how many use ketamine?

[stephend7799]

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I was wondering how many of you use ketamine on a reg basis..

I do not. I personally feel ketamine should be reserved for anesthesia for cardiac tamponade.. A few people in my practice use it ROutinely. They use it for mac sedation for all types..

Ketamine in my opinion has too many side effects to be used routinely. ANd this is what was practiced in my residency..

what do you guys think? those of you in practice..

 

[Noyac]

I was wondering how many of you use ketamine on a reg basis..

I do not. I personally feel ketamine should be reserved for anesthesia for cardiac tamponade.. A few people in my practice use it ROutinely. They use it for mac sedation for all types..

Ketamine in my opinion has too many side effects to be used routinely. ANd this is what was practiced in my residency..

what do you guys think? those of you in practice..

I use it frequently. About 3-6 times per week. I use it for sedation with midaz or as propamine/ketafol . I use it as a background anesthetic for postop pain mgmt. I use it for colonoscopy, ERCP, EGD and any other type of sedation outside the OR. I generally use it as much as possibe. I have never (not joking here) had a complication with it and all the side effects that you are worried about can easily be avoided.

 

[militarymd]

I almost never use it, but the reason is because of the packaging...and wasting ....


otherwise, I would use it on a lot of MACs...

 

[CanGas]

Use it regularly as an infusion for chronic pain pts undergoing painful surgery (knowing they will be a nightmare to control post-op and every little bit helps), also for pts on TIVA with remifent to try and prevent acute tolerance.

Love 15 Ketamine + 1 midaz prior to turning a little old person with a broken hip for placing their spinal. That does seems to gork them out comfortably without doing anything to their hemodynamics. Same recipe works for pts in a monitored setting that you just can't seem to get control of their pain, ie. in ICU with guy who has taken elephant doses of narcotic with little apparent relief, hit those NMDA receptors and off they go to being nice and comfortable. They might need a little more than 15+1 but it works every time. Never felt comfortable using it with difficult pain patients on the floor where there is crappy cardio-resp monitoring though I do know of a couple colleagues who have used the good old Special K to get the person comfortable and the nurses off their back. In those setting where I have exhausted everything and can’t get them comfortable but am not able to use a regional technique and before transferring to a monitored setting to load them up good I try Magnesium. Totally anecdotal, but the NMDA receptors are your friends, and in the end the chronic pain patients who were in uncontrollable pain post surgery said that whatever I told the nurse to put in the bag worked miracles.

Just another tool in the armamentarium.

 

[UTSouthwestern]

Use it fairly frequently, and especially on the thoracolumbar or thoracosacral ALIF's/PLIF's and chronic pain patients. Give Versed and use 2.5-5 mg boluses or a very low infusion rate. Works wonders.

Also have a cardiac recipe using continuous infusion of remifentanil and small bolus of ketamine 10-15 mg 20-30 minutes prior to shutting off the remi that allows them the patients to be rapidly extubated with no pain and no respiratory depression.

 

[jetproppilot]

Use it regularly as an infusion for chronic pain pts undergoing painful surgery (knowing they will be a nightmare to control post-op and every little bit helps), also for pts on TIVA with remifent to try and prevent acute tolerance.

Love 15 Ketamine + 1 midaz prior to turning a little old person with a broken hip for placing their spinal. That does seems to gork them out comfortably without doing anything to their hemodynamics. Same recipe works for pts in a monitored setting that you just can't seem to get control of their pain, ie. in ICU with guy who has taken elephant doses of narcotic with little apparent relief, hit those NMDA receptors and off they go to being nice and comfortable. They might need a little more than 15+1 but it works every time. Never felt comfortable using it with difficult pain patients on the floor where there is crappy cardio-resp monitoring though I do know of a couple colleagues who have used the good old Special K to get the person comfortable and the nurses off their back. In those setting where I have exhausted everything and can’t get them comfortable but am not able to use a regional technique and before transferring to a monitored setting to load them up good I try Magnesium. Totally anecdotal, but the NMDA receptors are your friends, and in the end the chronic pain patients who were in uncontrollable pain post surgery said that whatever I told the nurse to put in the bag worked miracles.

Just another tool in the armamentarium.

How much mag in the bag, Dude? A gram?

Interesting.

 

[Noyac]

How much mag in the bag, Dude? A gram?

Interesting.

I'm interested as well. Is it 2 gms?

I always gave 2gms on induction in the heart cases. It works well.

 

[Gator05]

Just starting out in anesthesiology here. I can still remember the first time an attending advised "just a little" (10mg) of ketamine at the end of a case. Smoothest wake-up I'd had. And while my n is still rather limited, I haven't had a case with ketamine go poorly in terms of patient comfort post-op.

I'm more inclined to use it nowadays as well, what with the direction the research is taking concerning intra-op fentanyl/remi and post-op hyperalgesia. That said, had a great speaker down from MGH a few weeks ago who commented that ketamine's effect on NMDA was relatively weak!

 

[stephend7799]

HOw about th e ******* I NG nightmares guys? patients wake up with ketamine the wildest people.. just crazy and wild

try inducing with it..

 

[Noyac]

HOw about th e ******* I NG nightmares guys? patients wake up with ketamine the wildest people.. just crazy and wild

try inducing with it..

Never seen it. Give versed if you are using it. Small doses don't seem to have that effct as far as I have seen. The PACU nurses would say "Oh no, you gave him ketamine, he's gonna be wild." Now they love it.
If you are using it with propofol or volatile, then you don't have to worry for the most part. By the way, I did a TIVA with just propofol last week and that pts had a dream that she was drunk and then in rehab. So its not just ketamine that can give you bad dreams. Are you gonna quit using propofol? I still warn them of bad dreams but I have not seen it.

 

[rn29306]

Never seen it. Give versed if you are using it. Small doses don't seem to have that effct as far as I have seen. The PACU nurses would say "Oh no, you gave him ketamine, he's gonna be wild." Now they love it.
If you are using it with propofol or volatile, then you don't have to worry for the most part. By the way, I did a TIVA with just propofol last week and that pts had a dream that she was drunk and then in rehab. So its not just ketamine that can give you bad dreams. Are you gonna quit using propofol? I still warn them of bad dreams but I have not seen it.

Have had some patients state that the dreams are quite "warm and vivid". Not exactly sure what a "warm" dream is, but go figure. Worst patient that experienced this was a woman receiving a colonoscopy with propofol MAC. She must have been having a really "warm and vivid" one because she made the most sexual moaning and groaning sounds before I changed this from an average MAC to an IV general just so she would stop acting like a porn star during the exam.

Not sure if age has anything to do with this, but peds cancer patients receiving intrathecal methotrexate that we sleep for treatments get a syringe of propofol and every one of these guys looks forward to the anesthetic. The parents swear that the children dream during this short anesthetic and actually like propofol.

 

[jwk]

HOw about th e ******* I NG nightmares guys? patients wake up with ketamine the wildest people.. just crazy and wild

try inducing with it..

It's not near as common as most people think, especially with a little versed.

We used to use it all the time until it became a scheduled drug.

There's nothing better for poly-lordy syndrome. 😉

 

[CanGas]

Yeah, 2 grams.

Both pt's were chronic pain patients. Both colon resections on Morphine PCA. Both had bowel preps (so likely starting a little low on Mg post prep). Can't remember why they did not have epidurals but for some reason they did not and by the time I see them in agony they already got their LMWH. Eating narcotics like crazy with 10/10 pain despite giving industrial doses above usual baseline needs. Co-analgesics optimized. One of the pain guys I work with had mentioned Magnesium before so out of desperation I went for it. Would rather have given 5g but nursing policy on the floor is no faster than 1g/hr (in the OR I give way faster as am monitoring for hypotension, ect) so I gave 2g with the idea of re-assessing after. Both times after the 2hrs pain 2/10 pain without a significant increase in narcotics. Like I said totally anecdotal but I can't see any harm in trying it again in the future.

 

[militarymd]

Yeah, 2 grams.

Both pt's were chronic pain patients. Both colon resections on Morphine PCA. Both had bowel preps (so likely starting a little low on Mg post prep). Can't remember why they did not have epidurals but for some reason they did not and by the time I see them in agony they already got their LMWH. Eating narcotics like crazy with 10/10 pain despite giving industrial doses above usual baseline needs. Co-analgesics optimized. One of the pain guys I work with had mentioned Magnesium before so out of desperation I went for it. Would rather have given 5g but nursing policy on the floor is no faster than 1g/hr (in the OR I give way faster as am monitoring for hypotension, ect) so I gave 2g with the idea of re-assessing after. Both times after the 2hrs pain 2/10 pain without a significant increase in narcotics. Like I said totally anecdotal but I can't see any harm in trying it again in the future.

Is there data to support this? I think I'm going to start trying it.

there is data to support using gabapentin 600 to 1200 mg po prior to spine surgery (I suspect generalizable to other surgeries) to lower narcotic requirements.

 

[advoxxx]

It's not near as common as most people think, especially with a little versed.

We used to use it all the time until it became a scheduled drug.

There's nothing better for poly-lordy syndrome. 😉

on the contrary, the nightmares are prevalent.

heed some "anecdotal" advice from someone here who in a previous life experimented with ketamine recreationally.

the nightmares are real, they are BAD, and they are part of the trip. maybe the versed helps. we never had that lying around the house. thank god.

there are few things i could imagine worse than being in a paranoid dark introspective K-dirge during a colonoscopy.

 

[stephend7799]

on the contrary, the nightmares are prevalent.

heed some "anecdotal" advice from someone here who in a previous life experimented with ketamine recreationally.

the nightmares are real, they are BAD, and they are part of the trip. maybe the versed helps. we never had that lying around the house. thank god.

there are few things i could imagine worse than being in a paranoid dark introspective K-dirge during a colonoscopy.

Thats why I never use Ketamine.. ever.. Just one case (cardiac tamponade). If you pay attention you see how much different the patients behave if they have had ketamine. Thanks for the input man..

 

[jwk]

on the contrary, the nightmares are prevalent.

heed some "anecdotal" advice from someone here who in a previous life experimented with ketamine recreationally.

the nightmares are real, they are BAD, and they are part of the trip. maybe the versed helps. we never had that lying around the house. thank god.

there are few things i could imagine worse than being in a paranoid dark introspective K-dirge during a colonoscopy.

Hallucinations are minimal or non-existent with smaller doses and a little versed on board. That's from 25 years of real experience in my current life. 😉 It's a great drug when used appropriately, with far more indications and usefulness than just cardiac tamponade.

That being said, riding the black snake in a pharmacologically-induced psychosis would definitely suck.

 

[UTSouthwestern]

Is there data to support this? I think I'm going to start trying it.

there is data to support using gabapentin 600 to 1200 mg po prior to spine surgery (I suspect generalizable to other surgeries) to lower narcotic requirements.

Chi, I just happened to propose a study for preop gabapentin when the Vioxx ****e was hitting the fan. IRB shot it down for cost reasons, but I am going to try to get it restarted at UTSW next fall. Want to join in?

 

[militarymd]

Chi, I just happened to propose a study for preop gabapentin when the Vioxx ****e was hitting the fan. IRB shot it down for cost reasons, but I am going to try to get it restarted at UTSW next fall. Want to join in?

Sure

 

[starsop93]

Is there data to support this? I think I'm going to start trying it.

there is data to support using gabapentin 600 to 1200 mg po prior to spine surgery (I suspect generalizable to other surgeries) to lower narcotic requirements.

Yeah, that group in Turkey has done this with numerous surgeries (Spine, Gyn, General, etc.) and has remarkable results. If I remember correctly they drop their post-op PCA consumption by half. I'd love to try it sometime, but I would prefer that (no offense to the Turks) there was some data from North America or Western Europe.

 

[Putmetosleep]

Has anyone ever used low-dose ketamine infusion (5mcg/kg/min) intraoperatively for opiate-tolerant patients? If so, any positive experience?

 

[jetproppilot]

Has anyone ever used low-dose ketamine infusion (5mcg/kg/min) intraoperatively for opiate-tolerant patients? If so, any positive experience?

Theres a common, anecdotal mixture used by many practitioners...something I've always wanted to try...has propofol, fentanyl, and ketamine in a 250mL saline bag...or something like that...is supposed to work killer....

I'm sure JWK/Trin et al can elucidate further.....

 

[Noyac]

Has anyone ever used low-dose ketamine infusion (5mcg/kg/min) intraoperatively for opiate-tolerant patients? If so, any positive experience?

Yes. I did it today. Worked like a charm as always. I checked on her 6 hours later and she still had not had any pain from her mastectomy.

 

[UTSouthwestern]

Sure

Let me talk to the profs and see if there is any interest in reviving this study.

 

[Putmetosleep]

Yes. I did it today. Worked like a charm as always. I checked on her 6 hours later and she still had not had any pain from her mastectomy.

What sort of dosing do you use? I've only used it once as follows: bolus of 0.5mg/kg followed by 5mcg/kg/min. The only time I used it it sure worked great. I didn't time the wake-up to well and the patient woke up crazy, though. Pain free, but crazy. At what point do you turn on off the infusion if you don't plan or cannot continue it post-operatively?

 

[jetproppilot]

Yes. I did it today. Worked like a charm as always. I checked on her 6 hours later and she still had not had any pain from her mastectomy.

OK Noy,

enlighten me. I havent been a big ketamine user in my career...mostly, like mil said, because of the pain-in-the-ass issues.

Moving past that, how do you integrate ketamine into your anesthetic plan? And how do you, albeit anecdotally, see ketamine improving your outcomes? Do you put it on a pump? Do you squirt 500mg into a liter of IVF and let it roll? Do you render the pain-troll motionless with 100mg, then every time the BIS rises above 60, give another 50mg? ( last sentence in jest)

Say I'm a chronic-lumbar-pain-jewel. I'm allergic to tylenol, toradol, flexeril,soma, aspirin, ibuprofen.... ....you get the point.

My daily meds are percocet (yeah i know I'm allergic to tylenol but...welll..blow me...), mepergan, valium, ativan.

I've come to you because of your pain-troll-anesthetic-prowess.

Gimme your pharmacologic plan for a 3 level lumbar lam.

 

[Noyac]

OK Noy,

enlighten me. I havent been a big ketamine user in my career...mostly, like mil said, because of the pain-in-the-ass issues.

Moving past that, how do you integrate ketamine into your anesthetic plan? And how do you, albeit anecdotally, see ketamine improving your outcomes? Do you put it on a pump? Do you squirt 500mg into a liter of IVF and let it roll? Do you render the pain-troll motionless with 100mg, then every time the BIS rises above 60, give another 50mg? ( last sentence in jest)

Say I'm a chronic-lumbar-pain-jewel. I'm allergic to tylenol, toradol, flexeril,soma, aspirin, ibuprofen.... ....you get the point.

My daily meds are percocet (yeah i know I'm allergic to tylenol but...welll..blow me...), mepergan, valium, ativan.

I've come to you because of your pain-troll-anesthetic-prowess.

Gimme your pharmacologic plan for a 3 level lumbar lam.

Dude, you bee reading my OR schedule. That's my case tomorrow. No ****!

This how I did it today:
Induction: propofol 150mg, roc 30 mg, fent 150mcg. Squirt 100mg ketamine into 1L NS and let it fly. Sevo at 1.7 -1.9 whole case. I gave 250 mcg fentanyl for the 1:30 hr case. She woke up quickly (LMA) pulled deep as they started closing skin and gas off. Pulled the drapes down adn she was talking to us "you guys are awesome". I was done with the liter of NS with ketamine about 30 min b/4 closure therefore, no ketamine for the last 30 minutes. To PACU were she spent 30-45 minutes, wide awake and never need any pain meds. This is no joke, the PACU nurse asked me today why my pts were so comfortable and rarely needed much pain meds if any. I said "KETAMINE". I key is run it slowly and shut it off long b/4 the end of the case. It is a weak NMDA antagonist but it does the trick. The incidence of delirium is increased with doses over 2mg/kg and in pts with prior personality disorders. If I am putting them to sleep, I don't usually give versed. If I am using it for MAC, I give a fair amount of versed. Enoughto get them dozing if they are not stimulated.

I'll tell you tomorrow how the spine case goes if you are interested in how I do it with ketamine. I don't do it much differently and it also enhances SSEP's.

 

[jetproppilot]

Dude, you bee reading my OR schedule. That's my case tomorrow. No ****!

This how I did it today:
Induction: propofol 150mg, roc 30 mg, fent 150mcg. Squirt 100mg ketamine into 1L NS and let it fly. Sevo at 1.7 -1.9 whole case. I gave 250 mcg fentanyl for the 1:30 hr case. She woke up quickly (LMA) pulled deep as they started closing skin and gas off. Pulled the drapes down adn she was talking to us "you guys are awesome". I was done with the liter of NS with ketamine about 30 min b/4 closure therefore, no ketamine for the last 30 minutes. To PACU were she spent 30-45 minutes, wide awake and never need any pain meds. This is no joke, the PACU nurse asked me today why my pts were so comfortable and rarely needed much pain meds if any. I said "KETAMINE". I key is run it slowly and shut it off long b/4 the end of the case. It is a weak NMDA antagonist but it does the trick. The incidence of delirium is increased with doses over 2mg/kg and in pts with prior personality disorders. If I am putting them to sleep, I don't usually give versed. If I am using it for MAC, I give a fair amount of versed. Enoughto get them dozing if they are not stimulated.

I'll tell you tomorrow how the spine case goes if you are interested in how I do it with ketamine. I don't do it much differently and it also enhances SSEP's.

Noy,

F u k king awesome.

Am waiting with baited breath on tomorrows case.

 

[iron]

About a year ago, Anesthesiology had a review article about ketamine. Lots of data with using low-dose infusions. The most common regimen is :

Post-induction, prior to incision 0.5mg/kg load
infusion: 0.25mg/kg/hr, turn off about 1/2h before end.
But since I don't like mixing/programming I usually give a bolus q1h.

I love using it with patients who have chronic pain, drug seeking behaviours, cases where I would have used an epidural if I could have (pt. refusing/surgeon refusing/anticoagulated).

During CABGs, I like running prop/keta infusion (no gas). prop 200mg/keta 50mg in one syringe, running at prop 50mcg/kg/min rate. They come off pump nice, use a lot less fentanyl, great for fast-track, early extubation. I used the same infusion for a heavy sedation for ax-bifem vascular case. I should post that case. Sick as all patient, did awesome...

 

[militarymd]

Yeah, that group in Turkey has done this with numerous surgeries (Spine, Gyn, General, etc.) and has remarkable results. If I remember correctly they drop their post-op PCA consumption by half. I'd love to try it sometime, but I would prefer that (no offense to the Turks) there was some data from North America or Western Europe.

I've only read about the spine surgery reports....I guess I need to look for the lit on the other types of surgery...

Obviously, this is an intervention that falls into those that anesthesiologists won't see "first hand"....ie it is difficult to see the benefit of the intervention although it is truely there.....

 

[CanGas]

Ok so I did a quick search on Magnesium and Pain to see if I could pull up anything more than my simple anecdote. Here are a couple abstracts.


P. S. With regards to some of your concerns regarding the psychotic aspects of Ketamine. Might happen with larger doses and without a benzo but I have never seen it with the addition of some Midaz. People just seem happy and comfortable.


http://www.sciencedirect.com/scienc...d=458507&md5=1629185163cf05de48483bb0a64f4c82

The Safety and Efficacy of a Single Dose (500 mg or 1 g) of Intravenous Magnesium Sulfate in Neuropathic Pain Poorly Responsive to Strong Opioid Analgesics in Patients with Cancer

Abstract

Neuropathic pain may respond poorly to morphine and is often difficult to relieve. Recent attention has been drawn to the role of the N-methyl-Image-aspartate (NMDA) receptor in the potentiation of neuropathic pain. Magnesium is known to block the NMDA receptor. It reduces the neuropathic pain response in animals, and attenuates postoperative pain and migraine in humans. We have examined the safety, tolerability, and efficacy of two intravenous doses of magnesium sulfate in 12 patients with neuropathic pain due to malignant infiltration of the brachial or lumbosacral plexus. The first six patients received 500 mg, the remainder 1 g. Apart from a mild feeling of warmth at the time of the injection, both doses were well tolerated. After receiving 500 mg, three patients experienced complete pain relief and two experienced partial pain relief for up to 4 hours duration; pain was unchanged in one patient. After receiving 1 g, one patient experienced complete relief and four experienced partial pain relief of similar duration; pain was unchanged in one patient. Intravenous magnesium sulfate in these doses appears to be safe and well tolerated. A useful analgesic effect may be obtained in some patients and further evaluation is warranted.

http://bja.oxfordjournals.org/cgi/content/full/89/4/594

Evaluation of effects of magnesium sulphate in reducing intraoperative anaesthetic requirements

Background. The present randomized, placebo-controlled, double-blind study was designed to assess the effect of peroperatively administered i.v. magnesium sulphate on anaesthetic and analgesic requirements during total i.v. anaesthesia.

Methods. Eighty-one patients (36 women, 45 men) undergoing elective spinal surgery were included in one of two parallel groups. The magnesium group received magnesium sulphate 30 mg kg–1 as a bolus before induction of anaesthesia and 10 mg kg–1 h–1 by continuous i.v. infusion during the operation period. The same volume of isotonic solution was administered to the control group. Anaesthesia was maintained with propofol (administered according to the bispectral index) and remifentanil (adjusted according to heart rate and arterial blood pressure) infusions.

Results. A significant reduction in hourly propofol consumption was observed with magnesium administration. For example, the mean infusion rate of propofol in the second hour of the operation was 7.09 mg kg–1 h–1 in the control group vs 4.35 mg kg–1 h–1 in the magnesium group (P<0.001). The magnesium group required significantly less remifentanil (P<0.001) and vecuronium (P<0.001). No side-effects were observed with magnesium administration.

Conclusion. The administration of magnesium led to a significant reduction in the requirements for anaesthetic drugs during total i.v. anaesthesia with propofol, remifentanil and vecuronium.

http://bja.oxfordjournals.org/cgi/content/full/89/5/711

Efficacy of intravenous magnesium in neuropathic pain

Background. Postherpetic neuralgia is a complication of acute herpes zoster characterized by severe pain and paraesthesia in the skin area affected by the initial infection. There is evidence that the N-methyl-D-aspartate receptor is involved in the development of hypersensitivity states and it is known that magnesium blocks the N-methyl-D-aspartate receptor.

Method. A double-blind, placebo-controlled, cross-over study was conducted in which magnesium sulphate was administered as an i.v. infusion. Spontaneous pain was recorded and qualitative sensory testing with cotton wool was performed in seven patients with postherpetic neuralgia before and after the i.v. administration of either magnesium sulphate 30 mg kg–1 or saline.

Results. During the administration, pain scores were significantly lower for magnesium compared with placebo at 20 and 30 min (P=0.016) but not at 10 min. I.V. magnesium sulphate was safe, well-tolerated and effective in patients with postherpetic neuralgia.

Conclusion. The present study supports the concept that the N-methyl-D-aspartate receptor is involved in the control of postherpetic neuralgia.

http://bja.oxfordjournals.org/cgi/content/full/96/4/444

Magnesium moderately decreases remifentanil dosage required for pain management after cardiac surgery{dagger}

Background. Magnesium is a calcium and an NMDA-receptor antagonist and can modify important mechanisms of nociception. We evaluated the co-analgesic effect of magnesium in the postoperative setting after on-pump cardiac surgery.

Methods. Forty patients randomly received either magnesium gluconate as an i.v. bolus of 0.21 mmol kg–1 (86.5 mg kg–1) followed by a continuous infusion of 0.03 mmol–1 kg–1 h–1 (13.8 mg kg–1 h–1) or placebo for 12 h after tracheal extubation. After surgery, remifentanil was decreased to 0.05 µg kg–1 min–1 and titrated according to a pain intensity score (PIS, range 1–6) in the intubated, awake patient and a VAS scale (range 1–100) after extubation. If PIS was &#8805;3 or VAS &#8805;30, the infusion was increased by 0.01 µg kg–1 min–1; if ventilatory frequency was &#8804;10 min–1 it was decreased by the same magnitude.

Results. Magnesium lowered the cumulative remifentanil requirement after surgery (P<0.05). PIS &#8805;3 was more frequent in the placebo group (P<0.05). Despite increased remifentanil demand, VAS scores were also higher in the placebo group at 8 (2 vs 8) and 9 h after extubation (2 vs 7) (P<0.05). Dose reductions attributable to a ventilatory frequency &#8804;10 min–1 occurred more often in the magnesium group (17 vs 6; P<0.05). However, time to tracheal extubation was not prolonged.

Conclusions. Magnesium gluconate moderately reduced the remifentanil consumption without serious side-effects. The opioid-sparing effect of magnesium may be greater at higher pain intensities and with increased dosages.

 

[jetproppilot]

Ok so I did a quick search on Magnesium and Pain to see if I could pull up anything more than my simple anecdote. Here are a couple abstracts.


P. S. With regards to some of your concerns regarding the psychotic aspects of Ketamine. Might happen with larger doses and without a benzo but I have never seen it with the addition of some Midaz. People just seem happy and comfortable.


http://www.sciencedirect.com/scienc...d=458507&md5=1629185163cf05de48483bb0a64f4c82

The Safety and Efficacy of a Single Dose (500 mg or 1 g) of Intravenous Magnesium Sulfate in Neuropathic Pain Poorly Responsive to Strong Opioid Analgesics in Patients with Cancer

Abstract

Neuropathic pain may respond poorly to morphine and is often difficult to relieve. Recent attention has been drawn to the role of the N-methyl-Image-aspartate (NMDA) receptor in the potentiation of neuropathic pain. Magnesium is known to block the NMDA receptor. It reduces the neuropathic pain response in animals, and attenuates postoperative pain and migraine in humans. We have examined the safety, tolerability, and efficacy of two intravenous doses of magnesium sulfate in 12 patients with neuropathic pain due to malignant infiltration of the brachial or lumbosacral plexus. The first six patients received 500 mg, the remainder 1 g. Apart from a mild feeling of warmth at the time of the injection, both doses were well tolerated. After receiving 500 mg, three patients experienced complete pain relief and two experienced partial pain relief for up to 4 hours duration; pain was unchanged in one patient. After receiving 1 g, one patient experienced complete relief and four experienced partial pain relief of similar duration; pain was unchanged in one patient. Intravenous magnesium sulfate in these doses appears to be safe and well tolerated. A useful analgesic effect may be obtained in some patients and further evaluation is warranted.

http://bja.oxfordjournals.org/cgi/content/full/89/4/594

Evaluation of effects of magnesium sulphate in reducing intraoperative anaesthetic requirements

Background. The present randomized, placebo-controlled, double-blind study was designed to assess the effect of peroperatively administered i.v. magnesium sulphate on anaesthetic and analgesic requirements during total i.v. anaesthesia.

Methods. Eighty-one patients (36 women, 45 men) undergoing elective spinal surgery were included in one of two parallel groups. The magnesium group received magnesium sulphate 30 mg kg–1 as a bolus before induction of anaesthesia and 10 mg kg–1 h–1 by continuous i.v. infusion during the operation period. The same volume of isotonic solution was administered to the control group. Anaesthesia was maintained with propofol (administered according to the bispectral index) and remifentanil (adjusted according to heart rate and arterial blood pressure) infusions.

Results. A significant reduction in hourly propofol consumption was observed with magnesium administration. For example, the mean infusion rate of propofol in the second hour of the operation was 7.09 mg kg–1 h–1 in the control group vs 4.35 mg kg–1 h–1 in the magnesium group (P<0.001). The magnesium group required significantly less remifentanil (P<0.001) and vecuronium (P<0.001). No side-effects were observed with magnesium administration.

Conclusion. The administration of magnesium led to a significant reduction in the requirements for anaesthetic drugs during total i.v. anaesthesia with propofol, remifentanil and vecuronium.

http://bja.oxfordjournals.org/cgi/content/full/89/5/711

Efficacy of intravenous magnesium in neuropathic pain

Background. Postherpetic neuralgia is a complication of acute herpes zoster characterized by severe pain and paraesthesia in the skin area affected by the initial infection. There is evidence that the N-methyl-D-aspartate receptor is involved in the development of hypersensitivity states and it is known that magnesium blocks the N-methyl-D-aspartate receptor.

Method. A double-blind, placebo-controlled, cross-over study was conducted in which magnesium sulphate was administered as an i.v. infusion. Spontaneous pain was recorded and qualitative sensory testing with cotton wool was performed in seven patients with postherpetic neuralgia before and after the i.v. administration of either magnesium sulphate 30 mg kg–1 or saline.

Results. During the administration, pain scores were significantly lower for magnesium compared with placebo at 20 and 30 min (P=0.016) but not at 10 min. I.V. magnesium sulphate was safe, well-tolerated and effective in patients with postherpetic neuralgia.

Conclusion. The present study supports the concept that the N-methyl-D-aspartate receptor is involved in the control of postherpetic neuralgia.

http://bja.oxfordjournals.org/cgi/content/full/96/4/444

Magnesium moderately decreases remifentanil dosage required for pain management after cardiac surgery{dagger}

Background. Magnesium is a calcium and an NMDA-receptor antagonist and can modify important mechanisms of nociception. We evaluated the co-analgesic effect of magnesium in the postoperative setting after on-pump cardiac surgery.

Methods. Forty patients randomly received either magnesium gluconate as an i.v. bolus of 0.21 mmol kg–1 (86.5 mg kg–1) followed by a continuous infusion of 0.03 mmol–1 kg–1 h–1 (13.8 mg kg–1 h–1) or placebo for 12 h after tracheal extubation. After surgery, remifentanil was decreased to 0.05 µg kg–1 min–1 and titrated according to a pain intensity score (PIS, range 1–6) in the intubated, awake patient and a VAS scale (range 1–100) after extubation. If PIS was &#8805;3 or VAS &#8805;30, the infusion was increased by 0.01 µg kg–1 min–1; if ventilatory frequency was &#8804;10 min–1 it was decreased by the same magnitude.

Results. Magnesium lowered the cumulative remifentanil requirement after surgery (P<0.05). PIS &#8805;3 was more frequent in the placebo group (P<0.05). Despite increased remifentanil demand, VAS scores were also higher in the placebo group at 8 (2 vs 8) and 9 h after extubation (2 vs 7) (P<0.05). Dose reductions attributable to a ventilatory frequency &#8804;10 min–1 occurred more often in the magnesium group (17 vs 6; P<0.05). However, time to tracheal extubation was not prolonged.

Conclusions. Magnesium gluconate moderately reduced the remifentanil consumption without serious side-effects. The opioid-sparing effect of magnesium may be greater at higher pain intensities and with increased dosages.

Nice post!

Thanks for your invested time.

 

[Xclamp]

Nice post!

Thanks for your invested time.

Dudes and dudetts....

Try this on for size in the LDR suite...you are in a C-section and the baby is already born, mommy is c/o this "wierd" sensation that is making her turn green cuz the uterus is externalized so the OB "surgeons" can sew her up....well hit her with the rest of the fentanyl (like 85-80mcg) from the spinal you gave her, then 1 of midaz with a 10-20 mg ketamine chaser, repeat as necessary (usually only need like 2mg midaz and 20mg of ketamine total). Its nap time till the staples are in, everybody is happy.

XC

 

[Noyac]

Dudes and dudetts....

Try this on for size in the LDR suite...you are in a C-section and the baby is already born, mommy is c/o this "wierd" sensation that is making her turn green cuz the uterus is externalized so the OB "surgeons" can sew her up....well hit her with the rest of the fentanyl (like 85-80mcg) from the spinal you gave her, then 1 of midaz with a 10-20 mg ketamine chaser, repeat as necessary (usually only need like 2mg midaz and 20mg of ketamine total). Its nap time till the staples are in, everybody is happy.

XC

I agree that ketamine is good for that and I know that I have said that I can't remember any pt of mine c/o bad dreams/nightmares. But this is the last pt I want to experience this SE. So I tend to give 20-30 mg propofol at this point. It works just as well. They also seem to remember the delivery better which is one reason we don't put these pts to sleep. I had an attending when I was in training that would never let us give versed in the c/s because he was sued by a pt after giving versed b/c she said that she could not remember her baby's birth. I don't know the outcome of the case, sorry. So this is my prefered practice at this time. Now if the c/s is under epidural and the pt is uncomfortable then ketamine will get her through it safely.

 

[UTSouthwestern]

I agree that ketamine is good for that and I know that I have said that I can't remember any pt of mine c/o bad dreams/nightmares. But this is the last pt I want to experience this SE. So I tend to give 20-30 mg propofol at this point. It works just as well. They also seem to remember the delivery better which is one reason we don't put these pts to sleep. I had an attending when I was in training that would never let us give versed in the c/s because he was sued by a pt after giving versed b/c she said that she could not remember her baby's birth. I don't know the outcome of the case, sorry. So this is my prefered practice at this time. Now if the c/s is under epidural and the pt is uncomfortable then ketamine will get her through it safely.

Had that happen to a friend of mine in an OB exclusive group. Case was thrown out because nowhere in the consent for anesthesia does it say that recall was guaranteed. Lawyer successfully argued that if you didn't want amnesia, you shouldn't ask for anesthesia without clearly specifying you are willing to risk remembering pain, nausea, etc. to the anesthesiologist and are willing to sign off on liability.

 

[Noyac]

Had that happen to a friend of mine in an OB exclusive group. Case was thrown out because nowhere in the consent for anesthesia does it say that recall was guaranteed. Lawyer successfully argued that if you didn't want amnesia, you shouldn't ask for anesthesia without clearly specifying you are willing to risk remembering pain, nausea, etc. to the anesthesiologist and are willing to sign off on liability.

There you have it.
Now, when I do give some propofol the these pts, I always tell them b/4 that they could forget/not remember certain parts of the procedure, even the delivery. They always say "that's ok with me". I still feel uneasy giving it but your post gives me some comfort, UT.

 

[UTSouthwestern]

There you have it.
Now, when I do give some propofol the these pts, I always tell them b/4 that they could forget/not remember certain parts of the procedure, even the delivery. They always say "that's ok with me". I still feel uneasy giving it but your post gives me some comfort, UT.

Still a big damn waste of his time. Deposition, pretrial "just pay us $10,000" and we'll drop the suit, actually made it to court, having to testify that he *gasp* didn't want the patient to continue to feel the pain and nausea associated with having your uterus flopped out on your belly while the OB ponders whether or not it looks like a pork chop, etc.

 

[Xclamp]

your uterus flopped out on your belly while the OB ponders whether or not it looks like a pork chop, etc.[/QUOTE]

Pork Chop!!! That's some funny s h it...it really does look like a pork chop.

 

[ThinkFast007]

Ok so I did a quick search on Magnesium and Pain to see if I could pull up anything more than my simple anecdote. Here are a couple abstracts.


P. S. With regards to some of your concerns regarding the psychotic aspects of Ketamine. Might happen with larger doses and without a benzo but I have never seen it with the addition of some Midaz. People just seem happy and comfortable.


http://www.sciencedirect.com/scienc...d=458507&md5=1629185163cf05de48483bb0a64f4c82

The Safety and Efficacy of a Single Dose (500 mg or 1 g) of Intravenous Magnesium Sulfate in Neuropathic Pain Poorly Responsive to Strong Opioid Analgesics in Patients with Cancer

Abstract

Neuropathic pain may respond poorly to morphine and is often difficult to relieve. Recent attention has been drawn to the role of the N-methyl-Image-aspartate (NMDA) receptor in the potentiation of neuropathic pain. Magnesium is known to block the NMDA receptor. It reduces the neuropathic pain response in animals, and attenuates postoperative pain and migraine in humans. We have examined the safety, tolerability, and efficacy of two intravenous doses of magnesium sulfate in 12 patients with neuropathic pain due to malignant infiltration of the brachial or lumbosacral plexus. The first six patients received 500 mg, the remainder 1 g. Apart from a mild feeling of warmth at the time of the injection, both doses were well tolerated. After receiving 500 mg, three patients experienced complete pain relief and two experienced partial pain relief for up to 4 hours duration; pain was unchanged in one patient. After receiving 1 g, one patient experienced complete relief and four experienced partial pain relief of similar duration; pain was unchanged in one patient. Intravenous magnesium sulfate in these doses appears to be safe and well tolerated. A useful analgesic effect may be obtained in some patients and further evaluation is warranted.

http://bja.oxfordjournals.org/cgi/content/full/89/4/594

Evaluation of effects of magnesium sulphate in reducing intraoperative anaesthetic requirements

Background. The present randomized, placebo-controlled, double-blind study was designed to assess the effect of peroperatively administered i.v. magnesium sulphate on anaesthetic and analgesic requirements during total i.v. anaesthesia.

Methods. Eighty-one patients (36 women, 45 men) undergoing elective spinal surgery were included in one of two parallel groups. The magnesium group received magnesium sulphate 30 mg kg–1 as a bolus before induction of anaesthesia and 10 mg kg–1 h–1 by continuous i.v. infusion during the operation period. The same volume of isotonic solution was administered to the control group. Anaesthesia was maintained with propofol (administered according to the bispectral index) and remifentanil (adjusted according to heart rate and arterial blood pressure) infusions.

Results. A significant reduction in hourly propofol consumption was observed with magnesium administration. For example, the mean infusion rate of propofol in the second hour of the operation was 7.09 mg kg–1 h–1 in the control group vs 4.35 mg kg–1 h–1 in the magnesium group (P<0.001). The magnesium group required significantly less remifentanil (P<0.001) and vecuronium (P<0.001). No side-effects were observed with magnesium administration.

Conclusion. The administration of magnesium led to a significant reduction in the requirements for anaesthetic drugs during total i.v. anaesthesia with propofol, remifentanil and vecuronium.

http://bja.oxfordjournals.org/cgi/content/full/89/5/711

Efficacy of intravenous magnesium in neuropathic pain

Background. Postherpetic neuralgia is a complication of acute herpes zoster characterized by severe pain and paraesthesia in the skin area affected by the initial infection. There is evidence that the N-methyl-D-aspartate receptor is involved in the development of hypersensitivity states and it is known that magnesium blocks the N-methyl-D-aspartate receptor.

Method. A double-blind, placebo-controlled, cross-over study was conducted in which magnesium sulphate was administered as an i.v. infusion. Spontaneous pain was recorded and qualitative sensory testing with cotton wool was performed in seven patients with postherpetic neuralgia before and after the i.v. administration of either magnesium sulphate 30 mg kg–1 or saline.

Results. During the administration, pain scores were significantly lower for magnesium compared with placebo at 20 and 30 min (P=0.016) but not at 10 min. I.V. magnesium sulphate was safe, well-tolerated and effective in patients with postherpetic neuralgia.

Conclusion. The present study supports the concept that the N-methyl-D-aspartate receptor is involved in the control of postherpetic neuralgia.

http://bja.oxfordjournals.org/cgi/content/full/96/4/444

Magnesium moderately decreases remifentanil dosage required for pain management after cardiac surgery{dagger}

Background. Magnesium is a calcium and an NMDA-receptor antagonist and can modify important mechanisms of nociception. We evaluated the co-analgesic effect of magnesium in the postoperative setting after on-pump cardiac surgery.

Methods. Forty patients randomly received either magnesium gluconate as an i.v. bolus of 0.21 mmol kg–1 (86.5 mg kg–1) followed by a continuous infusion of 0.03 mmol–1 kg–1 h–1 (13.8 mg kg–1 h–1) or placebo for 12 h after tracheal extubation. After surgery, remifentanil was decreased to 0.05 µg kg–1 min–1 and titrated according to a pain intensity score (PIS, range 1–6) in the intubated, awake patient and a VAS scale (range 1–100) after extubation. If PIS was &#8805;3 or VAS &#8805;30, the infusion was increased by 0.01 µg kg–1 min–1; if ventilatory frequency was &#8804;10 min–1 it was decreased by the same magnitude.

Results. Magnesium lowered the cumulative remifentanil requirement after surgery (P<0.05). PIS &#8805;3 was more frequent in the placebo group (P<0.05). Despite increased remifentanil demand, VAS scores were also higher in the placebo group at 8 (2 vs 8) and 9 h after extubation (2 vs 7) (P<0.05). Dose reductions attributable to a ventilatory frequency &#8804;10 min–1 occurred more often in the magnesium group (17 vs 6; P<0.05). However, time to tracheal extubation was not prolonged.

Conclusions. Magnesium gluconate moderately reduced the remifentanil consumption without serious side-effects. The opioid-sparing effect of magnesium may be greater at higher pain intensities and with increased dosages.

nice...it drove me crazy, i was trying to find this post for the longest time. nice post CanGas, i recall trying to do a pubmed search on this, but it wouldnt let me access to some of the articles.

👍

 

[LandenTD]

I'm a 19 year Active Army Infantryman. Not 19 years old, been in 19 years. I was wounded on Iraq had my chest crushed pretty bad, lost a rib, lots of nerve damage, yada yada. I was in Walter Reed Army Medical Center for two years. They got me all patched up. However, I struggle with ridiculous pain in the right side of my chest. I even went so far as to have a dorsal root ganglionectomy.

I'm based out of Fort Benning, GA and am currently in Houston, TX where I had the ganglionectomy. My Neurosurgeon, Dr. Ashwin Viswanathon out of Baylor referred me to Houston Pain Associates, Dr. Allen Burton. What a guy! He has run the gauntlet with Cryo, Pulse RF, Blocks, epidurals, etc. Now, I'm on my 12th, 1 hour Ketamine infusion tomorrow.

I realize this forum isnt for an Army Grunt, I just wanted to give you some feedback. So, here it is.

Ketamine SUCKS!!! It is great for pain and with back to back 1 hour infusions can last me weeks, however, the only way it was tolerable was when Dr. Burton administered Versed along with it. The hallucinations and disassociation coupled with having experienced a lot of up close and personal combat, is nothing short of horrifying. Today, even with the Versed, something went nuts. Apparently I tweaked out, my blood pressure shot up and it took them a while to bring me back to earth. The Versed with my wife holding my hand for the entire hour is the only way I stay tethered to earth. Its great for pain but the disassociative properties have to be taken into consideration. PLEASE, give your patients whatever you can so they can sleep through it or something. I think Dr. Burton suggested that he thought I was becoming tolerant to the dosage of Versed. Sometimes, he splits it, gives me half up front then the other, halfway through the infusion. However, tomorrow I think he is going to have to give me more. Its my last infusion as well.

I've had literally everything done for pain management, even have a peripheral neuro stim implant as well. I am also fighting to remain on active duty but I may have to take the medical retirement. We'll see if I can manage with regular scheduled infusions around Fort Benning.

Again, Feel free to hit me up with any questions. I've had ten surgeries relating to this ranging from Walter Reed, to Johns Hopkins to Baylor/St Lukes in Houston. So, if it would help anyone, shoot me an email. [email protected]

Again, Ketamine is wonderful for pain but the disassociation is horrible during administration. I like the analgesic effects but am horrified of the actual infusions. The only way tolerable is with Versed. Imagine you have a trauma patient that was driving to work and wakes up in an ER on Ketamine. It would be terrifying without something to "ground" him. Is there anything else that could be given safely with it by the way?

Thanks folks. Good luck. Take care of our Servicemembers.

Master Sergeant Todd Landen.

 

[Dejavu]

HOw about th e ******* I NG nightmares guys? patients wake up with ketamine the wildest people.. just crazy and wild

try inducing with it..

In close to 7 yrs of giving 2mg Versed and 10mg Ketamine for sedation for blocks (about 6-20 times daily) and giving 10 - 20 mgs to every pt as part of their anesthetic (both general and sedation/regional/MAC) and using it as a first-line drug in PACU for pain control, I have had two people report seeing vivid colors (not upsetting to them) and, admittedly, one young woman asked never to have it again after being upset by the "flying" feeling for about 10 minutes. Many other pts enjoy that "flying" aspect of the drug.

That is seven years of pretty good results, but as always, "Results may Vary" I suppose.

Anyway, I give it to almost every one I meet, and have for several years.

I love the drug, and the evidence in the literature of pain scores being down 30-40% for a day or so after 0.1 - 0.15 mg/kg (without significant problems) far outways all the problems you can have with narcs (they are hardly "clean" drugs either).

 

[sevoflurane]

I'm running it right now with my scoli case.

Ketafol 2:1
Magnesium 4 mg over 15 minutes
Precedex
Remi
.3 Mac Des at low flows.

Ketamine is hugely opiod sparing. Add to that propofol and magnesium and you have some serious synergism.

Re: Ketamine infusions

I understand your concerns Master Sergeant Todd Landen. With nothing more than 1-2 mg of versed on board, it can have the effect you describe. Ketamine infusions used in the way you describe are generally reserved for those who have opiod tolerance. Supposedly, it can reset your opiod receptors and make them more sensetive to lower doses of opiates. This is a different application of ketamine than how we use it in the anesthesia world. Ask for a larger dose of a benzo or have anesthesia involved so you can get a smaller dose of propofol with your treatments. Lastly, thank you very much for your service. I'm sorry you were injured.

 

[sevoflurane]

1/2 life of ketamine is pretty long btw.... about 3 hrs.

 

[doctor712]

Lastly, thank you very much for your service. I'm sorry you were injured.

I second that. 👍👍

 

[Dejavu]

I'm running it right now with my scoli case.

Ketafol 2:1
Magnesium 4 mg over 15 minutes
Precedex
Remi
.3 Mac Des at low flows.

Ketamine is hugely opiod sparing. Add to that propofol and magnesium and you have some serious synergism.

Re: Ketamine infusions

I understand your concerns Master Sergeant Todd Landen. With nothing more than 1-2 mg of versed on board, it can have the effect you describe. Ketamine infusions used in the way you describe are generally reserved for those who have opiod tolerance. Supposedly, it can reset your opiod receptors and make them more sensetive to lower doses of opiates. This is a different application of ketamine than how we use it in the anesthesia world. Ask for a larger dose of a benzo or have anesthesia involved so you can get a smaller dose of propofol with your treatments. Lastly, thank you very much for your service. I'm sorry you were injured.

I would like to agree with everything you just said. Especially the last two sentences. As a veteran, I salute you Master Sargeant.

 

[imfrankie]

Thats why I never use Ketamine.. ever.. Just one case (cardiac tamponade). If you pay attention you see how much different the patients behave if they have had ketamine. Thanks for the input man..

small dose effect much different than large dose

 

[imfrankie]

Chi, I just happened to propose a study for preop gabapentin when the Vioxx ****e was hitting the fan. IRB shot it down for cost reasons, but I am going to try to get it restarted at UTSW next fall. Want to join in?

already done and shown beneficial in peds back surgery by L. Rusy

 

[Foodie]

I've worked with several attendings who love ketamine for ortho cases with a tourniquet. Pts receive 50mg ketamine IV push (0.75-1mg/kg) 5 min before tourniquet inflation. Cuts down on opioids nearly by half. Of note, out of ~50 patients [that I managed intraop] who had that amount of ketamine, despite being premedicated with 2mg of versed, 3 woke up either:
1) screaming for water, or
2) agitated, uncomfortable, rambling about some weird dream s/he is having.
Serious sialorrhea, to boot.

Drooling is manageable. Delirium and having to explain said delirium to spouse are not.

Thank you for the interesting anesthetic cocktails -- would love to try the ketofol and low-dose, high-vol ketamine on our chronic pain county patients.

A study for your perusal (pro-ketamine):
Takada M et. al. Preadministration of Low-dose Ketamine Reduces Tourniquet Pain in Healthy Volunteers. J Anesth. 2005;19(2):180-2. (Department of Anesthesia, Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan.)

Has anyone else been using acetaminophen 1000mg IV for chronic pain management? Pain guys here love that stuff for acute pain management in chronic pain pts.

 

[pgg]

Has anyone else been using acetaminophen 1000mg IV for chronic pain management? Pain guys here love that stuff for acute pain management in chronic pain pts.

I'd love to but the pharmacy wankers here are too cheap to stock it. Or maybe the Toradol rep brought them sandwiches, I don't know.

 

[sevoflurane]

Has anyone else been using acetaminophen 1000mg IV for chronic pain management? Pain guys here love that stuff for acute pain management in chronic pain pts.

It's no silver bullet for the chronic pain patient... but it does have it's place in multimodal acute pain management.

Although Dr. Scott Reuben falsified much of his data, multimodal anesthesia does work and IV tylenol is a nice weapon to have in your box.

I use IV tylenol just about every day.