ketamine in asthma

[name?]

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I had a great experience with ketamine last night--severe asthmatic who was altered, markedly tachypneic and super tight. She wasn't hypoxic yet, but looked like she was going to need a tube even after epi x 2, mag, steroids and continuous nebs. Opted to attempt BiPAP which improved her tidal volumes, but she did not tolerate the mask well in her altered state. Gave a 0.5mg/kg dose of ketamine for sedation/bronchodilatory effect and she got calm, compliant and, voila! No tube, tolerated her treatments and turned around in the next 30 minutes to be a safe non-tubed ICU admit for her status.

I had initially requested the ketamine for induction, but decided to try to buy some time and it worked like a charm. Love me some Special K!

It's very nice to have that in our tool box, and even though the nurses and medics thought I was nuts and had never seen or done it, they all appreciated the result.

 

[alphaholic06]

Interesting. Is 0.5mg/kg the typical dose? Has anyone tried or had success with a ketamine gtt for patients that you are trying to avoid intubating?

 

[la gringa]

i tried 1mg/kg -- patient came in looking like crap, his breath sounds improved but his MS did not. he was hyperventilating and bug-eyed. maybe i should have chased it w/ some ativan... ended up tubing him, still my only tubed asthmatic in my career 🙁 i literally did try EVERYTHING!!

 

[RustedFox]

0.5 to 1 mg/kg. I've seen it work like magic. I've seen it do.... absolutely nothing.

 

[Hernandez]

Interesting. Is 0.5mg/kg the typical dose? Has anyone tried or had success with a ketamine gtt for patients that you are trying to avoid intubating?

Typically initial dose I give is 1mg/kg, and if I repeat I give 0.5mg/kg up to 2 more doses. I also always give with a slug of a benzo. I haven't (and likely wouldn't) use ketamine gtt for non-intubated pts, but I do like it on tubed asthmatics. It does induce a nice bronchodilator is pretty well every asthmatic I've used it it, but it hasn't saved all from eating plastic where I used it to try and prevent tubing.

 

[cyclohexanol]

I had a great experience with ketamine last night--severe asthmatic who was altered, markedly tachypneic and super tight. She wasn't hypoxic yet, but looked like she was going to need a tube even after epi x 2, mag, steroids and continuous nebs. Opted to attempt BiPAP which improved her tidal volumes, but she did not tolerate the mask well in her altered state. Gave a 0.5mg/kg dose of ketamine for sedation/bronchodilatory effect and she got calm, compliant and, voila! No tube, tolerated her treatments and turned around in the next 30 minutes to be a safe non-tubed ICU admit for her status.

I had initially requested the ketamine for induction, but decided to try to buy some time and it worked like a charm. Love me some Special K!

It's very nice to have that in our tool box, and even though the nurses and medics thought I was nuts and had never seen or done it, they all appreciated the result.

That's awesome, I'm glad it worked for you!

I had what sounds like the same patient 2 weeks ago that I tried this on. Severe asthmatic with hx of prior intubation. Got nebs, epi x 3, 2g mag over 2 mins, steroids. Wouldn't tolerate BiPAP. Gave 0.5mg/kg ketamine for sedation/bronchodilation, but didn't fly. Decided to induce her with a full 2mg/kg and put her on BiPAP while waiting to see if she dilated, but she didn't so we just gave succ and tubed her. We did give her a full 2 minutes or so while completely dissociated on BiPAP before tubing. Put her on a ketamine gtt for sedation (7mcg/kg/min). Her pressure-volume loops on the vent showed massive obstructive pathology (flat-elongated). At that point I gave her vec and a continuous neb in addition to the ketamine gtt. Tweaked her PEEP (finally settled on 15) based on her loops and within 20 minutes, we had an almost normal appearing pressure-volume loop. She was extubated 12 hours later in the ICU and signed out AMA 🙄

I really wanted the ketamine to work to avoid the tube, but she had a good physiologic improvement shortly after. As for the AMA.. well.. can't fix stupid right?

 

[name?]

I was aiming to low-ball and titrate if needed, but really just wanted a sub-dissociative dose for analgesia and I think that's basically where we ended up--just out of it enough to quit fighting and let the treatments do their thing. I debated on adding the benzo, but figured if she got any significant sedation/respiratory depression that we'd be putting in the tube so I went single agent.

Probably the single greatest use I've had (aside from the fun last night) is in the diaphoretic and combative patient that can't get a line in--at least you can get them calm with an IM slug (I'd probably go for the full 4mg/kg), keep them breathing spontaneously and hopefully get a line in and paralyze if need be for the tube. Any bronchodilatation at that point is a bonus and it buys you time to actively manage them instead of the pre-code thrash of the crashing respiratory patient.

 

[Rendar5]

Ever use a subdissociative dose before for pain control? just curious, always wanted to try 10mg ketamine for a pt for pain, but never really had a great opportunity to test it out.

 

[dotcb]

I feel the same about ketamine for asthma as I do Bipap for asthma - unlikely to harm, might help. That describes my experience as well - occasional success. These are patients that are headed for an ETT, so anything that might help avoid intubation is worth a shot. Usually throw the kitchen sink at these patients, including IM epi if I think their coronaries can tolerate it.

 

[shookwell]

I've had some success with Ketamine for severe asthma, although I've always used the full dose, 1-1.5mg/kg bolus.

As for pain control, I've used sub-anesthetic doses of Ketamine in patients who were on suboxone who had significant trauma and no relief with fentanyl or dilaudid. Always worked well.

 

[cyclohexanol]

Ever use a subdissociative dose before for pain control? just curious, always wanted to try 10mg ketamine for a pt for pain, but never really had a great opportunity to test it out.

Yes. In fact, I just got approved by the IRB at my institution for a prospective randomized double-blinded trial comparing it (ketamine 0.25mg/kg - 1 re-dose allowed) to a standard weight based dose of dilaudid (0.015 mg/kg - 1 re-dose allowed) for patients who are opiate tolerant. I had used it on about 10 patients in the past year with great results. I'm excited about our new study - hopefully you can read about it next year 🙂

There is a retrospective paper out of UNM (PMID: 20837262) that looked promising for use in the ED. The pain guys have been using it for quite some time.

 

[Apollyon]

Ever use a subdissociative dose before for pain control? just curious, always wanted to try 10mg ketamine for a pt for pain, but never really had a great opportunity to test it out.

Yes. In fact, I just got approved by the IRB at my institution for a prospective randomized double-blinded trial comparing it (ketamine 0.25mg/kg - 1 re-dose allowed) to a standard weight based dose of dilaudid (0.015 mg/kg - 1 re-dose allowed) for patients who are opiate tolerant. I had used it on about 10 patients in the past year with great results. I'm excited about our new study - hopefully you can read about it next year 🙂

There is a retrospective paper out of UNM (PMID: 20837262) that looked promising for use in the ED. The pain guys have been using it for quite some time.

I know it is only anecdote, but didn't it work for Dr. Greg House?

 

[Stitch]

Definitely a good drug when used with the right patient. I've seen it used in kids at 0.5-1 mg/kg as a continuous infusion and leave them on bipap. Sometimes it works, sometimes not, but we rarely intubate kids for asthma anyway, so it's difficult to objectively measure efficacy. Certainly my sedation agent of choice if they're already tubed, and would be my induction agent of choice if it came down to it.

 

[Hamhock]

Tweaked her PEEP (finally settled on 15) \

PEEP of 15 in an asthmatic? Peds?

HH

 

[Hamhock]

At that point I gave her vec and a continuous neb in addition to the ketamine gtt

I also don't understand the quote above.

Was your patient not on continuous nebs before? Were you trying ketamine without continuous nebs?

HH

 

[Hernandez]

PEEP of 15 in an asthmatic? Peds?

HH

Why not in an adult?

 

[Hamhock]

Yes. In fact, I just got approved by the IRB at my institution for a prospective randomized double-blinded trial comparing it (ketamine 0.25mg/kg - 1 re-dose allowed) to a standard weight based dose of dilaudid (0.015 mg/kg - 1 re-dose allowed) for patients who are opiate tolerant. I had used it on about 10 patients in the past year with great results. I'm excited about our new study - hopefully you can read about it next year 🙂

Cyclo -- I am really not trying to get on your case here -- please believe me...I am just confused by some of your recent posts.

In fact, I am super excited to hear about any study to get sub-disocciative ketamine into the EM literature more. I think this will get more docs using it and it will be nice to as "back-up" with the old-schoolers and RNs get all excited for nothing.

However, I don't understand how you are going to do a "double-blind" trial using ketamine. I am a "heavy user" (for my patients) of sub-dissociative ketamine (which I think is a mis-nomer -- analgesic-dosed ketamine is a better description, as the dissociation is not all or none, as many people believe) and it is very RARE that EVERYONE involved (MD, RN, patient, janitor) doesn't notice that ketamine was used.

If you can share how you are going to blind your study before publishing it, I would love to hear. However, I understand if you need to keep it secret for now.

Either way, I really look forward to your publication.

HH

 

[Hamhock]

Why not in an adult?

Assuming the poster is using AC (volume), which the majority of EM docs use in my somewhat limited experience (about 10-15 EDs), I guess I am just a bit surprised that an EM doc would:

1. be in the group of docs who believe in "small airway stenting" for asthmatics
2. if #1, then have enough guts to increase the PEEP to 15 in the acute phase in the ED; especially in a patient with persistent "flat-elongated" "pressure-volume" loops, who must have quickly increasing plateau pressures (likely requiring manual compression every few breaths with a PEEP of 15 (again we are in the acute phase here, just after intubation
3. if #1 and #2, then not aware that ketamine alone is insufficient for "dialation" of airways and that nebulized bronchodialtors are needed (and that a "full 2 minutes" is not going to be enough time)

Just doesn't seem plausible, nevermind a good idea in the minutes after intubation.

HH

 

[cyclohexanol]

Damn, I go to work and have all these questions to answer..

PEEP of 15 in an asthmatic? Peds?

HH

No, she was 43.

I also don't understand the quote above.

Was your patient not on continuous nebs before? Were you trying ketamine without continuous nebs?

HH

Yes she was on continuous nebs, and all of the above. I guess that could have been said more clearly. I added vec to her in line nebs and ketamine in order to increase vent synchrony.

Cyclo -- I am really not trying to get on your case here -- please believe me...I am just confused by some of your recent posts.

In fact, I am super excited to hear about any study to get sub-disocciative ketamine into the EM literature more. I think this will get more docs using it and it will be nice to as "back-up" with the old-schoolers and RNs get all excited for nothing.

However, I don't understand how you are going to do a "double-blind" trial using ketamine. I am a "heavy user" (for my patients) of sub-dissociative ketamine (which I think is a mis-nomer -- analgesic-dosed ketamine is a better description, as the dissociation is not all or none, as many people believe) and it is very RARE that EVERYONE involved (MD, RN, patient, janitor) doesn't notice that ketamine was used.

If you can share how you are going to blind your study before publishing it, I would love to hear. However, I understand if you need to keep it secret for now.

Either way, I really look forward to your publication.

HH

I should rephrase. The patient and clinician will be blinded, the nurse will be the only one to know. We tried to get pharmacy to premix syringes so nobody who would be directly involved with care would know but it wasn't feasible.

Assuming the poster is using AC (volume), which the majority of EM docs use in my somewhat limited experience (about 10-15 EDs), I guess I am just a bit surprised that an EM doc would:

1. be in the group of docs who believe in "small airway stenting" for asthmatics
2. if #1, then have enough guts to increase the PEEP to 15 in the acute phase in the ED; especially in a patient with persistent "flat-elongated" "pressure-volume" loops, who must have quickly increasing plateau pressures (likely requiring manual compression every few breaths with a PEEP of 15 (again we are in the acute phase here, just after intubation
3. if #1 and #2, then not aware that ketamine alone is insufficient for "dialation" of airways and that nebulized bronchodialtors are needed (and that a "full 2 minutes" is not going to be enough time)

Just doesn't seem plausible, nevermind a good idea in the minutes after intubation.

HH

In response to 1 and 2. I set the PEEP based on the patients lower inflection point, and TV based on the upper. There are plenty of critical care manuscripts that support this for any intubated patient. Her plateaus were consistently less than 30 with those settings, and she turned around quickly.

Here is a quick read/summary regarding PEEP settings off the LIP measurement

http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=89&seg_id=1712

Maybe I'm completely wrong but using the LIP from the PV loop to set PEEP makes sense to me. It takes the guesswork out of the picture.

Lastly, in response to 3, sure ketamine and nebs may take longer than "a full 2 minutes" but how long do you really want to wait to see if something works for a patient who is already on nebs, epi, steroids, mag, initial subdissociative dose of ketamine, etc... With a pCO2 of 100 who isn't turning around? 2 minutes after a full dose ketamine and BiPAP seemed like a reasonable time to me. She didn't turn around so she got tubed, and turned around shortly after.

Sorry if I come off sounding defensive, im not trying to sound like an ******* in my response, I just got a "holy **** this guy is ******ed wtf is he doing" vibe from your questions. And maybe I really have no idea wtf I'm doing, I'm still a newbie.

 

[Hernandez]

Assuming the poster is using AC (volume), which the majority of EM docs use in my somewhat limited experience (about 10-15 EDs), I guess I am just a bit surprised that an EM doc would:

1. be in the group of docs who believe in "small airway stenting" for asthmatics
2. if #1, then have enough guts to increase the PEEP to 15 in the acute phase in the ED; especially in a patient with persistent "flat-elongated" "pressure-volume" loops, who must have quickly increasing plateau pressures (likely requiring manual compression every few breaths with a PEEP of 15 (again we are in the acute phase here, just after intubation
3. if #1 and #2, then not aware that ketamine alone is insufficient for "dialation" of airways and that nebulized bronchodialtors are needed (and that a "full 2 minutes" is not going to be enough time)

Just doesn't seem plausible, nevermind a good idea in the minutes after intubation.

HH

1) at least he didn't set at 5 and walk away and hope pulm would save the day (or even worse walk away while to is still in extremis on vent)
2) what makes you assume you'd need to do manual compressions between breaths in a freshly tubed asthmatic? Peep is only harmful in hypovolunemic pts, ancedotataly, I don't think I've ever seen an asthmatic pt in resp failure become hypotensive from a vent )
A flat-elongated pressure/volume is just a graphical representation of air flow obstruction,
3) well.....ok




cyclohexanol, the one thing I would caution about using LIP is that they tend to be very skewed in a pt who isn't paralyzed, but assuming you just tubed the pt, then would be a good time, otherwise I tend to use Expiratory pauses to calculate total peep then set my peep at ~75% of total peep (if I can get an Expiratory pause)

 

[AlmostJesus]

Ever use a subdissociative dose before for pain control? just curious, always wanted to try 10mg ketamine for a pt for pain, but never really had a great opportunity to test it out.

North Memorial in Minneapolis has Ketamine as an option for pain control in their ambulance protocols right now.
Their dose is 0.25mg/kg up to 25mg over 3-5 minutes
Hennepin County also has it in their protocol at 0.5mg/kg up to 50mg
I would really be interested in trying it to see how it works out, unfortunately working rural, we are usually the last to adopt everything.