Is the combo of Ketamine and Dexmedetomidine Hazardous?

[vector2]

not an argument but a reminder that this drug, like most we give, are poisons and not good for the brain and body if not necessary

one of these poisons is necessary and the other is completely avoidable

you cant really think that ketamine is as essential to your anesthetic as fentanyl and ephedrine..

im not proud to give any of these poisons but i know that sometimes you have to

think about how much we do to avoid giving opiates due to side effects/opiate crisis

here is a a dangerous drug that has 0 clinical impact and we are giving it

You literally could not be more mistaken about ketamine being a “poison” or its clinical relevance to modern anesthesia practice

[PDF] In Vogue: Ketamine for Neuroprotection in Acute Neurologic Injury | Semantic Scholar

In this focused review, the evidence for ketamine as a neuroprotective agent in stroke, neurotrauma, subarachnoid hemorrhage, and status epilepticus is highlighted, with a focus on its applications for excitotoxicity, neuroinflammation, and neuronal hyperexcitability. Neurologic deterioration...

pdfs.semanticscholar.org

Neuroprotective potential of ketamine prevents developing brain structure impairment and alteration of neurocognitive function induced via isoflurane through the PI3K/AKT/GSK-3β pathway

The aim of the current experimental study was to scrutinize the neuroprotective effect of ketamine on the isoflurane (iso)-induced cognitive dysfunction in rats via phosphoinositide 3 kinase (PI3K)/protein kinase B (AKT)/glycogen synthase kinase 3β ...

www.ncbi.nlm.nih.gov

Posttraumatic administration of a sub-anesthetic dose of ketamine exerts neuroprotection via attenuating inflammation and autophagy - PubMed

As a complex disease, traumatic brain injury (TBI) can result in long-term psychiatric changes and sensorimotor and cognitive impairments. The TBI-induced loss of memory and long-term cognitive dysfunction are related to mechanistic factors including an increased inflammatory response...

www.ncbi.nlm.nih.gov

Ketamine: new uses for an old drug?

In 1996, we published an editorial ‘Ketamine, mechanism(s) of action and unusual clinical uses’ in the British Journal of Anaesthesia.1 In that editorial, we de

academic.oup.com

Also, in regard to ketamine being essential, some of you may be able to guess that propofol is one of two IV induction agents listed in the WHO essential medicines list...guess what the other is

WHO Model List of Essential Medicines - Wikipedia

en.m.wikipedia.org

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[deleted171991]

I must have missed the news about the national ketamine crisis.

It's not a crisis. It's a WAR.

 

[deleted162650]

Also, in regard to ketamine being essential, some of you may be able to guess that propofol is one of two IV induction agents listed in the WHO essential medicines list...guess what the other is

Ketamine is essential in the 3rd world. It's an adjunct in the 1st world.

 

[projectpat]

Not all trips are bad trips.. jus' sayin! But I haven't witnessed this negative effect of ketamine. Great agent with so many different applications. Ketafol, multi modal techniques, opioid tolerant pts, combative gorilla requiring AFOI, etc.

Precedex is hit or miss for me. Much less titratable than all the other agents. More often just causes post op hypotension that the PACU has to deal with. Primarily seen it used as part of a multi modal technique run at low dose (0.2 mcg/kg/hr) or for deep MAC i.e. TAVR, often run at 1 mcg/kg/hr then decreased. Some bolus 1 mcg/kg over 10 mins, some bolus 0.5 mcg/kg over 20 mins and some do not bolus.
How do you dose it in different scenarios?

 

[Noyac]

I have no clue why any of us would use ketamine for an anesthetic. Don't see any reason why a trained anesthesiologist would want to garble people's mind. Leave that to Peds/IM/ER residents.

It like all the techies who are nudging on LSD at work to get more creative. It’s all in the dosing.

 

[epidural man]

Ketamine, like all drugs may be a poisen.

However, don't forget that NMDA receptor antagonists are very useful treatments for dementia patients. Ketamine likely protects and helps brain function in the elderly.

Great intra-op adjunt....

 

[urge]

Ketamine, like all drugs may be a poisen.

However, don't forget that NMDA receptor antagonists are very useful treatments for dementia patients. Ketamine likely protects and helps brain function in the elderly.

Great intra-op adjunt....

Where are you getting this info from?

Please provide references.

 

[Planktonmd]

Please educate me if I am wrong, This guy is suggesting the following protocol pre-op:
Preoperative Multimodal Analgesia Program

• Gabapentin 300 mg orally (PO) 5 times a day for 2 weeks preoperatively as tolerated (gabapentin 300 mg each day if glomerular filtration rate (GFR) is greater than 70) (100 mg on prescription 3 times daily [TID] if GFR is less than 50)
• Celecoxib (Celebrex) 200 mg PO twice daily (BID) (caution in renal patients).
• Methadone 20 mg intravaneously (IV) preoperatively (preoperative electrocardiogram [EKG] must be performed to measure QT interval less than 0.45 and the patient denies any cardiac disease, arrhythmias, obstructive sleep apnea, or liver insufficiency)
• Acetaminophen (Tylenol) 1000 mg PO
• Melatonin 5 mg PO for angiolysis
• Dexamethasone 10 mg IV
• Ketorolac (Toradol) 30 mg IV
• Prehydration with carbohydrate load, 40 ounces of sports drink (Gatorade) at bedtime, 10 ounces morning of surgery 2 hours before surgery.
• Dexamethasone 10 mg IV

Is he really serious? Are you fu**ing kidding me?
I think anesthesiology is plagued by this type of crazy individuals who think they have discovered the magical potion to cure all ailments and there are 2 possibilities:
1- They are fu**ing crazy and some how they are still allowed to exist among us
2- They are snake oil salesmen and somehow they manged to dupe the whole medical profession into buying their BS

 

[deleted171991]

I think it is a misspelling of anXiolysis. Still, melatonin is about as valuable as homeopathy. I cringe when I see people prescribing it left and right in the hospital.

 

[Planktonmd]

I think it is a misspelling of anXiolysis. Still, melatonin is about as valuable as homeopathy. I cringe when I see people prescribing it left and right in the hospital.

Not only the Melatonin but the whole poly pharmacy that he calls "multimodal analgesia", it's just crazy.

 

[SolidWater]

I searched but didn't see anyone mentioning use of versed. Obviously if elderly be cautious, but versed is known to reduce ketamine-induced dysphoria. Therefore, why not use it? Great analgesia, great sedation, reduce your chance of psych issues.

Also, what is the logic behind monitoring someone on ketamine - by an anesthesiologist? I can see monitoring, but plenty of academic institutions and outpatient practices give ketamine infusions for migraines, depression, etc. with nothing more than intermittent nursing checks and daily MD rounds.

I get that you add dex and it synergizes, but how is this more risky than the immediate post-op emergence someone experiences after volatile GA? I'd argue not much, if at all.

 

[vector2]

Not only the Melatonin but the whole poly pharmacy that he calls "multimodal analgesia", it's just crazy.

Lose the melatonin and toradol (there’s already celebrex), replace the methadone with some preop PO OxyContin, replace neurontin with lyrica, do the PNBs, and you essentially have the ortho eras protocol I trained with. Anecdotally, pts on our regimen used way less postop morphine and oxycodone IR than those who couldn’t for reasons of intolerance or refusal.

 

[epidural man]

Where are you getting this info from?

Please provide references.

Getting what from? NMDA RECEPTOR agonists for dementia?

 

[urge]

Getting what from? NMDA RECEPTOR agonists for dementia?

Unfortunately that’s not a refererence. Thus I will consider your info must come from The Journal of Your Rear End.

 

[Mman]

Unfortunately that’s not a refererence. Thus I will consider your info must come from The Journal of Your Rear End.

well memantine is an FDA approved NMDA receptor antagonist for treating dementia so there is that...

 

[urge]

well memantine is an FDA approved NMDA receptor antagonist for treating dementia so there is that...

And ketamine is just identical to memantine, right? Why not give memantine instead of ketamine?

Come on guys, you can’t really be that poor scientists (and clinicians by consequence).

But maybe you are.

 

[Mman]

And ketamine is just identical to memantine, right? Why not give memantine instead of ketamine?

Come on guys, you can’t really be that poor scientists (and clinicians by consequence).

But maybe you are.

you ridiculed the idea that NMDA antagonists have a role in treating dementia. I merely provided the name of an FDA approved therapy for you that fits in that category. If you are too lazy to dig up the data for yourself, than maybe you really are that bad of a clinician.

 

[urge]

you ridiculed the idea that NMDA antagonists have a role in treating dementia.

I questioned the idea that ketamine has a role in treating dementia.

I ridiculed the assumption that one NMDA antagonist is equivalent to another.

If you can’t even understand that I cannot help you, or your patients.

 

[Mman]

I questioned the idea that ketamine has a role in treating dementia.

I ridiculed the assumption that one NMDA antagonist is equivalent to another.

If you can’t even understand that I cannot help you, or your patients.

LOL

You questioned NMDA antagonists having any role in treating dementia. I provided you one example. Nobody implied equivalence, that is merely a straw man you set up for yourself. Congrats on knocking down your own straw man.

 

[urge]

LOL

You questioned NMDA antagonists having any role in treating dementia. I provided you one example. Nobody implied equivalence, that is merely a straw man you set up for yourself. Congrats on knocking down your own straw man.

If it makes you feel better, sure...

But where is it you two practice so I don't go there?

 

[Mman]

If it makes you feel better, sure...

But where is it you two practice so I don't go there?

I practice on earth where NMDA antagonists can have a role in treating dementia. I do not practice in some other alternate universe where that is not the case.

 

[epidural man]

I questioned the idea that ketamine has a role in treating dementia.

No you didn’t. You made a vague statement and I asked for calcification because I wasn’t sure what you were asking about since it could have been several things. Then you ridiculed me for trying to seek understanding.

Are you always a dick head or just on that single occasion?

 

[psychbender]

No you didn’t. You made a vague statement and I asked for calcification because I wasn’t sure what you were asking about since it could have been several things. Then you ridiculed me for trying to seek understanding.

Are you always a dick head or just on that single occasion?

Are you always a dick head or just on that single occasion?

Just when someone's practice or experience doesn't mirror his exactly. Mostly areas such as ketamine use, regional anesthesia, and critical care.

 

[Arch Guillotti]

Keep it professional or the thread will be locked.

 

[Spacedman]

Ketamine, like all drugs may be a poisen.

However, don't forget that NMDA receptor antagonists are very useful treatments for dementia patients. Ketamine likely protects and helps brain function in the elderly.

Great intra-op adjunt....

Ketamine most certainly has its uses, but I have yet to see any decent evidence of neuroprotection...in fact plenty of preclinical evidence that it's neurotoxic in development, for what it's worth. Only large trial I know of is the PODCAST trial - largest multicenter RCT showing ketamine had no effect on postop delirium.

Ketamine is not just an NMDA receptor antagonist - did you ever wonder why the ketamine antidpressant craze seems to only focus on ketamine? that's becuause not a SINGLE OTHER NMDAR antagonist has comparable efficacy... so either ketamine is magically more specific than memantine, d-cycloserine, lanicemine, CERC-301, etc, etc, (there are many) or ketamine is a dirty, dirty drug whose multiplicity of targets culminates in a medicine with all the uses we currently enjoy.

Whether NMDAR antagonism is a useful target for older patients is questionable - even the evidence that the prototypical clinical NMDAR antagonist, memantine, has efficacy in alzheimer's is weak af - no effect on disease progression (see Aricept as well), with an effect size that's barely clinically meaningful.

 

[nimbus]

Ketamine most certainly has its uses, but I have yet to see any decent evidence of neuroprotection...in fact plenty of preclinical evidence that it's neurotoxic in development, for what it's worth. Only large trial I know of is the PODCAST trial - largest multicenter RCT showing ketamine had no effect on postop delirium.

Ketamine is not just an NMDA receptor antagonist - did you ever wonder why the ketamine antidpressant craze seems to only focus on ketamine? that's becuause not a SINGLE OTHER NMDAR antagonist has comparable efficacy... so either ketamine is magically more specific than memantine, d-cycloserine, lanicemine, CERC-301, etc, etc, (there are many) or ketamine is a dirty, dirty drug whose multiplicity of targets culminates in a medicine with all the uses we currently enjoy.

Whether NMDAR antagonism is a useful target for older patients is questionable - even the evidence that the prototypical clinical NMDAR antagonist, memantine, has efficacy in alzheimer's is weak af - no effect on disease progression (see Aricept as well), with an effect size that's barely clinically meaningful.

Part of the reason ketamine is so clinically useful is because it is “dirty”. Sometimes dirty is good.

Thanks for the references and great username

 

[deleted162650]

Sometimes dirty is good.

Yeah, this guy knows what I’m talkin’ about.

 

[epidural man]

Keep it professional or the thread will be locked.

I thought is was a very reasonable question that many would probably appreciate an answer too.