Ketamine for Special Needs Patients?

Started by Versed0101
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Versed0101

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I am a dentist who treats special needs patients under GA in the hospital or surgical center.

We have some patients who are too big and combative to mask down. During my residency we would dart these patients with ketamine (sometimes in the waiting room) before bringing them back to the OR.

Most private practice anesthesiologists resist this method. I was wondering what your thoughts were and if you guys had any suggestions for these patients.

Thanks!
 
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I spend a significant amount of my time taking care of pediatric patients and use ketamine/versed darts regularly. I think it is underutilized. It works quickly and lessens the risk that an uncooperative patient may cause an injury resisting a mask induction or IV placement.
 
The reason why many anesthesiologists are reluctant using Ketamine in kids with behavioral or mental problems is that they don't want to be blamed for any further deterioration of the kid's condition.
What do you guys think about that?
Can ketamine make them worse?
 
Versed0101 said:
I am a dentist who treats special needs patients under GA in the hospital or surgical center.

We have some patients who are too big and combative to mask down. During my residency we would dart these patients with ketamine (sometimes in the waiting room) before bringing them back to the OR.

Most private practice anesthesiologists resist this method. I was wondering what your thoughts were and if you guys had any suggestions for these patients.

Thanks!
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Have you asked them yourself? That'd be the easiest way to find out why they don't like doing it. I had lots of special needs OR patients like this during my dental residency, and several of them had to be darted. Our anesthesia people never seemed to have a problem with it.
 
aphistis said:
Have you asked them yourself? That'd be the easiest way to find out why they don't like doing it. I had lots of special needs OR patients like this during my dental residency, and several of them had to be darted. Our anesthesia people never seemed to have a problem with it.
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A few of the MD anesthesiologists I spoke with just said they were uncomfortable with the whole idea. I did not pursue the matter further. On the other hand DDS anesthesia folks are all comfortable with the technique. As you know there are not many available.
 
I just finished a pediatric anesthesia rotation where we had one patient just like you are describing. We actually gave an oral versed/ketamine premed, and it worked great. I think the oral dosing was like 4-5 mg/kg.
 
I haven't seen the dart employed yet, but have d/w people its use. I'm itching to try it, and have been withdrawing it daily from the pyxis in hopes of getting lucky. Who knows, maybe when I do my peds rotation in jan-feb-march.
 
.5 to 1 mg/kg IM with a humane gauge needle should be an acceptable contigency to mask +/- oral premed. Fact is, special needs pt.'s (autism, CP, uncontrollable NOS) don't always take oral versed. Furthermore, it's all in how you choose to manage the situation. If you are confident in your ability to handle the situation with IM Ketamine, you should inform the guardian and proceed with a Ketamine IM premed. It is the safest and most effective way to approach the anesthetic. It provides sedation, amnesia, analgesia, and a more manageable airway. As for concerns about recovery room agitation, that's just peds anesthesia. Between sevo-related agitation, post-op pain, separation anxiety, nausea, hunger, and the long list of other psychological factors in a bad peds recovery - ketamine is not the ratel limiting factor in the scenario. Any reservations in using pre-op IM Ketamine is driven by one thing - protocol. Want to use it? Do your homework, and get some cases under your belt to prove you know what your doing. When others see you peacefully carrying your patient into the OR, and your comfortably catching up on chartwork when the surgeons cut skin - you will have less objections.
 
holidoc said:
.5 to 1 mg/kg IM with a humane gauge needle should be an acceptable contigency to mask +/- oral premed. Fact is, special needs pt.'s (autism, CP, uncontrollable NOS) don't always take oral versed. Furthermore, it's all in how you choose to manage the situation. If you are confident in your ability to handle the situation with IM Ketamine, you should inform the guardian and proceed with a Ketamine IM premed. It is the safest and most effective way to approach the anesthetic. It provides sedation, amnesia, analgesia, and a more manageable airway. As for concerns about recovery room agitation, that's just peds anesthesia. Between sevo-related agitation, post-op pain, separation anxiety, nausea, hunger, and the long list of other psychological factors in a bad peds recovery - ketamine is not the ratel limiting factor in the scenario. Any reservations in using pre-op IM Ketamine is driven by one thing - protocol. Want to use it? Do your homework, and get some cases under your belt to prove you know what your doing. When others see you peacefully carrying your patient into the OR, and your comfortably catching up on chartwork when the surgeons cut skin - you will have less objections.
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Couldn't agree more. In residency, I sometimes (n=<3) used to use the dart for mentally disabled teens or young adults. These patients are often quite strong (and perhaps bigger then you), will not accept an IV or oral meds, and will not allow themselves to be masked down. This puts both you and the patient into a potentially dangerous situation, i.e., they are likely to fight you if you were to try to mask them down which can result in injuries to yourself or the patient.

With an airway box at my side, I would give 0.5-1mg/kg of 100mg/cc ketamine, 2.5 mg of 5 mg/cc versed, and 1 ml of 0.2 mg/ml glycopyrolate in a 3 cc syringe with an 18g needle. I would have someone distract the patient then give it IM in either the thigh or deltoid. Although I would love to be "humane" and use a smaller needle, this is not practical as a smaller guage neeedle takes a longer time to inject, and you need to be exceedingly quick when you have a fighting patient.
 
9french said:
Couldn't agree more. In residency, I sometimes (n=<3) used to use the dart for mentally disabled teens or young adults. These patients are often quite strong (and perhaps bigger then you), will not accept an IV or oral meds, and will not allow themselves to be masked down. This puts both you and the patient into a potentially dangerous situation, i.e., they are likely to fight you if you were to try to mask them down which can result in injuries to yourself or the patient.

With an airway box at my side, I would give 0.5-1mg/kg of 100mg/cc ketamine, 2.5 mg of 5 mg/cc versed, and 1 ml of 0.2 mg/ml glycopyrolate in a 3 cc syringe with an 18g needle. I would have someone distract the patient then give it IM in either the thigh or deltoid. Although I would love to be "humane" and use a smaller needle, this is not practical as a smaller guage neeedle takes a longer time to inject, and you need to be exceedingly quick when you have a fighting patient.
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Nice combo!! I'll keep this in mind.
 
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