Higher street value than Fentanyl?! I would suspect Fent would be much more desirable to the drug abusing population. "K" is more of a club drug up here in the north.
We use primarily Fentanyl and Versed at my fellowship. "2 and 2" is standard with our patients. We have almost no opioid or benzo naive patients.
Propofol is often used as well, probably 40% of the patients. Occasionally Ketamine is thrown in the mix.
I'm fine with using Versed and Fentanyl but as a non-anesthesiologist I'd much rather deal with the rare emergence phenomena from ketamine and versed than respiratory depression. In the below study 5 out of 77 patients had very mild emergence phenomena. Thats why I'm thinking this way. But of course I'm open to suggestions and thus posting here.
Intersting study: Chudnofsky et al. • MIDAZOLAM AND KETAMINE FOR PROCEDURES, ACADEMIC EMERGENCY MEDICINE • March 2000, Volume 7, Number 3
Abstract. Objective: To describe the clinical characteristics
of a combination of midazolam and ketamine
for procedural sedation and analgesia in adult
emergency department (ED) patients. Methods: This
was a prospective, observational trial, conducted in
the ED of an urban level II trauma center. Patients
$ 18 years of age requiring procedural sedation and
analgesia were eligible, and enrolled patients received
0.07 mg/kg of intravenous midazolam followed
by 2 mg/kg of intravenous ketamine. Vital signs were
recorded at regular intervals. The adequacy of sedation,
adverse effects, patient satisfaction, and time to
reach discharge alertness were determined. Descriptive
statistics were calculated using statistical analysis
software. Results: Seventy-seven patients were
enrolled. Three were excluded due to protocol violations,
three due to lack of documentation, and one
due to subcutaneous infiltration of ketamine, leaving
70 patients for analysis. The average age was 31
years, and 41 (59%) were female. Indications for procedural
sedation and analgesia included abscess incision
and drainage (66%), fracture/joint reduction
(26%), and other (8%). The mean dose of midazolam
was 5.6 6 1.4 mg and the mean dose of ketamine was
159 6 42 mg. The mean time to achieve discharge
criteria was 64 6 24 minutes. Five patients experienced
mild emergence reactions, but there were no
episodes of hallucinations, delirium, or other serious
emergence reactions. Eighteen (25%) patients recalled
dreaming while sedated; twelve (17%) were described
as pleasant, two (3%) unpleasant, three (4%)
both pleasant and unpleasant, and one (1%) neither
pleasant nor unpleasant. There were four (6%) cases
of respiratory compromise, two (3%) episodes of emesis,
and one (1%) case of myoclonia. All of these were
transient and did not result in a change in the patient's
disposition. Only one (1%) patient indicated
that she was not satisfied with the sedation regimen.
Conclusions: The combination of midazolam and
ketamine provides effective procedural sedation and
analgesia in adult ED patients, and appears to be
safe. Key words: procedural sedation; procedural analgesia;
ketamine; midazolam. ACADEMIC EMERGENCY
MEDICINE 2000; 7:228–235
You should ask locally. It is not the standard of care in this area (USA).
Great street value, super duper quality high. If people knew it was stocked in your office, the safe would be stolen weekly.
Not a good idea. How about fentanyl and versed. It's called 1 and 1 and you still will not get paid for administering it, but at least you get the liability of providing MAC in your office. I had to canel a procedure on an opioid naive patient when I walked in and a fellow just gave 2 and 2. We flipped her over, gave her a little narcan, and put the O2 on. Fortunately she was fine in 5 mminutes and we didn't even have to bag her.
What did you do in fellowship training?
- just kidding
