Does subdissociative Ketamine equal moderate sedation?

[photodr2]

0.1 to 0.3 mg/kg of ketamine for pain relief, brief procedures, etc.... Do you need to treat this as moderate sedation, get a full consent, etc, or do you just treat it like another analgesic, push the drug and go forth?

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[GeneralVeers]

In reality ketamine for proedures should not rationally be treated as moderate sedation. Unfortunately we get no say in this, and as with most hospital "policy" rationality doesn't apply. Every place I've worked has treated Ketamine just like any other drug for moderate sedation

 

[DeadCactus]

Probably varies by institution but I would argue no. I find it hard to apply the classic grading of sedation to ketamine because they are designed around medications that cause a concurrent drop in airway protection and respiratory drive with AMS. Dissociative dosing at 1 mg/kg is moderate sedation in terms of being the normal goal for procedural sedation; they're not responding to commands but their airway is protected and they are breathing spontaneously. Deep sedation would be induction with 2-4 mg/kg.

The 0.1 to 0.3 mg/kg is purely analgesia and no more of a sedation than giving opiates. I've given it before without the sedation circus but there were some raised eye brows from nursing as ketamine for pain is still relatively new...

 

[TooMuchResearch]

0.1 to 0.3 mg/kg of ketamine for pain relief, brief procedures, etc.... Do you need to treat this as moderate sedation, get a full consent, etc, or do you just treat it like another analgesic, push the drug and go forth?

For analgesic doses, I don't do anything special.

 

[Daedalus]

Definitely not - I use 0.5 mg/kg for analgesia. It's not moderate sedation, so no need to do all the associated craziness.

 

[Janders]

Medically speaking, truly sub-dissociative dose Ketamine should be treated just like Dilaudid.

Administratively speaking, there is probably nothing in your hospital's rules and regs about using ketamine in this manner. As such, RN staff or pharmacy staff are going to hold you to the procedural sedation standards where ketamine in its "typical" usage is likely regulated at your institution.

So go to P&T and present your intention to use ketamine for analgesia, explain its safety, and have it treated, at appropriate dosages like any other analgesic.

 

[link2swim06]

It's all about the culture of your hospital.

At my hospital they starting to do it on the floors without a physician present.

The data is actually pretty interesting...it really seems to reduce the chance of have chronic pain from an acute event and sometimes can even 'reset' some chronic pain people.

 

[Tiger26]

As with any sedation, it depends on your intent. If your intent is to treat pain and you use a "pain dose," then it does not equate with sedation.

Keep in mind that anesthesia uses fentanyl in some cases as an induction agent whereas it gets ordered everyday in the ED without any concern for sedation.

 

[WilcoWorld]

Definitely not - I use 0.5 mg/kg for analgesia. It's not moderate sedation, so no need to do all the associated craziness.

That dose is pretty high for analgesia. You might try 0.1mg/kg a few times and find that you can get good effect with much lower doses.

 

[LaBusqueda]

I have lost all tolerance for RNs or Admins beefing over something like this on a "policy" or "procedure" basis.

I have no problem, and actually love it, when people come to me to ask a clinical or science question like why I use x, y, z.
But when the second they block with this crap I just push it myself.
ketamine, push dose pressors, peri procedure anxiolytic dose benzo, is where this comes in all the time.

 

[K31]

I've discussed this with the charge nurse and ED pharmacist the first time I did this. There is no hospital policy on it, and we all agreed that we didn't have to treat it as a sedation. I did wind up having to push it myself though. I usually do 10-20 mg at a time for what it's worth.

 

[Tiger26]

Yeah--I use 0.1 - 0.15/kg. It's much smoother if put in a 100 cc bag of saline and ran over 10 min. Still, I'd say I only order ketamine very infrequently for refractory (real) pain to opioids.

The first few times I did this created a big pissing contest with pharmacy and nursing, so I ended up writing a clinical policy on it

 

[Birdstrike]

Has anyone on here seen either respiratory depression or laryngospasm with ketamine?

Both are listed as potential adverse reactions to ketamine, but I've never seen either with any route or dose, and I've given ketamine a lot of times.

 

[pianoman511]

Once saw laryngospasm in a kid during sedation, one squeeze of the bvm and it was gone.

 

[TooMuchResearch]

I've seen attendings concerned it could happen, but none of them have ever seen it.

 

[BAM!]

I saw laryngospasm once as a medical student. They were fine with BVM. I saw a kid get 100x the dose by accident. They were drowsy for a long time, but had no respiratory depression.

 

[Makati2008]

Yeah--I use 0.1 - 0.15/kg. It's much smoother if put in a 100 cc bag of saline and ran over 10 min. Still, I'd say I only order ketamine very infrequently for refractory (real) pain to opioids.

The first few times I did this created a big pissing contest with pharmacy and nursing, so I ended up writing a clinical policy on it

Would you mind pm me a copy or the basic template of the policy? Would be interesting to read.

 

[Daedalus]

That dose is pretty high for analgesia. You might try 0.1mg/kg a few times and find that you can get good effect with much lower doses.

Eh, I disagree - it's well within subdissociative doses, and I've had good success with it as an analgesic at this dose. I tend not to use ketamine for pain unless the patient is in severe pain or is refractory to other therapies, and ketamine is a very safe drug. Lots of studies have shown it to be safe even at massive doses. Case in point is the quote below...

I saw laryngospasm once as a medical student. They were fine with BVM. I saw a kid get 100x the dose by accident. They were drowsy for a long time, but had no respiratory depression.

 

[Janders]

I haven't seen laryngospasm myself but I know a guy... (really, actual second hand info!)

As far as respiratory depression, I've not seen prolonged respiratory depression. However, if you slam a large bolus IV push you can get a brief period of apnea rivaling propofol given in a similar manner.

 

[Arch Guillotti]

I saw laryngospasm once as a medical student. They were fine with BVM. I saw a kid get 100x the dose by accident. They were drowsy for a long time, but had no respiratory depression.

What was "the dose"? .1 mg/kg or 1 mg/kg? Or something else?

 

[Arch Guillotti]

Has anyone on here seen either respiratory depression or laryngospasm with ketamine?

Both are listed as potential adverse reactions to ketamine, but I've never seen either with any route or dose, and I've given ketamine a lot of times.

I too have given ketamine lots of times. I have only seen respiratory depression once and it was in a critically ill patient due to a moderate dose of ketamine.

I have never seen laryngospasm. I guess is that laryngospasm could conceivably occur in a child who has copious secretions due to ketamine and some of those secretions tickle the vocal cords. The only times I have seen this amount of secretions is IM induction doses of ketamine on the order of 4-6 mg/kg.

 

[Arch Guillotti]

I saw laryngospasm once as a medical student. They were fine with BVM. I saw a kid get 100x the dose by accident. They were drowsy for a long time, but had no respiratory depression.

BVM isn't really the initial treatment for laryngospasm. Controlling the airway, a tight seal with the face mask and gentle, increasing cpap usually breaks the spasm. This is usually readily accomplished in the OR where the equipment set-up is different than the ED. If that doesn't work then we go to positive pressure ventilation. If it is a significant laryngospasm, attempting to ventilate will be like trying to squeeze air into a rock. At that point we go to a small dose of succinylcholine which always works. Hypoxia also breaks laryngospasm although this is not a good position to be in.

My experience comes from the OR, not the ED obviously. Laryngospasm is seen most often upon emergence although sometimes can happen on induction of anesthesia.

 

[WilcoWorld]

Eh, I disagree - it's well within subdissociative doses, and I've had good success with it as an analgesic at this dose. I tend not to use ketamine for pain unless the patient is in severe pain or is refractory to other therapies, and ketamine is a very safe drug. Lots of studies have shown it to be safe even at massive doses. Case in point is the quote below...

I think ketamine is a very safe drug, and I never said 0.5mg/kg was an unsafe dose. I said that you could probably get away with lower doses. The literature on sub dissociative ketamine supports that claim.

Lest you think I'm a ketaminophobe - ketamine is my second favorite drug (droperidol is still #1 even though I can't get it).

 

[EDParallax]

Once saw laryngospasm in a kid during sedation, one squeeze of the bvm and it was gone.

Me too. It was during anesthesia in the OR. 3 or 5 BVM and it resolved. I think they pushed it fast that time. Anyone have experience with fast vs slow push?

 

[TooMuchResearch]

I've seen attendings concerned it could happen, but none of them have ever seen it.

Okay, now I've seen it. It was procedural sedation in a kid. Spasm terminated spontaneously before BVM was used.

 

[deleted547339]

I'll do 0.1mg/kg in 100cc as above.

I find it helps with chronic pain people, e. g. Chronic back pain with new insult or on chronic narcotics for x, y, z then breaks their wrist.

I almost exclusively use it for MSK stuff.

Every once in a while when I get a patient that I know just wants some "gee, I don't know, I think it starts with a D" I'll give them ketamine- they all seem to really dislike it and want to leave.

 

[deleted206819]

My experience has been with those patients presenting with complex regional pain syndromes, MSK pain, and chronic pain where opioid medications are not having the intended effect. I've done several studies in my residency on ketamine infusions (drips), ketamine boluses and ... what I've found to work best is a 0.1 - 0.15 mg/kg bolus and then a 0.3 mg/kg in 100mL saline dripped over 30 minutes. YMMV.

 

[Angry Birds]

Based on this thread I used IM ketamine and the patient barfed many times and I was even concerned with aspiration.

I had even pre-medicated with zofran odt.

Quite a sub-stellar first experience.

Edit: maybe it was another thread. This was a moderate sedation I did, not pain control.

 

[la gringa]

having ED pharmacists helps with use of ketamine for pain significantly -- discuss the dosing (i've used 0.25mg/kg), indication, and good to go. once was a suboxone patient with a nasty distal radius fx, another was a former opiate addict who didn't want to get opiates. needed to I&D a large abscess.

both worked like a charm. patients were happy with level of pain control, no airway issues, no nothing.

 

[Angry Birds]

having ED pharmacists helps with use of ketamine for pain significantly -- discuss the dosing (i've used 0.25mg/kg), indication, and good to go. once was a suboxone patient with a nasty distal radius fx, another was a former opiate addict who didn't want to get opiates. needed to I&D a large abscess.

both worked like a charm. patients were happy with level of pain control, no airway issues, no nothing.

That's IV dosing, correct?

 

[southerndoc]

I'm a huge fan of ketamine -- for pain, sedation, and acute delirium. Thinking of allowing the paramedics to administer it (I'm an EMS medical director).

Unfortunately, the state nursing board won't allow nurses to give it because the manufacturer considers it an anesthetic. So if I order it IM, IV, or IN, I'm giving it myself.

 

[la gringa]

That's IV dosing, correct?

Yes, that's IV

I had to review "policy" also to give 1mg/kg IM to an autistic child to facilitate IV etc and the subdissociative doses are all ok under "policy" for "anxiolysis", thank God.... this spot though is at least moderately progressive in that "deep sedation" has been allowed for a few years whereas the local community shops under the "big teaching hospital" just got around to propofol being ok a year ago and still don't allow etomidate for procedural sedation at all.

 

[shookwell]

I am also a huge fan of ketamine. Love low dose ketamine for asthmatics who are really sick and anxious.

Anecdotally, I have had the occasional experience of relatively low doses of ketamine (0.2-0.3 IV range) causing dissociation and sometimes even causing an emergence reaction. Every time I've seen this the dissociation only lasted minutes and the analgesic and anxiolytic effects lasted even after the dissociation wore off.

Most hospitals I have worked in treated all ketamine use as sedation. We just approved ketamine for our medics, can't wait to see the nurses' reactions.