how many use ketamine?

[MRW]

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I like ketamine. I don't have a tremendous amount of experience, but I have seen it used in a wide variety of ways successfully.

When faced with a patient with tremendously large opioid requirements, one of my attendings would use a potent drip for post-op pain control:
1000mg ketamine
50mg Versed
500mL Normal Saline

50mL/hour - titrate to effect

I have also used 10mg (1mL) of ketamine with 200mg propofol for endoscopies on frail patients to great effect, and ketafol infusions of various recipes for a number of cases.

I like the stuff a lot, but larger does without enough versed and some of the patients definitely get weirded out.

 

[epidural man]

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.

Master Sergeant Landen,

Thanks for your feedback. Ask Dr Burton if you are a candidate for a Qutenza patch. It is a new treatment that might give you some benefit - worth a discussion anyway.

I use outpatient ketamine infusions, and inpatient infusion a lot so your concerns are valid - and we look for those side effects and problems you discuss.

However, this discussion is talking about intraoperative infusion with the patients under general anesthesia, or sedated with other means during an operation. That is a completely different ballgame than an infusion for pain treatment - different dosages as well.

 

[epidural man]

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..

This is a good thread to bump - some new great data since it's originally posting.

One article attached was done last year for spine using ketamine. Note that there were no differences in side effects - but very impressive results.

The other was done in 2001. I love this article (for bowel surgery) because they show that 6 MONTHS later patients that had ketamine had less pain and periwound hyperalgesia. Think of that...we can affect outcomes significantly, just with a minor alteration in how we do our anesthestic.

 

[psychbender]

We use ketamine quite a bit in our casualty care cases, and even more post-operatively on the ward. It is not at all uncommon to walk onto the surgical ward, and see a dozen patients mentating appropriately in their beds on ketamine infusions running at 100-600mcg/kg/hr for days (or weeks) on end. We have standing orders for ativan for hallucinations/vivid dreams, but it rarely ends up being used. I have seen a few interesting events in patients who received large induction doses of ketamine on top of their infusions, which were left on during the case. Unfortunately, in some of those events, it was enough to scare the patient into not wanting it continued on the ward, and their acute pain increased significantly, as a result. The main reason that I don't use more ketamine in the OR or PACU is that I don't like wasting nearly the entire bottle (we only stock the 500mg/10mL bottles).

 

[proman]

One article attached was done last year for spine using ketamine. Note that there were no differences in side effects - but very impressive results.

Nice articles. A confounder is that in every study that I've seen on ketamine, an opioid sparing effect is seen. Not surprising at all given the analgesia provided by ketamine. But is this a benefit of NMDA antagonism or simply a benefit of giving less opioid. Opioid induced hypergesia is real, happens in real-time with certain drugs (remi, fentanyl in particular) and causes increased pain and subsequent opioid consumption. So maybe instead of giving ketamine, we should just not be giving opioid (and use something like esmolol for intraoperative anti-nociception). I don't know. Either way, the evidence overwhelming shows that the more intraop opioid given, the more pain and more opioid used post op.

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.

I'm sure you had railroad track vitals with that combo. I'm unsure what the remi gave you. You had analgesia with the ketamine. Remi definitely causes OIH, and for that reason I aim to give as little opioid as possible intraop and save it for postop when the patient is no longer anesthetized. But that's just me.

 

[Foodie]

I use IV tylenol just about every day.

Please elaborate -- you use it in the OR as analgesic adjunct? How and when do you give it?

 

[psychbender]

Please elaborate -- you use it in the OR as analgesic adjunct? How and when do you give it?

I like to use it about 30min before the end of the procedure, and it seems to cut down PACU opiate use a bit. I haven't given it early in the case yet, to atempt to spare intraop opiates, but that is something I plan on trying. As for how, just spike the bottle, and run it in.

 

[WholeLottaGame7]

I like to use it about 30min before the end of the procedure, and it seems to cut down PACU opiate use a bit. I haven't given it early in the case yet, to atempt to spare intraop opiates, but that is something I plan on trying. As for how, just spike the bottle, and run it in.

I think technically you're supposed to run it in over 15 min, but not sure what the drawback is to running it in faster. I've been using it a lot, also (early CA-1 year).

 

[LandenTD]

After today's infusion they are sending me to Walter Reed again for their 5 day, inpatient Ketamine Infusion. Hope they sedate me or something. I'm scared to death of it. However, It really helps me after. I did email Dr. Burton about the Qutenza patch. Its late so I'll probably hear from him tomorrow.

Also, sorry to distract from the real subject of this thread. Was just researching Ketamine, found this forum and hoped my experience and insight might help. Probably nothing anyone hasnt learned already.

Much appreciated

Todd

 

[bullard]

I also use esmolol for intraoperative anti-nociception. Despise remifentanil. But I still used it yesterday for an ACDF. It has its uses.

Nice articles. A confounder is that in every study that I've seen on ketamine, an opioid sparing effect is seen. Not surprising at all given the analgesia provided by ketamine. But is this a benefit of NMDA antagonism or simply a benefit of giving less opioid. Opioid induced hypergesia is real, happens in real-time with certain drugs (remi, fentanyl in particular) and causes increased pain and subsequent opioid consumption. So maybe instead of giving ketamine, we should just not be giving opioid (and use something like esmolol for intraoperative anti-nociception). I don't know. Either way, the evidence overwhelming shows that the more intraop opioid given, the more pain and more opioid used post op.


I'm sure you had railroad track vitals with that combo. I'm unsure what the remi gave you. You had analgesia with the ketamine. Remi definitely causes OIH, and for that reason I aim to give as little opioid as possible intraop and save it for postop when the patient is no longer anesthetized. But that's just me.

 

[sevoflurane]

I'm sure you had railroad track vitals with that combo. I'm unsure what the remi gave you. You had analgesia with the ketamine. Remi definitely causes OIH, and for that reason I aim to give as little opioid as possible intraop and save it for postop when the patient is no longer anesthetized. But that's just me.

Yep, train tracks. Extremely smooth, predictable anesthetic with apnea, healthy bradycardia and permissive hypotension. Unfortunately, my surgeons insist on a wake up test. Ugghhhh 🙁 I find Remifentanyl useful in this situation (and others). Keep in mind I have a multimodal recepie here and as such, I'm always between .025 mcg/kg/min and .1 mcg/kg/min.

Correct me if I'm wrong proman, but isn't remifentanyl hyperalgesia a dose dependent phenomenon (at least moderate to high doses needed)? Isn't there evidence that agents such as magnesium, ketamine and alpha 2 agonists/clonidine/dexmedatomidine attenuate or abolish hyperalgesia?

Although opioid induced hyperalgesia seems to be more prevalent with remi, it can happen with any narcotic. No?

In what situations do you find remifentanyl useful? AFO's? Just curious. 🙂

My little pedi patient woke up happy as a clam. Today she is doing very well considering the whack she got yesterday.

I agree with you in trying to minimize IV opiods. I use as little as possible. Regional (when possible) + Toradol and/or IV Tylenol along with other non-opioids are strategies I use in most patients who don't have a contraindication.

As a side note, I must say magnesium is one of my favorite perioperative adjuvants. It's profile is one of the best out there:

Sedative
Analgesic
Opiod sparing
Synergistic with ketamine and propofol (independently and together)
Cardio protective. DOC for torsades.
Mild muscle relaxant
Bronchodilator
Antihypertensive
Tocolytic (some recent studies are arguing this)
Anti-seizure (preeclampsia/elcampsia)
Laxative. May reduce or abolish opioid induced constipation.
There are a couple more I can't remember off the top of my head right now.

http://www.ncbi.nlm.nih.gov/pubmed/21596876

Freag'n safe, exceptional agent with little in the way of side effects IMHO.

I wonder how many people use it routinely.

 

[epidural man]

Isn't there evidence that agents such as magnesium, ketamine and alpha 2 agonists/clonidine/dexmedatomidine attenuate or abolish hyperalgesia?

Although opioid induced hyperalgesia seems to be more prevalent with remi, it can happen with any narcotic. No?

Very good evidence that ketamine stops or prevents the remifentanil induced hyperalgesia.

And yes, it happens for every drug, and at every dose. Steve Cohen did the coolest little study - (in chronic opioid use) and showed that at all doses, patients on opioids tolerated a moderate pain stimulus less than non-opioid patients - and not only that, they reported the unpleasantness of pain way more. What I find funny about this (that people on opioids hurt and complain more), is that almost every patient I see that is asking for more oxycontin will start out and say "I am so pain tolerant, I can withstand much more pain than most people, but this pain is just so bad...blah blah blah." Whatever....

(I love that we can attach articles....)

 

[sevoflurane]

Very good evidence that ketamine stops or prevents the remifentanil induced hyperalgesia.

And yes, it happens for every drug, and at every dose. Steve Cohen did the coolest little study - (in chronic opioid use) and showed that at all doses, patients on opioids tolerated a moderate pain stimulus less than non-opioid patients - and not only that, they reported the unpleasantness of pain way more. What I find funny about this (that people on opioids hurt and complain more), is that almost every patient I see that is asking for more oxycontin will start out and say "I am so pain tolerant, I can withstand much more pain than most people, but this pain is just so bad...blah blah blah." Whatever....

(I love that we can attach articles....)

👍 Nice read.

 

[proman]

Unfortunately, my surgeons insist on a wake up test. Ugghhhh 🙁 I find Remifentanyl useful in this situation (and others). Keep in mind I have a multimodal recepie here and as such, I'm always between .025 mcg/kg/min and .1 mcg/kg/min.

The guy does wake up tests for all of his cases? Sound like he's not a 21st century surgeon. Does he also do neuromonitoring? I feel bad for his patients.

Correct me if I'm wrong proman, but isn't remifentanyl hyperalgesia a dose dependent phenomenon (at least moderate to high doses needed)? Isn't there evidence that agents such as magnesium, ketamine and alpha 2 agonists/clonidine/dexmedatomidine attenuate or abolish hyperalgesia?

Although opioid induced hyperalgesia seems to be more prevalent with remi, it can happen with any narcotic. No?

In what situations do you find remifentanyl useful? AFO's? Just curious. 🙂

I don't know about the dose dependent phenomenon. Remi has such high opioid binding affinity that I'd expect to see it even at low dose. I think any opioid can do it, in order of potency/binding affinity. Except, of course, for methadone. Methadone is my preferred opioid, especially for the opioid tolerant. I don't know what the effect of alpha2 is on OIH.

I used remi today. 12 hour parotid tumor/facial reconstruction. Old lady with a sick heart. The plan was to keep her intubated but I didn't want to give her 12 hours of fentanyl either (what the CRNA had planned). I'll use remi for cases that don't have much pain post op, that I can't paralyze or are very short and intense stimulation. Examples are TEVARs with neuromonitoring or the interventional pulmonary stuff like rigid bronchs and airway stents. I just won't use it for a long painful case like spine or crani.

 

[sevoflurane]

The guy does wake up tests for all of his cases? Sound like he's not a 21st century surgeon. Does he also do neuromonitoring? I feel bad for his patients.

I know dude... I know... 🙁 I've gone back and forth with them on this issue. I'm hoping we can change this practice soon.

Yes on the neuromonitoring.

Beyond feeling bad for the patients (I've yet to have any with recall and they all get a sit down from the surgeon and myself), it is a serious risk for extubation in the prone position with a back wide open. Although I seriously dislike them, I'm on my best game when we do wake up tests.

 

[Ronin2258]

Got experience with ketamine darts (in humans, at least,) on day 1 of clinical work.

22 year old, 5'10", 200lb (all muscle,) mentally challenged, and deaf patient had to come in for general anesthesia for a pilonidal cyst removal. Got one 150mg dart of ketamine after 20mg oral midazolam in holding, only to require another 100mg dart because he was still fighting us. Ended up having to do a inhalational induction (yes, I am being taught old school style,) and intubation while he was on a recliner chair with 3 nurses and his father holding him down. Found out later that this was his usual routine for surgery.

Woke up fine.

For those doing research with swine, 500mg in a 5cc syringe with a hefty (20ga or bigger,) needle from above between the shoulder blades will get a 50-100kg pig down to be tubed and changed over to a more definitive anesthetic right quick. Just don't give either fentanyl due to their resistance (PI got called by the DEA for the extreme consumption (like the whole eastern seaboard worth of use for 5 pigs,) of fentanyl years ago,) and be generous with propofol if you have to use it for TIVA (ended up going 400mcg/kg/min on the frakkers just to keep them down.) They tend to do OK with inhaled or barbiturates.

 

[RxBoy]

I use ketamine often. I love the stuff. Our pharmacy only gives us the 500mg/10ml vials but I usually just dilute them down to 10 per (2 cc ketamine with 8cc off their iv bag) and give intermittent boluses of 20-40 intraop. I hate when I give it and immediately after the attending walks in and the BIS is in the 70s they always freak out. I find that when used with propofol or volatiles, it rarely has bad reactions. It also makes wake ups super easy.

The only time I ever see the goofiness is with c/s... It usually drives my patients bananas even after drowning them with versed. The other day on call, I burned through 250 of ketamine and 14 mg of Versed for a 3 hour c/s with a SAB that wore off (thank you july for all the new OB residents). Patient was totally freaking out in recovery. She keep shouting that her baby is dead... anyways it only lasted 15 or so minutes.

 

[Foodie]

I hate when I give it and immediately after the attending walks in and the BIS is in the 70s they always freak out. I find that when used with propofol or volatiles, it rarely has bad reactions. It also makes wake ups super easy.

Are you using BIS on everyone? Any particular reason?

... Patient was totally freaking out in recovery. She keep shouting that her baby is dead... anyways it only lasted 15 or so minutes.

Oh man... glad it was over quick. I can only imagine what kind of effect that had on other PACU pts.

 

[pgg]

the other day on call, i burned through 250 of ketamine and 14 mg of versed for a 3 hour c/s with a sab that wore off (thank you july for all the new ob residents). Patient was totally freaking out in recovery.

Do a CSE?

 

[jwk]

I use ketamine often. I love the stuff. Our pharmacy only gives us the 500mg/10ml vials but I usually just dilute them down to 10 per (2 cc ketamine with 8cc off their iv bag) and give intermittent boluses of 20-40 intraop. I hate when I give it and immediately after the attending walks in and the BIS is in the 70s they always freak out. I find that when used with propofol or volatiles, it rarely has bad reactions. It also makes wake ups super easy.

The only time I ever see the goofiness is with c/s... It usually drives my patients bananas even after drowning them with versed. The other day on call, I burned through 250 of ketamine and 14 mg of Versed for a 3 hour c/s with a SAB that wore off (thank you july for all the new OB residents). Patient was totally freaking out in recovery. She keep shouting that her baby is dead... anyways it only lasted 15 or so minutes.

Way too much ketamine and versed. Your SAB has worn off? Put em to sleep and tube them or have your surgeons put in some local.

BTW - your wacky patient problem could just as easily be due to all that versed.

 

[sevoflurane]

I concur. Too much buddy. Remember that ketamine's half life is LONG... 250mg.....😱 I'll give 10mg here and there + some nitrous (can't remember the last time I actually did this... prolly residency)....

If you are not getting what you need, just tube them. OB AW's are not difficult.

Freaking out in pacu with 250mg of ketamine = not good business.

You'll get it down soon enough.... 🙂

 

[sevoflurane]

If you are routinely doing 3 hr. sections, then PGG is spot on... CSE.

PP sections take about 40 minutes skin to skin.

 

[dhb]

I use ketamine often. I love the stuff. Our pharmacy only gives us the 500mg/10ml vials but I usually just dilute them down to 10 per (2 cc ketamine with 8cc off their iv bag)

I dilute the K with 8cc of fentanyl or sufentanyl that way i always give them in conjunction 4/40mcg for 10mg of K.

PP sections take about 40 minutes skin to skin.

I've done a couple with a crazy OB 20min in and out of the OR (w GETA)

 

[goosegas]

I burned through 250 of ketamine and 14 mg of Versed .

The appropriate use of Ketamine/Versed for a C/S type of situation would be 1-2mg Versed and 10-50mg Ketamine to get through the last 15 min of skin closure when a block is wearing off. I would have slept this patient. Just my opinion, FWIW.

In 13 years of giving anesthesia, I have never given 14mg of Versed to a single patient and you are guaranteed to have some sort of problems with that much ketamine.

Well, I just lied. I guess I have given that much Versed to a CABG but that is probably it.

 

[pgg]

In 13 years of giving anesthesia, I have never given 14mg of Versed to a single patient and you are guaranteed to have some sort of problems with that much ketamine.

I did a midazolam-only induction once as a wide-eyed new CA1 after my attending said "wanna do a midazolam induction?" I think we used about that much but can't quite remember.

It was an outpatient ... who had to be admitted overnight and left the hospital the next day with no memory of the entire previous day.

Not my finest moment as a resident, nor his as an attending.

 

[RxBoy]

I concur. Too much buddy. Remember that ketamine's half life is LONG... 250mg.....😱 I'll give 10mg here and there + some nitrous (can't remember the last time I actually did this... prolly residency)....

If you are not getting what you need, just tube them. OB AW's are not difficult.

Freaking out in pacu with 250mg of ketamine = not good business.

You'll get it down soon enough.... 🙂

I totally agree... I wanted to tube her myself but my attending was insistent on no tube. I basically did a TIVA on a potentially full stomach with no controlled airway (NPO>8 hrs but pregnant). I'm not sure but just because ketamine maintains SV doesn't necessarily mean they still have an intact gag/cough reflex. I am just happy she didn't aspirate.

Her BMI was >40... which is our typical OB patient. She would of been a disaster had I lost her airway.

 

[sevoflurane]

I totally agree... I wanted to tube her myself but my attending was insistent on no tube. I basically did a TIVA on a potentially full stomach with no controlled airway (NPO>8 hrs but pregnant). I'm not sure but just because ketamine maintains SV doesn't necessarily mean they still have an intact gag/cough reflex. I am just happy she didn't aspirate.

Her BMI was >40... which is our typical OB patient. She would of been a disaster had I lost her airway.

All good bro...! 👍

I hate to say it... but some attendings have a lot to be desired (both in PP and in Academics). Question authority if you feel your patient is not getting good care. They are just as much your patients as they are theirs. 😉

 

[goosegas]

I totally agree... I wanted to tube her myself but my attending was insistent on no tube. I basically did a TIVA on a potentially full stomach with no controlled airway (NPO>8 hrs but pregnant). I'm not sure but just because ketamine maintains SV doesn't necessarily mean they still have an intact gag/cough reflex. I am just happy she didn't aspirate.

Her BMI was >40... which is our typical OB patient. She would of been a disaster had I lost her airway.

It really sucks to be stuck in that position. Its hard to believe your attending would have been willing to do the same thing had they been personally sitting the case. Sounds like you did the best you could with what you had.

 

[RxBoy]

Are you using BIS on everyone? Any particular reason?
.

Yeah I generally use BIS whenever I can. You could argue its a waste of money but I really don't care seeing as I am a resident and there to learn, its not my PP group. It works great if you put it on before induction to get a baseline specially with the geriatrics. One of my attendings has a rule a for anyone >60. Take their age, double it and subtract from 200 for the induction dose of propofol (unless they are chronic alcoholics ect). Of course he always pushes at least 3 cc of fentanyl on induction as well (usually 5 cc) to block the sympathetic response. Its amazing to see when 40 mg of propofol on an 80 y.o decrease their BIS from 80 to 20. If their BIS is still on the higher side, he will push 20 to 40 more.

It also works great with the combined epidural/general cases. I usually get a 10 cc loading dose of post op solution (usually 0.075 bup + 5 mcg/ml fentanyl) before incision and slowly titrate the pump up to get the lowest MAC at a BIS in the 40 to 60 range. I usually could run a maintenance open hysterctomy at 0.5 MAC. Wake ups were super quick and patients were always pain free.

 

[RxBoy]

Question authority if you feel your patient is not getting good care. They are just as much your patients as they are theirs. 😉

I totally agree. I mean I try not to make waves trying to prove them wrong with things I just read from the most recent literature but sometimes they push stupidity too far.

A month ago I had a whipple and was supervised by one of the B-team attendings (my nickname for those part time attendings who never know what they are doing). He wanted me to put in an epidural in preop to run during the case and for post op pain. I thought great, I love epidurals for post op pain... I always push for them.

Well anyways he tells me to make sure I put it in no higher than L2-L3 to reduce the risk of damage to the spinal cord. I was dumbfounded. I refused to do it and told him that unless I was going anywhere from T6 to T8 I wouldn't put it in. I had to actually show him a figure from big miller (i have it on my ipad). After he saw it, he finally said OK go ahead.

I was going to subject this patient to unnecessary procedure that would of resulted in nothing but even more complications (sympathetomy) with no pain relief. 2 weeks later I get a page during a call to manage a patients epidural in the ICU for extreme pain. I go up there... patient is s/p gastrectomy. Look at the anesthesia record and the same attending placed the epidural L2-L3. I was so upset I took it out and placed a new one where it should be. Patient was happy as could be the next day.

 

[epidural man]

Well, I just lied. I guess I have given that much Versed to a CABG but that is probably it.

I loved it when my attendings let me do versed inductions on the pump cases. 14-20mg, very smooth.

 

[epidural man]

I totally agree. I mean I try not to make waves trying to prove them wrong with things I just read from the most recent literature but sometimes they push stupidity too far.

A month ago I had a whipple and was supervised by one of the B-team attendings (my nickname for those part time attendings who never know what they are doing). He wanted me to put in an epidural in preop to run during the case and for post op pain. I thought great, I love epidurals for post op pain... I always push for them.

Well anyways he tells me to make sure I put it in no higher than L2-L3 to reduce the risk of damage to the spinal cord. I was dumbfounded. I refused to do it and told him that unless I was going anywhere from T6 to T8 I wouldn't put it in. I had to actually show him a figure from big miller (i have it on my ipad). After he saw it, he finally said OK go ahead.

I was going to subject this patient to unnecessary procedure that would of resulted in nothing but even more complications (sympathetomy) with no pain relief. 2 weeks later I get a page during a call to manage a patients epidural in the ICU for extreme pain. I go up there... patient is s/p gastrectomy. Look at the anesthesia record and the same attending placed the epidural L2-L3. I was so upset I took it out and placed a new one where it should be. Patient was happy as could be the next day.

👍👍

Advantage of a thoracic epidural - they can get up and walk. Not with a lumbar epidural.

Lumbar epidural for a belly case = lots of pain, and no patient walking = pissed off surgeon = no more epidurals for that surgeon - which in my opinion is the wrong thing. Getting a patient to breath normal or deep, and get up and walk around after a belly case - is huge.

By the way, consider using dilaudid in your epidural, and running lower concentration if you can. I think that 20th percent (0.05) works about 80% of the time, but only if you are running 10mcg/cc of dilaudid. See attached article that recently came out.