Ketamine during a Bronchoscopy

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So I'm a CA-1 and aware that I'm still a rookie in anesthesia. I've been taught in lecture/read in books that when you use ketamine you should anticipate an increase in salivation usually helped with the administration of Robinul. I was in a bronchoscopy last week when I saw an attending use a mixture of propofol and ketamine on microdrip tubing along with an LMA as the airway. He didn't use any Robinul even when the RN at bedside continually suctioned the mouth. I know that with all the secretions you would be concerned with laryngospasm. I've heard a different anesthesiologist tell me they never use Ketamine during any airway procedure especially an EGD.

I'm just curious what your typical practice is. I'm becoming more aware that there are 1000 different ways to deliver an anesthetic and most of them are right.

 

[drmwvr]

If you end up using less than 1mg/kg over extended periods of time (> 20 min?) it isn't often an issue. It comes down to dose and timing. I wouldn't give an antisialogogue to that patient if I wasn't going to give it without ketamine.

 

[caligas]

Bronchoscopy, especially EBUS is often challenging anesthetic. Sick patients, stimulating with lots of irrigation and bloody biopsies. We do igel LMA with combo of gas and lido/prop drip. Ketamine is a reasonable adjunct in modest doses and shouldn’t necessitate glyco. Rarely small dose of sux if everything else is not enough to stop the coughing.

 

[coffeebythelake]

if predictable end time (rarely the case), then tube + roc
otherwise
tube, suxx gtt for short cases
tube, remi gtt for long cases

prefer running tiva's. inhaled gas might get all over the place and theoretically impact cilia function and airway clearance afterwards

 

[Hoya11]

a ketofol infusion and an LMA is a fine way to do that case..

 

[Impromptu]

Unless it is a high biopsy, our pulmonologists have been requesting ETTs for EBUS's recently.

 

[Planktonmd]

That whole Ketamine and secretions thing is way over rated and in most instances not an issue.
I use Ketamine frequently for intubation in difficult airways where I don't think an awake technique is going to work, and I have to admit that half the time I forget to use Glyco. I don't remember ever having a secretion problem even with Fiberoptic intubation.

 

[Lecithin5]

That whole Ketamine and secretions thing is way over rated and in most instances not an issue.
I use Ketamine frequently for intubation in difficult airways where I don't think an awake technique is going to work, and I have to admit that half the time I forget to use Glyco. I don't remember ever having a secretion problem even with Fiberoptic intubation.

I’ll admit it’s been a looong time since I’ve used ketamine for induction/intubation- Will an induction dose keep a (difficult airway) patient spontaneously breathing? If so, how confident of this are you? Or are you using less than a standard induction dose?

 

[deleted162650]

Will an induction dose keep a (difficult airway) patient spontaneously breathing?

Not reliably. I've seen 2mg/kg result in apnea.

 

[Planktonmd]

I’ll admit it’s been a looong time since I’ve used ketamine for induction/intubation- Will an induction dose keep a (difficult airway) patient spontaneously breathing? If so, how confident of this are you? Or are you using less than a standard induction dose?

I usually use less than 1mg/kg in combination with topical anesthesia and airway blocks as time permits.

 

[fakin' the funk]

I was in a bronchoscopy last week when I saw an attending use a mixture of propofol and ketamine on microdrip tubing along with an LMA as the airway.

Ketafol on a microdripper, ballsy! Also please don't call it "Robinul." No one calls it that.

I know that with all the secretions you would be concerned with laryngospasm.

Well you MIGHT be, but if they're deep AF then I'm not worried at all.

I've heard a different anesthesiologist tell me they never use Ketamine during any airway procedure especially an EGD.

No. False. Like most things, it's dose dependent. Can be a great drug in small doses (20-30mg) for EGD.

 

[BigRedBeta]

That whole Ketamine and secretions thing is way over rated and in most instances not an issue.

Agreed, use ketamine for a lot of procedural sedations (2mg/kg dosing) in the Peds ICU. Rarely have an issue - probably less than 10% of the time...but man when it kicks in, it'll surprise you how juicy these kids get. But it's not like you're unable to suction through it.

But doing a bronch, your though process might change. The real issue is the onset of action for the glyco and so you've got to decide before what your approach is going to be.

 

[GA8314]

i just gave a sick fellow 50 of ketamine solo for an EGD the other day. in retrospect, i should have given at least 1 of versed also. he did fantastic, but did say he felt weird afterwards (albeit less depressed.... j.k.)

i think ketamine is underutilized.

 

[HalO'Thane]

So I'm a CA-1 and aware that I'm still a rookie in anesthesia. I've been taught in lecture/read in books that when you use ketamine you should anticipate an increase in salivation usually helped with the administration of Robinul. I was in a bronchoscopy last week when I saw an attending use a mixture of propofol and ketamine on microdrip tubing along with an LMA as the airway. He didn't use any Robinul even when the RN at bedside continually suctioned the mouth. I know that with all the secretions you would be concerned with laryngospasm. I've heard a different anesthesiologist tell me they never use Ketamine during any airway procedure especially an EGD.

I'm just curious what your typical practice is. I'm becoming more aware that there are 1000 different ways to deliver an anesthetic and most of them are right.

We do quite a few rigid bronchoscopies on sick babies where I practice. I find Ketamine to be a great supplement to either a propofol TIVA or volatile agent running through the rigid bronchoscopy side port. I titrate in 1 mg/kg at a time and my total those ends up being anywhere from 1 - 3 mg/kg for the case, varying based on the length of the procedure and patient response. In these cases I will often pre-treat with glycopyrrolate 10 µg/kg (max of about 0.2 mg). I don’t just do it for preventing secretions. I also like it because I think it can help prevent the baby from vagaling down during airway instrumentation and I also think that through it’s anti-muscarinic properties it can help prevent bronchoconstriction. I also agreed that ketamine is a vastly under utilized drug.