ketamine without versed

I only give Ketamine to people who don't mind a little hallucination.

Gas you down said:

i was told in residency that giving ketamine to an awake pt w/o a benzo beforehand was malpractice. so i've always given a little versed.
recently, a collegue had a pt call back to complain about hallucinating throughout her hip surgery. she got 20mg for spinal positioning. but no versed (she was almost 70).
has their been a precedent set in the courts in the past? there some studies out there which purposefully looked at omitting the benzo, so now i'm unsure...
your answers will not change my practice of keeping the benzo

Click to expand...

Malpractice is probably an exaggeration, but yes I always give a little bit of Versed before I plan on giving any ketamine. I was taught the same thing, but with better wording -- they are more likely to hallucinate/remember the hallucinations if you don't give them a benzo or propofol beforehand.

Even 1 mg of Versed does the trick. I suppose I could do a dose response study and try going lower, but since 1 mg of Versed is usually not a big deal I haven't felt the need to do so.

It's always been interesting to me how divergent two fields in medicine can be (especially anesthesia and EM).

If giving ketamine without a benzo is breaching standard of care, thousands of ER docs are committing malpractice daily. I give ketamine all the time, rarely ever with a benzo unless they're being goofy as they wake up.

A lot of ER docs are using ketofol:
http://www.epmonthly.com/clinical-skills/emrap/could-ketofol-be-the-perfect-drug-combo/

My preferred method of preventing emergence reaction:
http://www.youtube.com/watch?v=nFw01CXLGrI

I have a lot of patients receiving ketamine infusions (10-40mg/hr on healthy 70kg adult males -- 2.5 to 10 mcg/kg/min) on the ward without scheduled benzos (written prn, rarely receive), and most of them do just fine. Some, however, do not tolerate even a little ketamine, and start having hallucinations at only 5 or 10mg. If I have a patient that I feel I need to start on ketamine at a higher dose (say, jump straight to 30-40mg/hr), then I will usually write for a PO benzo (diazepam or lorazepam TID) to start before the infusion, and continue it for at least the first 24hrs. This approach, combined with prn benzo and lots of reassurance, seems to be much better tolerated. I will add the post-script disclaimer that this is in a young trauma population, and results may vary with your populations.

Make keta-mine, keta-yours.

Sent from my ASUS Transformer Pad TF300T using Tapatalk 2

I recently helped out one of our ortho buddies with a patient down in the ED. One of those guys had pushed 200mg of ketamine on a patient for a C/R.

She was def. having a "fear and loathing in las vegas" moment.



We can't stop here...
this is bat country.

Gas you down said:

i was told in residency that giving ketamine to an awake pt w/o a benzo beforehand was malpractice.

Click to expand...

Dose makes a big difference. Ketamine is a wonderful drug, and midazolam is the most overused drug in the world of anesthesia.

It's OK to use ketamine without midazolam, either in low doses, in conjunction with GA, in a ~1:10 or thereabouts mix with propofol, etc.

A low dose ketamine infusion, on the order of 10-20 mg/hr, is an effective pain adjunct and won't make people goofy. I would use it all the time if not for PACU/ward nurses who freak out about ketamine infusions.

I can also tell you that military medics give it in the field all the time, doses of 15 or 25 mg to people with combat wounds, with no other drugs given. In a scary environment that I can only imagine would predispose people to have weird crazy bad visions and reactions. They come in mellow. Sometimes a little spacy, especially if they've lost a lot of blood. I've not seen one with a bad reaction to it. I much prefer they use ketamine over the old standby, IM morphine or fentanyl lollipops.

Don't be under the impression that Versed works 100% of the time either. I've seen hallucinations occur even with Versed being on board.

Giving versed with ketamine is optional, and giving it PRN is just fine. I use ketamine often for sedation and have had only a handful of patients with negative emergence reactions with it, all of which were easily quelled by a single IV dose of versed.

http://emupdates.com/2011/01/27/taming-the-ketamine-tiger/

I had my first ketamine disphoric reaction in a lady going back for carpal tunnel release.....

Nervous lady (probably my first clue it wasn't a good idea). Gave 4 of Versed pre-op then pushed 25 mg Ketamine on the WAY to the OR.

Time we got in the room, this lady was freaking out (I think she even scared the surgeon whom I had to reassure.....lol). A definite first for me and it was obvious it was the ketamine. Gave something like another 4 of versed, and man am I glad she had that onboard (the initial mostly). Ran a propofol gtt with LA by the surgeon. No other events.

End of case and patient didn't recall anything but still looked "off" even in recovery. It was really profound.

People need to chill with ketamine: most people won't freak out or hallucinate with a small dose of ketamine. Keep in mindalso that hallucination will mean diffent things for different people.

Excellent post (as usual)

pgg said:

Dose makes a big difference. Ketamine is a wonderful drug, and midazolam is the most overused drug in the world of anesthesia.

It's OK to use ketamine without midazolam, either in low doses, in conjunction with GA, in a ~1:10 or thereabouts mix with propofol, etc.

A low dose ketamine infusion, on the order of 10-20 mg/hr, is an effective pain adjunct and won't make people goofy. I would use it all the time if not for PACU/ward nurses who freak out about ketamine infusions.

I can also tell you that military medics give it in the field all the time, doses of 15 or 25 mg to people with combat wounds, with no other drugs given. In a scary environment that I can only imagine would predispose people to have weird crazy bad visions and reactions. They come in mellow. Sometimes a little spacy, especially if they've lost a lot of blood. I've not seen one with a bad reaction to it. I much prefer they use ketamine over the old standby, IM morphine or fentanyl lollipops.

Click to expand...

I have been giving at least 10mg of ketamine to just about every pt I have taken care of (either intra-op, postop, or both) for six years now. Roughly 1600 pts per year times 6yrs; almost 10,000 pts, and only two have gone crazy, briefly, in all that time. Not crazy, really, but dysphoric.

With or without Versed.

Lots more people are helped by it than hurt.

pgg said:

Dose makes a big difference. Ketamine is a wonderful drug, and midazolam is the most overused drug in the world of anesthesia.

It's OK to use ketamine without midazolam, either in low doses, in conjunction with GA, in a ~1:10 or thereabouts mix with propofol, etc.

A low dose ketamine infusion, on the order of 10-20 mg/hr, is an effective pain adjunct and won't make people goofy. I would use it all the time if not for PACU/ward nurses who freak out about ketamine infusions.

I can also tell you that military medics give it in the field all the time, doses of 15 or 25 mg to people with combat wounds, with no other drugs given. In a scary environment that I can only imagine would predispose people to have weird crazy bad visions and reactions. They come in mellow. Sometimes a little spacy, especially if they've lost a lot of blood. I've not seen one with a bad reaction to it. I much prefer they use ketamine over the old standby, IM morphine or fentanyl lollipops.

Click to expand...

I hate hate hate Versed. I have almost completely omitted it from my practice and still give IV bolus ketamine for my spines and lidocaine infusions. I have actually started bolusing propofol in the preop area maybe 20-30mg with good results with anxiolysis. Sure I explain to the patient the IV will sting a little if its an AC vein usually not but in the hand yes thats when I increase the flow rate of my IV. Versed in my mind prolongs emergence and my patients wake up much more clear and level headed without it.

Gas you down said:

recently, a collegue had a pt call back to complain about hallucinating throughout her hip surgery. she got 20mg for spinal positioning. but no versed (she was almost 70).

Click to expand...

IIRC With ketamine, the younger the patient the less likely they are to have aversive hallucinations. Tendency to "hallucinate" goes up as you get older.

why are you all using ketamine so much? what for? i don't think i have ever run into a situation where i wanted or needed it. its just not something i use. i have better pain meds, and better anxiolytic meds, so why ketamine?

i'm not the only one, i'm not aware of any of my partners using it, and in residency i rarely saw it used, and that was only in OB for failed resident spinals during C/S.

is it a regional thing? honest question, because i really never see anybody use it.

Ketamine rocks.

A little goes a long way. In particular, great for chronic pain patients. Great analgesic, especially with propofol and magnesium. Def. opiod and GA sparing drug.

You just have to know how and when to use it.

The fact that it increases SSEP amplitude is just a bonus... as is it's ability to maintain spontaneous ventilation.

In hypotensive patients, it has the tendency to maintain blood pressure. I still use it for my acute temponade patients.

I've always liked ketamine, but I've really come to love it in trauma patients the last few months.

Pre-induction, induction, during surgery, and as a low-dose infusion postop.

I have had good luck with ketamine in these 2 situations:
1. RSI in hemodynamically unstable patients without neuro issues. 1-2 mg/kg and they don't remember intubation at all.
2. Awake chest tubes: .5 mg/kg in small pushes-- patient asked why i was tickling him and told me I was "really cool".
Have not used it with versed too often although some folks i work with won't give it without.

As mentioned before, I often take care of a rather unique patient population. These young folk come to us a few days to a week after getting some limb and/or other parts blown off, with significant wound contamination, and a big blank spot in their mind consisting of "I was on patrol downrange, now I'm stateside missing an arm and leg."

We have had enough experience taking care of these guys to somewhat predict their pain patterns based on injury and time. Most of these guys start out receiving only opiates in theater and in Germany (though, that is changing). Once they arrive back in the states (post-injury day 4-7), we usually switch them to a multimodal approach, including neuropathic agents (gabbapentin/lyrica, nortriptyline), tylenol, opiates, catheters/blocks, and NSAIDs (if possible). Even if there is no initial complaint of neuropathic or phantom limb pain, there almost always will be (in traumatic amputations and nerve injuries, not all-comers), and I have anecdotally noted decreased neuropathic symptoms when starting the drugs before they express the symptoms, as it takes a few days for the neurontin/lyrica to take effect. As is, with thrice-weekly washouts, and repeated revisions of amputations, opiate use still increases. Some of these guys end up on regimens like Oxy-SR 60mg TID, plus oxy-IR 15-20mg Q4hrs prn, plus neuropathics, tylenol, a catheter or two, and a dilaudid PCA 1mg q10min. I have taken care of guys receiving over 96mg of IV dilaudid from their PCA alone. The idea that it takes weeks to months to develop this kind of opiate tolerance is false.

These are some of the patients where ketamine is great. If started later (like with the above regimen), then opiate doses are often able to be decreased to more manageable levels within a few days (although, we often have to start at higher doses of ketamine). I prefer to start it early, when I predict, based on their injury pattern and initial assessment, that they will become one of these high opiate requirement patients. Even a low-dose infusion (say 10-15mg/hr) started within the first few days after injury, seems to decrease the overall opiate consumption in the long-term, and minimize further neuropathic and phantom pain. We believe that this is due to a combination of opiate-sparing, thereby decreasing the rate of opioid tolerance and opiate-induced hyperalgesia, and NMDA activity blunting the central wind-up of pain pathways.

Regardless, through the use of ketamine, we are able to better treat this particular patient population without having to escalate to insane amounts of opiates and their side-effects. Further, we have data showing its safe use as a continual infusion (and infusion plus PCA) in unmonitored settings (aka regular med/surg wards); although, I do not know when that data will actually be published.

Sent from my ASUS Transformer Pad TF300T using Tapatalk 2

Surfer said:

why are you all using ketamine so much? what for? i don't think i have ever run into a situation where i wanted or needed it. its just not something i use. i have better pain meds, and better anxiolytic meds, so why ketamine?

i'm not the only one, i'm not aware of any of my partners using it, and in residency i rarely saw it used, and that was only in OB for failed resident spinals during C/S.

is it a regional thing? honest question, because i really never see anybody use it.

Click to expand...

Here are some of the reasons I give it to everybody.

Mainly because it is analgesic without making the pt apneic. When you get the call from PACU about the pt with resp rate of 5 and pain of 9/10, ketamine is the boss.

There have been about a dozen papers in the past few years showing that a single dose of 0.1-0.15 mg/kg (roughly 10mg) before incision will drop pain scores by 30-40% for 2 days after surgery, on average. These studies were mostly ortho surgery study but one abd surgery study. Maybe more literature out there, but these are the ones I know about.

Ketamine attacks pain from different receptor pathways so it is often useful in chronic pain pts, rather than more narcs.

When you are doing a block by yourself and want sedation, try 2 mg Versed and 10mg Ketamine. It is almost as analgesic as 2 of Versed/2cc of Fentanyl, but the Pox stays at 98%, where as the 2 and 2 combo will put the Pox at 88%.