedation (ie: need for reversal, bagging, etc..)
2) quick recovery times - we watch them for 15 mins and if no sensory/motor changes they are discharged - can't have that kind of turnover w/ sedation
3) no delays (tons of delays w/ sedation - difficult IV stick, etc..)
4) if they are too sedated how do you know you didn't bag the nerve root?
5) most of my bread & butter procedures take less than 2 minutes - so why expose them to something for something very brief
6) for diagnostic procedures (medial branch blocks) i find that the sedation interferes with the diagnostic component of it - did they feel better because of fentanyl or because they had good true relief???

before you consider ketamine, maybe consider switzhing from 12 gauge needles to 25 gauge - just kidding

Originally Posted by Tenesma

office sedation....

when i was doing 100% of my procedures in the office we NEVER used IV sedation (except for the occasional SCS trial or the occasional IDET - and that was maybe 3 times total)... the most potent thing i would prescribe would be some po valium (primarily for intra-discal stuff or for those really anxious patients who vagal'ed in the past) on the very RARE occasion....

these are the reasons i don't use sedation at all
1) no sedation - therefore no complications with sedation (ie: need for reversal, bagging, etc..)
2) quick recovery times - we watch them for 15 mins and if no sensory/motor changes they are discharged - can't have that kind of turnover w/ sedation
3) no delays (tons of delays w/ sedation - difficult IV stick, etc..)
4) if they are too sedated how do you know you didn't bag the nerve root?
5) most of my bread & butter procedures take less than 2 minutes - so why expose them to something for something very brief
6) for diagnostic procedures (medial branch blocks) i find that the sedation interferes with the diagnostic component of it - did they feel better because of fentanyl or because they had good true relief???

before you consider ketamine, maybe consider switzhing from 12 gauge needles to 25 gauge - just kidding

wow, tenesma and I are in agreement with something......

in ortho cases at the ATC setting they are using ketamine to lessen effects of postop sedation.

ligament,
I am an anesthesiologist and have used ketamine many times in kids for closed reductions and cast specially for the quick cases and when patient is not NPO and surgeon says he has to do the case(so called emergency). I would not use ketamine routinly if I have other options as Ketamine will give lots of unpleasent feelings to the patient and more to the family members.

Originally Posted by lucyz02

in ortho cases at the ATC setting they are using ketamine to lessen effects of postop sedation.

yes...but this does not apply for most interventional pain procedures

i'm not involved in medicine though, i wonder whether ketamine anaesthesiacan be applied to kids? the daughter of a friend of mine is undergoing a serious surgery soon .. i'm worrying..

Ligament, I can offer you a different perspective on this, but I don't think it will change what you do

I did an anesthesia residency and a pain fellowship

I believe very low dose ketamine (ie, 5-10 mg) combined with 2mg versed can be used to augment versed *anxiolysis* and create more of an "I don't care" *sedation* (ie, pts feel minor discomfort but suffer less from it) in a very safe manner and cause very few side effects in patients who are not elderly and have poor cognitive reserve; It's not clear to me that you should be using more than anxiolysis if you are doing a *diagnostic* block

Please note that 5-10 mg of ketamine is very different from the 2mg/kg they gave in your ER study; you will not get *analgesia* from it; but you will also be very unlikely to make patients anxious, unless they already have severe anxiety to begin with and are on 3mg of clonazepam daily for it

My experience is based on recently working for an ASC where the culture is to use lots of pre-meds, 5-10-15mg of ketamine for the case, and NO fentanyl and NO midazolam for MAC and general anesthesia for cases. I would give the 5-10mg of ketamine up front a few minutes before induction and nobody was flipping out, even though they were laying on an OR table, and they had *not* gotten versed or anything else; zero incidince of agitation with this dose and hundreds of patients

so I don't think you will get much out of this (ie, slightly more sedation than anxiolysis, and not a lot of analgesia); there may be a role in giving it AFTER having given 2 and 2 and getting no anxiolysis in a patient with opiate and benzo tolerance

also as others have pointed out it is not SOC so if something else unrelated goes wrong you may be on the hook

If you were my fellow, I'd have no reservations about letting you try it to learn about it; I don't think it is dangerous and I don't think at ultra low doses patients will suffer; I just don't see yourself getting too much benefit from using the ultra-low doses you need to use to avoid side effects

Originally Posted by Tenesma

office sedation....

when i was doing 100% of my procedures in the office we NEVER used IV sedation (except for the occasional SCS trial or the occasional IDET - and that was maybe 3 times total)... the most potent thing i would prescribe would be some po valium (primarily for intra-discal stuff or for those really anxious patients who vagal'ed in the past) on the very RARE occasion....

these are the reasons i don't use sedation at all
1) no sedation - therefore no complications with sedation (ie: need for reversal, bagging, etc..)
2) quick recovery times - we watch them for 15 mins and if no sensory/motor changes they are discharged - can't have that kind of turnover w/ sedation
3) no delays (tons of delays w/ sedation - difficult IV stick, etc..)
4) if they are too sedated how do you know you didn't bag the nerve root?
5) most of my bread & butter procedures take less than 2 minutes - so why expose them to something for something very brief
6) for diagnostic procedures (medial branch blocks) i find that the sedation interferes with the diagnostic component of it - did they feel better because of fentanyl or because they had good true relief???

before you consider ketamine, maybe consider switzhing from 12 gauge needles to 25 gauge - just kidding

Even though this is 3-4 years old :

Originally Posted by joshmir

Ligament, I can offer you a different perspective on this, but I don't think it will change what you do

I did an anesthesia residency and a pain fellowship

I believe very low dose ketamine (ie, 5-10 mg) combined with 2mg versed can be used to augment versed *anxiolysis* and create more *sedation* (ie, pts feel minor discomfort but care less about it) in a very safe manner and cause very few side effects in patients who are not elderly and have poor cognitive reserve; It's not clear to me that you should be using more than anxiolysis if you are doing a *diagnostic* block

not 5-10 mg of ketamine is very different from the 2mg/kg they gave in your ER study; you will not get *analgesia* from it; but you will also be very unlikely to make patients anxious, unless they already have severe anxiety to begin with and are on 3mg of clonazepam daily for it

My experience is based on recently working for an ASC where the culture is to use lots of pre-meds, 5-10-15mg of ketamine for the case, and NO fentanyl and NO midazolam for MAC and general anesthesia for cases. I would give the 5-10mg of ketamine up front a few minutes before induction and nobody was flipping out, even though they were laying on an OR table, and they had *not* gotten versed or anything else; zero incidince of agitation with this dose and hundreds of patients

so I don't think you will get much out of this (ie, slightly more sedation than anxiolysis, and not a lot of analgesia); there may be a role in giving it AFTER having given 2 and 2 and getting no anxiolysis in a patient with opiate and benzo tolerance

also as others have pointed out it is not SOC so if something else unrelated goes wrong you may be on the hook

If you were my fellow, I'd have no reservations about letting you try it to learn about it; I don't think it is dangerous and I don't think at ultra low doses patients will suffer; I just don't see yourself getting too much benefit from using the ultra-low doses you need to use to avoid side effects

Cmon guys, this is a 3 year old thread, bumped today by a layperson asking for personal medical advice instead of discussing things with his doctor. READ THE TIMESTAMPS

Dillan, this forum is for physicians to have discussions with other physicians, this forum is not for giving medical advice to laypersons. I wish you well, but your friend needs to discuss any concerns with their particular doctor.

Originally Posted by mille125

ligament,


i am an anesthesiologist and have a lot of experience with ketamine. I think that it is a little extravagant for your purposes. Many of our procedures actually require little/no sedation. I give po valium. Fifty percent of my patients refuse any sedation (especially second timers). Ketamine is not a drug that i would suggest for those that have very little experience with it. Hallucinations and bad dreams still occur with benzo pre med (even at 2-4 mg of midazolam). If you need to give 2-4 mg of midazolam just to decrease the incidence of a side effect from another drug...then what are you actually doing???? In the office setting i would suggest keeping it simple...just my 2 cents....

1+

yep 3 years old...

It is now 3 years old and I have used low dose ketamine in hundreds of cases, no problems. works great.

actually, not hundreds of cases. just a few dozen, still has worked great no problems.

what's your dose?

who do you use it in?

which cases?

what other meds do you give with it?

thanks

Originally Posted by Ligament

It is now 3 years old and I have used low dose ketamine in hundreds of cases, no problems. works great.

actually, not hundreds of cases. just a few dozen, still has worked great no problems.

try po valium

I only use ketamine in the OR given my an anesthesiologist for MAC cases on pts very tolerant to meds in which we'd prefer no GA. Sometimes this is for cancer pain, for example.

So it certainly has a place in specific scenarios.

We don't use it in the office for sedation but we have been using it with mixed success as an outpt infusion. Midas 2 mg, infusion for 4 hours, then Midas 2 mg. This is done for 10 days. I won't speak to efficacy, but in terms of safety itmhas been fine. I've gone as high as 80-90 mg/hr for refractory CRPS. When pt feels too loopy I just decrease. Of note, starting is very cautious at 5-10 mg/hr and it is increased only every 1-2 hours.

you guys are nuts...

"this is gonna pinch" inject local...do case. done.

Originally Posted by drf

I only use ketamine in the OR given my an anesthesiologist for MAC cases on pts very tolerant to meds in which we'd prefer no GA. Sometimes this is for cancer pain, for example.

So it certainly has a place in specific scenarios.

We don't use it in the office for sedation but we have been using it with mixed success as an outpt infusion. Midas 2 mg, infusion for 4 hours, then Midas 2 mg. This is done for 10 days. I won't speak to efficacy, but in terms of safety itmhas been fine. I've gone as high as 80-90 mg/hr for refractory CRPS. When pt feels too loopy I just decrease. Of note, starting is very cautious at 5-10 mg/hr and it is increased only every 1-2 hours.

Originally Posted by DocShark

you guys are nuts...

"this is gonna pinch" inject local...do case. done.

Oh dude, but that it was that easy.

Originally Posted by 101N

Oh dude, but that it was that easy.

its that easy 30-40 times a week for me...

sedation 4 x a week maybe...

Twice a month. Fentanyl and versed. Reversible.

Originally Posted by Ligament

It is now 3 years old and I have used low dose ketamine in hundreds of cases, no problems. works great.

actually, not hundreds of cases. just a few dozen, still has worked great no problems.

Do you really feel that the other more standard methods of sedation are inadequate? I just dont like being that far outside of the box even if it does work. Seems like a long term loss somewhere down the road.

Originally Posted by mille125

Do you really feel that the other more standard methods of sedation are inadequate? I just dont like being that far outside of the box even if it does work. Seems like a long term loss somewhere down the road.

Agree with mille125. There is a very small minority of patients that "need" ketamine. If they do, it should be under MAC with anesthesia assisting.

I've used it for one case in 2 years. It was very helpful for that one case, but it's the only case that needed it, and that was done as MAC in ASC with anesthesia help.
Otherwise for my cases I do 95% in-office with local +/- PO valium, 4% IV sedation, 1% MAC.