Vitamin "K"

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esclavo

esclavo

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How many OMFS residents out there are using Ketamine routinely in clinic sedations? We go and shuck thirds at a private practice and use it on just about everyone and I must say, those anesthetics kick butt compared to the anesthetics we do in our clinic with propofol... if it weren't for this private practice guy letting us come in and do just about any anesthetic we want, I would have virtually zero experience using IV ketamine.
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esclavo said:
How many OMFS residents out there are using Ketamine routinely in clinic sedations? We go and shuck thirds at a private practice and use it on just about everyone and I must say, those anesthetics kick butt compared to the anesthetics we do in our clinic with propofol... if it weren't for this private practice guy letting us come in and do just about any anesthetic we want, I would have virtually zero experience using IV ketamine.
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Is this part of your program or are you moonlighting?
 
esclavo said:
How many OMFS residents out there are using Ketamine routinely in clinic sedations? We go and shuck thirds at a private practice and use it on just about everyone and I must say, those anesthetics kick butt compared to the anesthetics we do in our clinic with propofol... if it weren't for this private practice guy letting us come in and do just about any anesthetic we want, I would have virtually zero experience using IV ketamine.
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At a pedo res., saw a kid the other night while on call w/ an alveolar fx in area of 23 thru 26 w/ severe lingual displacement. Also a greenstick which obv needed no attention.

In any case, the oral sx resident came (on call at a nearby hospital and cover us if needed). We sedated the kid in the ED and someone mentioned a K dart but the attending in the ED bitched about some contraindication. I can't recall it for some reason...any idea what she may have referenced? We used prop and midaz. and reduced it w/ digital pressure. It was quite fun. What was not fun was bending 24g ortho wire in about 8 different directions to splint.

Which brings up another observation. Have you guys ever wondered why general MDs are so squeemish about intraoral stuff. There were about 8 people in the room w/ us when we reduced it and all the pediatric attendings had to look away. I thought it was quite humerous.
 
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esclavo said:
How many OMFS residents out there are using Ketamine routinely in clinic sedations? We go and shuck thirds at a private practice and use it on just about everyone and I must say, those anesthetics kick butt compared to the anesthetics we do in our clinic with propofol... if it weren't for this private practice guy letting us come in and do just about any anesthetic we want, I would have virtually zero experience using IV ketamine.
Click to expand...

I use low dose ketamine anesthesia (15-20mg IV) on a sedation if the pt is still is not quite "asleep" with propofol/versed. It works very well and provides analgesia as well. I personally haven't found that this low dose increases their secretions all that much so I generally don't use glycopyrrolate. If the patient is tachy, I won't use it. I definitely won't use it on anyone with heart disease.
 
capisce? said:
At a pedo res., saw a kid the other night while on call w/ an alveolar fx in area of 23 thru 26 w/ severe lingual displacement. Also a greenstick which obv needed no attention.

In any case, the oral sx resident came (on call at a nearby hospital and cover us if needed). We sedated the kid in the ED and someone mentioned a K dart but the attending in the ED bitched about some contraindication. I can't recall it for some reason...any idea what she may have referenced? We used prop and midaz. and reduced it w/ digital pressure. It was quite fun. What was not fun was bending 24g ortho wire in about 8 different directions to splint.

Which brings up another observation. Have you guys ever wondered why general MDs are so squeemish about intraoral stuff. There were about 8 people in the room w/ us when we reduced it and all the pediatric attendings had to look away. I thought it was quite humerous.
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Often times if the ED has any suspicion of head injury or that a CHI hasn't been ruled out definitively, they are reluctant to give ketamine because of the risk of increased ICP. Also, they don't like the extra secretions (aspiration risk).
 
At an externship I did (pedo), the residents used Ketamine/Versed on all of their sedation patients. Seemed to work well. I've heard others say that they wouldn't even consider using Ketamine w/ children, so who knows.
 
ItsGavinC said:
At an externship I did (pedo), the residents used Ketamine/Versed on all of their sedation patients. Seemed to work well. I've heard others say that they wouldn't even consider using Ketamine w/ children, so who knows.
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In a peds pt who walks in the door for a scheduled sedation, IM ketamine at 3-4mg/kg is a great drug to get the IV started and 20-25 mins of sedation. I don't like the idea of an IM ketamine dart and then not starting an IV. You need IV access for emergency drugs and also maintenance of sedation with versed if the procedure >20 mins. I think for a pediatric dentist with good training in anesthesia, this is a wonder drug. (situation is a little different in the ED in a kid who is brought in by EMTs after kissing the asphalt, has a C-collar on, and the ED is unwilling to clear him of a closed head injury until the staff radiologist reads the CT even though they know it's negative and the kid has a GCS of 15 and can name all the presidents in order. NPO status also becomes an issue.).
 
esclavo said:
How many OMFS residents out there are using Ketamine routinely in clinic sedations? We go and shuck thirds at a private practice and use it on just about everyone and I must say, those anesthetics kick butt compared to the anesthetics we do in our clinic with propofol... if it weren't for this private practice guy letting us come in and do just about any anesthetic we want, I would have virtually zero experience using IV ketamine.
Click to expand...

Interesting read... Subject kinda threw me off, but in my undergrad research we used Ketamine/Xylaxine to knock out the rats we were using for Vitamin K research (the original K). Had to stick them 60 times within an hour once... didn't like me after that... hmmm.....
 
scalpel2008 said:
In a peds pt who walks in the door for a scheduled sedation, IM ketamine at 3-4mg/kg is a great drug to get the IV started and 20-25 mins of sedation. I don't like the idea of an IM ketamine dart and then not starting an IV. You need IV access for emergency drugs and also maintenance of sedation with versed if the procedure >20 mins. I think for a pediatric dentist with good training in anesthesia, this is a wonder drug. (situation is a little different in the ED in a kid who is brought in by EMTs after kissing the asphalt, has a C-collar on, and the ED is unwilling to clear him of a closed head injury until the staff radiologist reads the CT even though they know it's negative and the kid has a GCS of 15 and can name all the presidents in order. NPO status also becomes an issue.).
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tx for the reply...as you mentioned it I recalled it was the increased secretions as the pt was already having some minor respitory issues.
 
We use ketamine to a certain degree...usually add glycopyrrolate to decrease secretions...nothing is weirder than that look of a patient on ketamine.

For some reason we must have the world's largest population of people with pseudotumor cerebri in Iowa City because we've had 3 in the past month that were planned for generals but had to nix ketamine due to increased ICPs. Supposedly pretty rare to have pseudotumor but 3 times in a month is surprising.
 
capisce? said:
We sedated the kid in the ED and someone mentioned a K dart but the attending in the ED bitched about some contraindication. I can't recall it for some reason...any idea what she may have referenced?
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If I remember my pharm correctly I think that ketamine in kids causes emergence ( awakening) problems so some practitioners may shy away from using it in order to avoid drama
 
kenniemd said:
If I remember my pharm correctly I think that ketamine in kids causes emergence ( awakening) problems so some practitioners may shy away from using it in order to avoid drama
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It seems that nearly every sedated kid I saw on the externship had emergence problems to some degree or another, so I think you're right on.
 
kenniemd said:
If I remember my pharm correctly I think that ketamine in kids causes emergence ( awakening) problems so some practitioners may shy away from using it in order to avoid drama
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yes, emergence phenomenon is a concern (not to be confused with the "staring into space" look of dissociative anesthesia that you will see in a good ketamine sedation). Like emergence delerium, this most commonly occurs in young teenage females, but can occur at any age. Also, it's more common with IV use rather than the IM dart. Adjunctive use of a benzo like versed helps (also reducing the amounts of stimuli like lights and sounds during recovery/wake up). But once you get past the fact that it's a temporary phenomenon and the patient usually doesn't remember it, it's easy to look past it for the sake of a good and safe sedation. For the OMS residents, the Knowledge Updates have a couple of pretty good chapters on ketamine anesthesia. Also, there was a recent Clinical Controversies in JOMS on the subject.
 
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I did 24 anesthetics this week using 12.5-75 mgs of ketamine (along with versed and fentanyl) and these patients hold still so much better than the anesthetics we normally do with fentanyl/versed and propofol. I like the fact that once that ketamine is in you got 15 to 20 minutes to do what ever the heck you want and the patients tidal volume and respiration rate is so strong. I also noticed no increase in secretions....
 
ItsGavinC said:
At an externship I did (pedo), the residents used Ketamine/Versed on all of their sedation patients. Seemed to work well. I've heard others say that they wouldn't even consider using Ketamine w/ children, so who knows.
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I thought that Ketamine was considered general anesthesia. I have never heard of a pedo program that gives residents a general anesthesia permit. I'm not saying that I don't believe you, but if you can get a general anesthesia permit without going through oral surgery or a dental anesthesia residency please tell me how.
 
KY2007 said:
I thought that Ketamine was considered general anesthesia. I have never heard of a pedo program that gives residents a general anesthesia permit. I'm not saying that I don't believe you, but if you can get a general anesthesia permit without going through oral surgery or a dental anesthesia residency please tell me how.
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I don't know (and still don't know) much about it. They had the anesthesia team in the room every time they did it, so maybe it was under their license or something? Sorry that I don't have a better answer for you!
 
We use ketamine routinely for sedations, 5mg versed and 50mg fentanyl is our usual sedation for 3rds. for average size pt (70kg) give 5 of versed wait for signs of sedation, then give 50 ketamine. similarly for small pt's (naive teenage girls 4 & 40). have seen an increase in nausea with use of ketamine and fentanyl so we usually avoid this. also we usually avoid redosing ketamine for the same reason, and use propofol if you need anything extra. personally i don't use anything for secretions and have not had a problem, many of our residents use glyc though if they use ketamine....
 
capisce? said:
...Which brings up another observation. Have you guys ever wondered why general MDs are so squeemish about intraoral stuff. There were about 8 people in the room w/ us when we reduced it and all the pediatric attendings had to look away. I thought it was quite humerous.
Click to expand...

I've seen a similar phenomenon when doing procedures requiring nerve blocks in the ER. This is foreign to the ER residents and staff and they always want to know if they can watch. I think nerve blocks are the coolest thing they've ever seen, based on how they gawk at me. It usually goes something like this:

ME: "So I'm gonna just numb up this guy's face so I can wail on him right here in your ER."
ER MUFFIN: "You mean...like....with a nerve block?!?"
ME: "Uhhhh, yep."
ER MUFFIN: <yelling to his buddies> "hey this guy's doing a nerve block over here!"
<the room fills with spectators....the patient is thinking 'oh god I must be really sick'.>
ME: <sticks needle in patient's mouth for V3 block>
ER MUFFINS: "Oooooooohhhh........Aaaaaahhhhhhh.........."
 
I'm a big fan of ketamine. I think it gets a bad wrap from some folks, but so what. They should grow some balls.

Esclavo, I worked with a local guy here that also touched 'em with 15-25mg of ketamine IV and I agree--it gives a great sedation.
 
Ketamine rocks. Gotta love the spaced-out look in their eyes as you see it kick in, right before you jam in the local...

The only downside is when you have a little hottie in your chair... I like to hear 'em moan a little... They don't do it so much on the ol' special K...

Works great on aboriginals, I find, who tend not to respond well to midazolam/fentanyl +/- propofol...
 
I just had to bring this thread back. I'm at a rotation where we only use vesed/fentanyl/ketamine and the stuff is awesome. They don't move for a good 15-20 min. Too bad that's not enough time for this lowly intern to take out a set of 3rds. :laugh:
 
UNLV OMS GUNNABE said:
I just had to bring this thread back. I'm at a rotation where we only use vesed/fentanyl/ketamine and the stuff is awesome. They don't move for a good 15-20 min. Too bad that's not enough time for this lowly intern to take out a set of 3rds. :laugh:
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UNLV! I miss ya man! How is H town treating you and the family?
Come on man... surely it doesnt take you longer than 20 mins;) In all seriousness, If I dont get a set out in under 30 mins... let me say, my upper isnt happy. (Disclaimer: Even though speed is desired, quality and patient safety is always first. Believe me... if anything gets masserated... :scared: )
 
UNLV OMS GUNNABE said:
Well I was going to change this but you beat me to it. For a 150lb light-weight 2versed/50fent/25ish ketamine usually puts them down nice.
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I have used it a few times on OMFS service and a few times on Anesthesia service. It is a great drug.
 
GatorDMD said:
UNLV! I miss ya man! How is H town treating you and the family?
Come on man... surely it doesnt take you longer than 20 mins;) In all seriousness, If I dont get a set out in under 30 mins... let me say, my upper isnt happy. (Disclaimer: Even though speed is desired, quality and patient safety is always first. Believe me... if anything gets masserated... :scared: )
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I am not ashamed to say that it takes me longer than 20 mins. The majority that I take out are at a county clinic. The typical pt is a 28 yo AA chick that is 6'2'', 180lbs. The teeth are horizontal, complete bony, below the crown of the second molar, the canal runs along the tooth from apex to crown, tough bone. Maybe I'm exagerating a bit, but not by much. When I do get the typical private practice pt (17-20 yo, roots not fully formed, mesial-angeled), then yes I can do them much faster. But those pt's are few and far between here.
 
UNLV OMS GUNNABE said:
I am not ashamed to say that it takes me longer than 20 mins. The majority that I take out are at a county clinic. The typical pt is a 28 yo AA chick that is 6'2'', 180lbs. The teeth are horizontal, complete bony, below the crown of the second molar, the canal runs along the tooth from apex to crown, tough bone. Maybe I'm exagerating a bit, but not by much. When I do get the typical private practice pt (17-20 yo, roots not fully formed, mesial-angeled), then yes I can do them much faster. But those pt's are few and far between here.
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I feel you. There are definitely cases that take a bit of drilling and sweat and patience. I was only razzin you about the 20 mins... more like 30-40 mins;) How many cases do you guys/gals do a day in the county clinic? I wish we had a county clinic to rotate out of where you could just go to town but most of our patients are referred from local dentists. Even though I have still seen some tough ones in a 5'-3" 17yo 85lbs WF. Good to hear from you man. Keep up the hard work.
 
The rotation I'm on now we do sedations twice a week in the mornings. I'll do 4-6 cases/week. I always knew orgon was country club ;) :laugh:
 
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