Ketamine infusions

[waterbottle10]

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Do ppl use ketamine infusion as main anesthetic for general anesthesia?? Do ppl use ketamine infusions for sedation in pacu/icu?

 

[sevoflurane]

Do ppl use ketamine infusion as main anesthetic for general anesthesia?? Do ppl use ketamine infusions for sedation in pacu/icu?

No and No. They may use a ketamine infusion for pain control however in pacu and to the floor.
Propofol is a superior choice for sedation.

 

[sevoflurane]

Can Ketamine be used for general anesthesia? Yes.
It was a frequent anesthetic in Haiti after the earthquake... but that was from a lack of other anesthetic modalities (think pediatric extremity amputations under ketamine). Ketamine is a safe drug for the most part but not a go to for general anesthesia here in the US.
Great adjunct for a multimodal approach.

 

[sevoflurane]

You know what is interesting about the history of ketamine? It replaced PCP otherwise known as Sernyl which was used to help induce general anesthsia in the 1950's.
That's right... part of the old school anesthesia actually used PCP as their GA cocktail.... until ketamine was discovered.

 

[waterbottle10]

No and No. They may use a ketamine infusion for pain control however in pacu and to the floor.
Propofol is a superior choice for sedation.

Any specific reason? Ketamine has analgesia, amnesia, sedation so it sounds so much more complete than propofol which pretty much just sedates.

 

[Noisewater-TDX]

Ketamine is used for pain in the PACU, ICU, and Stepdown floors. We also use it in the ER for pain and moderate sedation. Works well in some, causes others to freak out and then they attempt to kill their nurse.

 

[sevoflurane]

Any specific reason? Ketamine has analgesia, amnesia, sedation so it sounds so much more complete than propofol which pretty much just sedates.

You asked about sedation... not analgesia or amnesia.

Do ppl use ketamine infusion as main anesthetic for general anesthesia?? Do ppl use ketamine infusions for sedation in pacu/icu?

Ketamine is NOT a great sedative. It is "A" sedative, but a terrible one at that compared to what is available to us. It is one of my favorite drugs out there... but you need to understand it.

It absolutely creates a dissociative state that is not optimal for the person who is not in the right presence of mind.

The ED can be a chaotic place and I think it is overused down there although maintianing SV is a merit of the drug as it imparts a certain level of safety despite it's long half life.

Just imagine, however, a 200 lb lean machine of a dude who is freaking out because of this dissociateive state. This scenario can create an unpleasant pacu experience.

Just doesn't happen with the smootheness of other alternatives.

Again, we are talking about SEDATION.

 

[Noisewater-TDX]

Just imagine, however, a 200 lb lean machine of a dude who is freaking out because of this dissociateive state. This scenario can create an unpleasant pacu experience.

That's when the Ativan or Versed comes in to play in the ER. But I agree, procedures needing sedation seem to go smoother with Diprivan.

 

[Aether2000]

I used to do tubal ligations next day after delivery with ketamine alone, the patient was titrated to the point of hallucinating and they didn't feel the knife. But they were not sedated- when asked they would tell you about their current hallucination. It was very strange. Ketamine infusions are also not "sedating" consistently- depends on the rate of infusion. The hypertension, tachycardia, and drool can be significant. In order to combat the memory of the hallucinations and the intrainfusion sympathomimetic effects in some, one may have to give 3-4 other medications.

 

[waterbottle10]

I see. Thanks for the responses. Help a lot

 

[deleted162650]

I used to do tubal ligations next day after delivery with ketamine alone, the patient was titrated to the point of hallucinating and they didn't feel the knife. But they were not sedated- when asked they would tell you about their current hallucination. It was very strange. Ketamine infusions are also not "sedating" consistently- depends on the rate of infusion. The hypertension, tachycardia, and drool can be significant. In order to combat the memory of the hallucinations and the intrainfusion sympathomimetic effects in some, one may have to give 3-4 other medications.

Well that sounds like a great anesthetic

 

[PistolPete]

Psychiatrist here. What do you guys think about all the ketamine trials for major depression? My guess is they're using it at much lower doses than what you guys would usein the PACU. Sounds like you guys don't like to use it much, let alone for anyone even remotely mentally unstable.

 

[Hoya11]

Psychiatrist here. What do you guys think about all the ketamine trials for major depression? My guess is they're using it at much lower doses than what you guys would usein the PACU. Sounds like you guys don't like to use it much, let alone for anyone even remotely mentally unstable.

If you have someone who is an inpatient for a very long time and tried and failed ECT what do you have to lose by trying ketamine? But at the same time I would worry it may make positive psychotic symptoms worse.

 

[Ronin2258]

You asked about sedation... not analgesia or amnesia.



Ketamine is NOT a great sedative. It is "A" sedative, but a terrible one at that compared to what is available to us. It is one of my favorite drugs out there... but you need to understand it.

It absolutely creates a dissociative state that is not optimal for the person who is not in the right presence of mind.

The ED can be a chaotic place and I think it is overused down there although maintianing SV is a merit of the drug as it imparts a certain level of safety despite it's long half life.

Just imagine, however, a 200 lb lean machine of a dude who is freaking out because of this dissociateive state. This scenario can create an unpleasant pacu experience.

Just doesn't happen with the smootheness of other alternatives.

Again, we are talking about SEDATION.

I also worry about it in populations that are very prone to PTSD issues. The last thing I want to do with a Vietnam veteran who had time in the Tet offensive is make him relive the experience.

 

[Hoya11]

You asked about sedation... not analgesia or amnesia.



Ketamine is NOT a great sedative. It is "A" sedative, but a terrible one at that compared to what is available to us. It is one of my favorite drugs out there... but you need to understand it.

It absolutely creates a dissociative state that is not optimal for the person who is not in the right presence of mind.

The ED can be a chaotic place and I think it is overused down there although maintianing SV is a merit of the drug as it imparts a certain level of safety despite it's long half life.

Just imagine, however, a 200 lb lean machine of a dude who is freaking out because of this dissociateive state. This scenario can create an unpleasant pacu experience.

Just doesn't happen with the smootheness of other alternatives.

Again, we are talking about SEDATION.

Agree with what you said but why do you like it then? I use it rarely ... I give a little during AFOI (along with versed and fent and glyco). Sometimes to really sick unit players for PEG placements (gorked out anyways). Or IM for premedication of an unruly child/disabled person. I think the analgesia is over-rated. Its best use is as a hypnotic that acts quickly and minimally depresses SV and CO.

Ketamine might LOOK good to you on the outside, might not be so great to be on the inside of the skull tripping out to something unpleasant.

 

[sevoflurane]

Agree with what you said but why do you like it then? I use it rarely ... I give a little during AFOI (along with versed and fent and glyco). Sometimes to really sick unit players for PEG placements (gorked out anyways). Or IM for premedication of an unruly child/disabled person. I think the analgesia is over-rated. Its best use is as a hypnotic that acts quickly and minimally depresses SV and CO.

Ketamine might LOOK good to you on the outside, might not be so great to be on the inside of the skull tripping out to something unpleasant.

Hoya,

I guess I've been using it since early residency and really have a good feeling on what it does and doesn't do. I will say that a little bit goes a long way and it's very cheap.
Def. opioid and inhaled agent sparing which ultimately decreases nausea and vomiting while providing some pretty longish analgesic levels.
I use it mainly in big cases like spines, major abdominal stuff, as well as ortho. I do like ketafol along with .4 Mac of anesthesia + a block. Particularly useful for say knees that get ACB which obviously is the bastard stepchild to a FNB. We add celebrex, Tylenol and sometimes gaba the morning of surgery + LIA and perhaps some mag.
These patients do very well as pain control and N/V is preemptively addressed and therefore pacu stays are very short. Particularly useful for the opiod tolerant patient.
Careful eye on dosage is key. Again, a little bit goes a long way. It's also a style thing. Some prefer to crank the Sevo or Des to 1.4 mac and that's fine, but just not my particular way of doing these cases.

 

[deleted162650]

Psychiatrist here. What do you guys think about all the ketamine trials for major depression? My guess is they're using it at much lower doses than what you guys would usein the PACU. Sounds like you guys don't like to use it much, let alone for anyone even remotely mentally unstable.

My group runs a ketamine clinic for depression and chronic pain. Dosing is similar to what I use for a pain adjunct in spine cases with opioid tolerant pts. Occasionally people will have some visual hallucinations but no one has lost their **** yet.

 

[sevoflurane]

My group runs a ketamine clinic for depression and chronic pain. Dosing is similar to what I use for a pain adjunct in spine cases with opioid tolerant pts. Occasionally people will have some visual hallucinations but no one has lost their **** yet.

Nice Salty.

A couple of questions if you don't mind:

1) Is the ketamine clinic profitable?
2) What types of patients?
3) Does insurance cover the cost or is it out of pocket?
4) Where do you do them and is it an overnight stay?

Thanks.

 

[psychbender]

I also worry about it in populations that are very prone to PTSD issues. The last thing I want to do with a Vietnam veteran who had time in the Tet offensive is make him relive the experience.

Used in low doses (0.5mg/kg load, or 0.25-0.5mg/kg/hr), and the psychotomimetic effects are minimal or nonexistent, even in the PTSD patient population that I dealt with in residency (old and fresh combat traumas). Anecdotally, I actually noticed less agitation from the new traumas when they had some ketamine in the OR, compared to those with similar injuries who did not receiving ketamine.

 

[PistolPete]

My group runs a ketamine clinic for depression and chronic pain. Dosing is similar to what I use for a pain adjunct in spine cases with opioid tolerant pts. Occasionally people will have some visual hallucinations but no one has lost their **** yet.

Cool, good to know.

 

[zizzer]

So why is ketamine not a good choice for single agent maintenance anesthesia? Surely the unique cardiorespiratory effects would be beneficial in a certain subset of patients, and the behavior concerns shouldn't be a problem for general anesthesia, right? Does it make for a rough emergence?

 

[Mman]

So why is ketamine not a good choice for single agent maintenance anesthesia? Surely the unique cardiorespiratory effects would be beneficial in a certain subset of patients, and the behavior concerns shouldn't be a problem for general anesthesia, right? Does it make for a rough emergence?

Because if that's the only thing you are using you will be on a very high dose and the patient will be having major hallucinations. In anesthesia, we use ketamine as an adjunct in relatively small doses to get the effects we want but avoid the ones we don't. Patients come to the OR to have a pleasant experience. If ketamine was your sole drug to use, your patient would likely have a very bad trip unless they were a major drug user and just wanted to try a new high they've never experienced before.

Propofol provides very crisp and clean awakening and patients end up clear headed and not hungover feeling. Ketamine has patients drooling on themselves and talking about the monsters trying to attack them and the bugs crawling around the room.

 

[IlDestriero]

Ketamine and marines...
"There were little green dudes all over the place, like garden gnomes, under the bed and shït."
-Ok... was it scary?
"Naaa man, they're cool."
Oh, good.



--
Il Destriero

 

[dhb]

To all the people who freak out about ketamine: you should try it once.

 

[deleted162650]

To all the people who freak out about ketamine: you should try it once.

Just looking for an excuse.

 

[Mman]

To all the people who freak out about ketamine: you should try it once.

personally? or with patients? I use it daily on patients as an adjunct to my anesthetic and analgesia.

 

[Aether2000]

The PGA in NY presented some data showing single dose ketamine at the beginning of a surgery (more than an hour from administration to PACU) has no residual effects, yet significantly reduces opioid requirements in the PACU and thereafter.

 

[Man o War]

The PGA in NY presented some data showing single dose ketamine at the beginning of a surgery (more than an hour from administration to PACU) has no residual effects, yet significantly reduces opioid requirements in the PACU and thereafter.

This is precisely why I use it on the majority of my patients in this exact manner.

 

[Mman]

This is precisely why I use it on the majority of my patients in this exact manner.

I try to give it to almost any patient that is having a painful surgery. I mean opioid sparing doesn't help much for some things that aren't going to hurt much, but if you are getting a major abdominal, thoracic, spine, or ortho procedure it is very helpful.

 

[deleted162650]

Nice Salty.

A couple of questions if you don't mind:

1) Is the ketamine clinic profitable?
2) What types of patients?
3) Does insurance cover the cost or is it out of pocket?
4) Where do you do them and is it an overnight stay?

Thanks.

PM sent

 

[dhb]

personally? or with patients? I use it daily on patients as an adjunct to my anesthetic and analgesia.

Personally

 

[Hoya11]

The PGA in NY presented some data showing single dose ketamine at the beginning of a surgery (more than an hour from administration to PACU) has no residual effects, yet significantly reduces opioid requirements in the PACU and thereafter.

Care to post this study? I have found it to have minimal to no substantial analgesia acutely.

 

[Man o War]

I try to give it to almost any patient that is having a painful surgery. I mean opioid sparing doesn't help much for some things that aren't going to hurt much, but if you are getting a major abdominal, thoracic, spine, or ortho procedure it is very helpful.

My patient population is fairly homogenous these days (older and very sick), and our surgeons want them extubated ASAP. Definitely used it in the population you're describing here when I did those cases.

 

[Hoya11]

Personally

.

 

[d9sccr]

PM sent

Any chance you could send me that PM as well? Or post the information in here?

 

[deleted9493]

I use ketamine infusions as the sole anesthetic frequently in pediatric cath lab with great results. Our cardiologists are typically wanting the kids anesthetized on room air with hemodynamics that approximate everyday un-anesthetized values without using vasopressors. That is a very difficult thing to do in an non-stimulating procedure like a hemodynamic cath.

There is a lot of misunderstanding about the drug, namely with regard to the hallucinogenic effects. These are effects that are generally seen in the sedation range of dosing, not in the analgesic or anesthetic dosing ranges.

 

[anbuitachi]

I use ketamine infusions as the sole anesthetic frequently in pediatric cath lab with great results. Our cardiologists are typically wanting the kids anesthetized on room air with hemodynamics that approximate everyday un-anesthetized values without using vasopressors. That is a very difficult thing to do in an non-stimulating procedure like a hemodynamic cath.

There is a lot of misunderstanding about the drug, namely with regard to the hallucinogenic effects. These are effects that are generally seen in the sedation range of dosing, not in the analgesic or anesthetic dosing ranges.

what dose do you run it at for those caths?

 

[Planktonmd]

Ketamine with Propofol infusion is an excellent anesthetic technique that I use frequently. It provides more hemodynamic stability and it is less likely to cause apnea than Propofol alone.
Those hallucinations and bad reactions are very rare when Ketamine is combined with Propofol.

 

[zizzer]

I use ketamine infusions as the sole anesthetic frequently in pediatric cath lab with great results. Our cardiologists are typically wanting the kids anesthetized on room air with hemodynamics that approximate everyday un-anesthetized values without using vasopressors. That is a very difficult thing to do in an non-stimulating procedure like a hemodynamic cath.

There is a lot of misunderstanding about the drug, namely with regard to the hallucinogenic effects. These are effects that are generally seen in the sedation range of dosing, not in the analgesic or anesthetic dosing ranges.

At what infusion rate? Are they completely unresponsive throughout the case? Are behavior and psychomimetic issues on emergence a concern? Do you premedicate with anything (midazolam, glycopyrrolate for secreations)? I'm intrigued.

 

[deleted9493]

At what infusion rate? Are they completely unresponsive throughout the case? Are behavior and psychomimetic issues on emergence a concern? Do you premedicate with anything (midazolam, glycopyrrolate for secreations)? I'm intrigued.

Bolus of 2mg/kg to start the case followed by infusion at 4-6mg/kg/hr for maintenance. Most of these cath cases require intubation out of need for optimized physiologic parameters (pCO2 40, FiO2 .21, normotension, etc). I do use paralytic as well. Kids in recovery are chill and I honestly haven't found any untoward side effects beyond the secretions and tachycardia with the load.

I do not routinely use midazolam if I'm using anesthetic level of dosing, nor do I use anti-muscarinics because of the confounding nature of driving up CO in patients with single ventricle physiology.

The populations that I find myself most using this on are chronic lung disease kids failing to wean off vent (pulmonary htn?) and single ventricle kids who need very accurate measurements before they get their Glenn or Fontan.

 

[btbam]

Bolus of 2mg/kg to start the case followed by infusion at 4-6mg/kg/hr for maintenance. Most of these cath cases require intubation out of need for optimized physiologic parameters (pCO2 40, FiO2 .21, normotension, etc). I do use paralytic as well. Kids in recovery are chill and I honestly haven't found any untoward side effects beyond the secretions and tachycardia with the load.

I do not routinely use midazolam if I'm using anesthetic level of dosing, nor do I use anti-muscarinics because of the confounding nature of driving up CO in patients with single ventricle physiology.

The populations that I find myself most using this on are chronic lung disease kids failing to wean off vent (pulmonary htn?) and single ventricle kids who need very accurate measurements before they get their Glenn or Fontan.

I'm pretty sure the "pre-Glenn/Fontan checks" are just a way for the interventional cardiologists to rack up some more $$. It's like what's the alternative, not doing the surgery?

 

[anbuitachi]

Bolus of 2mg/kg to start the case followed by infusion at 4-6mg/kg/hr for maintenance. Most of these cath cases require intubation out of need for optimized physiologic parameters (pCO2 40, FiO2 .21, normotension, etc). I do use paralytic as well. Kids in recovery are chill and I honestly haven't found any untoward side effects beyond the secretions and tachycardia with the load.

I do not routinely use midazolam if I'm using anesthetic level of dosing, nor do I use anti-muscarinics because of the confounding nature of driving up CO in patients with single ventricle physiology.

The populations that I find myself most using this on are chronic lung disease kids failing to wean off vent (pulmonary htn?) and single ventricle kids who need very accurate measurements before they get their Glenn or Fontan.

what paralytic do you use?

 

[WholeLottaGame7]

I'm pretty sure the "pre-Glenn/Fontan checks" are just a way for the interventional cardiologists to rack up some more $$. It's like what's the alternative, not doing the surgery?

Yes. Had one a few months ago, very sad. Came from another children's hospital who declined surgery after seeing the cath report. We repeated it just to be sure, also declined. You don't HAVE to perform an operation if it's not going to help anything...

 

[Noyac]

There is a lot of misunderstanding about the drug, namely with regard to the hallucinogenic effects. These are effects that are generally seen in the sedation range of dosing, not in the analgesic or anesthetic dosing ranges.

In my experience the analgesic and anesthetic doses are quite different. Analgesic doses Re usually lower than even sedative doses while anesthetic doses are huge.
I also believe that the "bad" experiences come from anesthetic doses, not the smaller analgesic or even sedative doses.

In my opinion, ketamine is mostly just an adjunct drug. Not something I use solely. But I would if I were doing the type of cases Hudsontc is doing.

 

[Ezekiel2517]

I see patients with hallucinations on low analgesic doses of ketamine all the time. Even the chronic pain patients

 

[Steege305]

I see patients with hallucinations on low analgesic doses of ketamine all the time. Even the chronic pain patients

Yuuup. I dropped someone off in the PACU a few weeks ago and I could tell he was seeing and hearing things that I wasn't. He seemed cool with it, so I just let it ride.

 

[pjl]

In my experience the analgesic and anesthetic doses are quite different. Analgesic doses Re usually lower than even sedative doses while anesthetic doses are huge.
I also believe that the "bad" experiences come from anesthetic doses, not the smaller analgesic or even sedative doses.

In my opinion, ketamine is mostly just an adjunct drug. Not something I use solely. But I would if I were doing the type of cases Hudsontc is doing.

I use a lot of ketamine, it is a great, cheap drug. Hallucinations are mild below 0.25mg/kg from my patient population, most just say their eyesight is fuzzy or bright.

Most patients on chronic narcs get a dose initially (0.5/kg) then hourly during case(0.05/kg).
PACU patients get doses if they are having a hard time getting pain scores down with reasonable narc doses (10 mg). A single dose helps most people. It is around dose #3 that the hallucinations creep in, so I normally stop at 20 mg while they are awake.

Lowest dose I ever saw a patient get hallucinations from was 10 mg. She was a normal 22 year old, and looked a bit nervous after a dose, and asked me if her face was on fire. when I calmly explained that it wasn't, but that it was a side effect of the medicine to see things that weren't real, she was ok with that. I had to keep reassuring her for the next 10 minutes or so. Made me respect both the power of ketamine, and the power of using a calming voice. One of the stranger interactions I have had with a patient.

Another odd one was with a young teen girl who decided that the ceiling tiles were moving, due to spiders that had made nests in them. A calm voice was markedly less helpful for her. The hallucinations do need to be respected.


We looked into doing infusions for depression, and it sounded slightly promising. However it seemed like a bit of a pain, and you delve into a realm of medicine that I personally dislike. Profits were very good if you did it right.


Sent from my iPad using SDN mobile app

 

[Ezekiel2517]

Over the past couple years I've personally seen several patients get hallucinations from infusions as low as 5 mg/hr. Not in the pacu, but even just several hours after they've left the pacu. Just a few days ago , got called by RN saying patient wanted the ketamine stopped bc he was hallucinating seeing weird creatures. Was a chronic pain pt and was just on 10 mg an hr for a couple of hours .

 

[deleted9493]

In my experience the analgesic and anesthetic doses are quite different. Analgesic doses Re usually lower than even sedative doses while anesthetic doses are huge.
I also believe that the "bad" experiences come from anesthetic doses, not the smaller analgesic or even sedative doses.

In my opinion, ketamine is mostly just an adjunct drug. Not something I use solely. But I would if I were doing the type of cases Hudsontc is doing.

I haven't seen patients emerge with bad "trips" on anesthetic level of dosing, though I'm sure it is only a matter of time.

 

[deleted9493]

what paralytic do you use?

Rocuronium...that's what we stock our carts with.