Ketamine only, no narcs allowed

Discussion in 'Anesthesiology' started by trinityalumnus, May 8, 2008.

  1. Monty Python

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    Just wanted to see what others had to say about this.

    A particular neurosurgeon at my hospital now does only pain-related procedures. Lum-lams, cervical fusions, intradiscal electrothermy (percutaneous), etc.

    His standing "orders" to anesthesia:

    versed
    decadron
    toradol
    zofran
    diprivan
    sux
    volatile

    so far, so good

    .
    .
    .
    .
    .
    .

    absolutely no narcotics of any kind
    no paralysis - pt will breath spontaneously throughout the procedure
    ketamine 0.4 mg/kg q 30 minutes, max three doses.

    What's interesting is that 99.9% of his pts do quite well, are easily extubated within 2-3 minutes of the dressing going on, and are very comfortable in PACU. His cases rarely go longer than two hours.

    Occasionally I wonder why all pts aren't done this way?
     
  2. powermd

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    No narcotics for lumbar lamis and cervical fusions???
    I wake these guys up with a bare minimum 1.2 mg dilaudid. When do you give the ketamine, after extubation, or intraop?

     
  3. Monty Python

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    The pts get 0.4 mg/kg ketamine on induction, then repeated at 30 minutes and 60 minutes later. No more after that. He injects a lot of marcaine at the end.
     
  4. Arch Guillotti

    Arch Guillotti Senior Member
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    "Orders?"

    I don't think I would like it too much, regardless of how well it works.

    I would like to see him give those "orders" to MMD.
     
  5. Monty Python

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    Agreed, but ..... these are all cash-paying patients, no insurance paperwork. The hospital and all its minions kowtow to this particular surgeon since his patients are cash cows. The hospital just spent an absolute fortune buying a new, top of the line, Zeiss operating microscope for him.
     
  6. ear-ache

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    He might as well bill for the anesthesia portion of the case... :rolleyes:
     
  7. Arch Guillotti

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    Understood.
     
  8. dfk

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    not that i've done many lum-lams with patient breathing spontaneously (at least until i'm ready to flip in about 10 minutes), but is the patient SV for majority of procedure? what does help is the 2hr surgery time. i can't imagine that working for the 5 to 8 hour lum-lam. good to know though..
    oh, and how often/much is the prop going?
     
  9. Monty Python

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    The pts breathe spontaneously throughout the case once the sux wears off.

    The pts get ketamine 0.4 mg/kg plus titrated diprivan for induction (about 100-150 mg average), then sevo for maintenance along with the q 30 min rebolus of ketamine.
     
  10. urge

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    If it works and he doesn't care if they move, fine by me. Ketamine is a good analgesic.

    Anyone cares to elaborate on the reason he doesn't want narcotics?
     
  11. proman

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    Maybe his patients are chronic opioid users and the IV stuff is barely worth trying. I've found that ketamine works well particularly with the methadone patients. Plus, I bet his blood loss is insignificant. And, you have better V/Q matching prone than supine so the spontaneous ventilation shouldn't be a problem. I doubt the patients move since they're getting volatile anesthetic + ketamine. I think we paralyze too many patients.
     
  12. Bougie

    Bougie Junior Member
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    Interesting post; ketamine is a very underutilized med in my arsenal since I'm a resident and it's scary to most attendings. I had an attending tell me ketamine should only be used in third world countries. :eek:

    How much Versed up front? Any freak-outs in the PACU? How soon can you get these people out of the PACU?

    Also, please tell me such "standing (nursing?) orders" are rare in the real world.
     
  13. urge

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    Just FYI for the residents, there are places where lumbar lamis are done under spinal anesthesia. Pt prone breathing spontaneously with a couple of versed on board. They do ok too.
     
  14. Noyac

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    Trin, are you guys doing MEP's and SSEP's?

    We do them for all cervicals.

    The other procedures you mention are very minor and narcs are not needed. Ketamine is ideal since these pts are narc tolerant.

    I give a lot of special K in the spine room. Pts occasionally wake up a little spaced out but they recover quickly.
     
  15. Jeff05

    Jeff05 Senior Member
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    i'm working on IT, but i'm still offended at the idea of a surgeon dictating anesthetics to an anesthesiologist.

    i would never peek over the curtain and matter-of-factly suggest they go with the 3.0 nylon, or blunt dissect that sh1t over there...

    i think sugeons offering their opinions on matters of blood transfusion, extubation, drugs, etc is somewhat unprofessional on their part - we are the SPECIALIST consultants in the room, and they still think they know better.

    we have an ortho surgeon at our hospital that starts putting on gloves to take over placing the spinal if a resident misses the first time - WITH THE ANESTHESIA ATTENDING STANDING RIGHT THERE....that's so f()cking disrespectful. it's like an anesthesia attending scrubbing in and helping his slow a$$ residents close.


    for me, this is one of the worst parts of the field - a select, but significant group of surgeons that think you either do nothing, or that they can do what you do, or they know better. but i'm learning how to deal with it, as the problem is NOT going away.
     
  16. Planktonmd

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    A surgeon who has "standing orders" on how to give anesthesia is a deal breaker for me, I wouldn't touch his patients.
    The technique of giving GA without narcotics is not a new idea, many cases can be done successfully without narcotics especially if you are incorporating Ketamine.
     
  17. Noyac

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  18. Tenesma

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    i agree with requests for non-narcotic management -- i disagree with "orders"...

    any surgeon "order" can be given by the RN either in the holding area and/or in the PACU ...

    ketamine is great... under-utilized
     
  19. drccw

    drccw ASA Member
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    ketamine is a fun drug....

    on the issue of surgeon's orders/// let's face it, yes we are specialists but our specailty wouldnt exist without the surgeons... so if they have requests I do my best to accomodate them unless they are totally ******ed.. as some are....

    part of a good working relationship with a surgeon is to make there life easier... let's face it... use we are smart and awesome but in the end our job is to serve the surgeon and the patient... and if the patient isnt going to get hurt then I am ok with most things....

    i have a knee surgeon who protocols his anesthesia for TKA. Spinal, duramorph. He preaches these to any anesthesiologist who works with him and to his patients. His patients expect it because he has coached them thoroughly... i dont have to talk to them about the anesthetic. of coruse if a patient isnt appropriate for duramorph or a spinal he will defer to our judgement. When i first started working with him I talked to him about fem blocks and he was relucatant. Last week- GA'ed one of the TKA because they had some hardware in their back and I just didnt feel like dinking around for a while trying a spinal- asked he if I could do a fem block and he said yes... and was quite happy.... so yeah he had his protocol but he was willing to bend a bit....

    out in the real world a happy surgeon makes the day go smoothly... I like smooth days.
     
  20. Planktonmd

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    You are right about making the surgeons happy and doing whatever anesthetic technique they think is better as long as it won't hurt the patient.
    But, standing orders for specific medications to be used to induce and maintain GA is not acceptable and very humiliating.
    Executing protocols written by surgeons is not why you went to medical school and residency.
     
  21. Noyac

    Noyac ASA Member
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    If protocols are to be used then why do we need Dr's?
     
  22. loveumms

    loveumms Senior Member
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    I kinda feel like orders from a surgeon are demeaning. If they make suggestions - "I like ketamine for my cases b/c X,Y and Z" then thats fine. But, saying this is the only way I want my pts to undergoe anesthesia - thats crazy! What about a patients who are not candidates for ketamine? I agree that it's a great drug and is totally under utilized. We have an attending who will literally slip everyone ketamine. I would turn my back and he would be giving my pt ketamine - sometimes (and this is scary), he wouldn't even let me know he gave it. Anywho, I think it's great idea but, don't appreciate a surgeon dictating my anesthetic.

    We had a surgeon tell us that he wanted us to "put the pt back down" so he could do something at the end of the case (after he told us that he was done). After 2 seconds he got upset b/c it wasn't occuring immediately. He said, "just give him some propofol". Even though I had already done this, I felt like saying - and how much should I give him sir since you know anesthesia so well. I can pretty much guarantee he wouldn't have known the answer to that one.
     
  23. Monty Python

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    Generally they get 2 mg versed in holding, and I work in another 3 mg by the end of the case. We've had the rare pt in PACU with the 1,000 yard stare but very very infrequently, probably because we max out at 1.2 mg/kg of ketamine.

    They're discharged from PACU on the same criteria as other pts, and generally follow the same timelines.
     
  24. Monty Python

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    This neurosurgeon is a believer in NMDA antagonism.
     
  25. Monty Python

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    SSEPs only with the orthopods doing spinal hardware.
     
  26. Noyac

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    No motors for cervical fusions? Really!

    We do a lot of neuromonitoring and this is where I find ketamine beneficial, along with all the NMDA stuff as well.
     
  27. Pilot Doc

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    So I don't mean this to be incendiary ... though I feel it may be taken that way

    Is there a difference b/w a surgeon requesting/dictating anesthesia plan to a CRNA vs MD.
     
  28. Noyac

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    I wasn't going to bring that up but I suspect that there is some of that at play.
     
  29. Monty Python

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    This neurosurgeon's "orders" (or, how about this: "do it my way or I'm taking my cases down the road to JPP's hospital") are followed to the letter by both CRNAs and anesthesiologists. About 75% of the time a CRNA sits on that stool, but 25% of the time (give or take) an anesthesiologist will sit that stool. Our CRNA and doc staffing seems to be a constantly evolving work in progress and sort-of resembles Forrest Gump's box of chocolates.

    More generally (and this can vary from state to state, based on specific wording in the nurse practice act) this neurosurgeon would be assuming a boatload of liability for giving specific "orders" if no anesthesiogists were on duty. Instead of merely "supervising" he would be "directing." That can also (I think) impact on the billing status.
     
  30. Planktonmd

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    Agree.
     
  31. Planktonmd

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    Trinity,
    When you do an anesthetic does an anesthesiologist sign the record and discuss the plan with you?
     
  32. Monty Python

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    I've had two major employers during my career: one private practice setting (with JPP) and one state-wide university/charity system (on several different campuses). In addition, I've been active throughout my career in the military reserve, and have given anesthesia in just about every possible military setting.

    At the private practice setting the floater CRNA would initially see the pt pre-op and would complete the majority of the assessment form. Then an anesthesiologist would see the pt, discuss and finalize the anesthetic plan, and would sign the assessment indicating the plan. The case CRNA would take his cues from that.

    At one branch university hospital it wasn't uncommon for me to never see an anesthesiologist as a matter of routine. The CRNAs literally did everything. (This isn't meant disrespectfully - just statement of fact). The anesthesiologist might be in the ICU socializing or putting in a line, hob-knobbing in the CEO's office, leaving at noon for their gig at the VA, etc. The charts would be signed after-the-fact in the medical records file room. And after 1500 the anesthesiologist would be home or in bed, while I or another CRNA did everything completely solo. The anesthesiologist was only in-house 0700-1500 Monday-Thursday.

    At my current university hospital the anesthesiogists are much more visible and do the pre-op assessment, consent, and choose the type of anesthetic (except with this neurosurgeon with the ketamine). Our holding room set-up, paperwork, and room turnover procedures are so chaotic that there's no opportunity for a true discussion between CRNA and anesthesiologist. I might not even see an anesthesiologist before the case -- just the pre-op taped to the front of the chart.

    On a MAC case they might come by the OR at some point to sign the chart, if at all. I've taken many a MAC pt to the PACU with the chart still unsigned. And these are ASA 4E ESRD dialysis de-clots, stage 4 decubitus, cardiac cripples, AICD implantations, TEE/cardioversions, sick as s**t EGDs, etc. On a general case they'll usually be present on induction (after I call into the office), will sign the chart, then depart. Some are more active at rounding in the ORs periodically than are others. Some you never see again.

    In the military it just depends on the setting. At Bethesda I obviously had attendings who were present and involved. On the aircraft carrier I was the entire anesthesia department. At smaller military hospitals there might be one anesthesiologist as department head, but I rarely saw them in the OR doing their own room or supervising mine.

    My ships:

    USS George Washington: http://navysite.de/cvn/cvn73.html

    USNS Comfort: http://www.comfort.navy.mil/
     
  33. coprolalia

    coprolalia Bored Certified
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    If the surgeon does a lami right (with a lot of local in the incision), you don't need narcs.

    I don't see this as that big of a deal. Hell, you don't even really need the ketamine. And, Toradol works great. Also a WAY underutilized drug. If we only had IV acetaminophen like they do in Europe...

    -copro
     
  34. RabbMD

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    Ketamine is a great drug... However, I would Never give NO narcotics to a lot of the laminectomy patients that come in to my OR that are admitting to taking 10 percocets a day and probably taking 20. I give Narcs in these cases just to establish their baseline (diladid usually because of higher receptor affinity ect). They always seem to not have taken their morning usual dose of percs as well.
     
  35. jetproppilot

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    I'm over the turf battles.

    If it works, I'll do it.

    Hell, with that kinda payer-mix, I'll go get the dude's lunch if he wants me to.

    Somebody else said it already....happy surgeon equals nice day.

    Happy surgeon with patients that pay with C-notes? Wait....I'll get him lunch AND pull his 911 up to the lobby when he's done. :laugh:
     
  36. jetproppilot

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    I respect your feelings on this subject.

    Keep in mind, though, we are not the only specialty that takes "orders" from a referring doctor.

    Successful heart surgeons rarely say no to their referring cardiologists. If the cardiologist wants the CABG done on Friday afternoon, most heart surgeons don't argue.

    Same with general surgeons who have cash-cow-referring-primary care-docs.

    Yeah, the neurosurgeons tact is lacking, but Trin says it works.

    I'll battle when necessary....which is usually once or twice a year. This isnt something I'd battle. When you examine the adverse responses to this guy's "requests" (albeit without tact), its all ego driven, wouldnt ya say? I understand that, too. Ten years ago it probably wouldve offended me.

    I've accepted the give and take of our specialty.

    I'd keep it low, say OK, (since...uhhhh...it works) and add more zeros to my fu$k you account.
     
  37. Planktonmd

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    I disagree,
    Your role as an anesthesiologist is to select the appropriate anesthetic for the patient and the surgeon, this is your main job, and this is why you are paid the big bucks.
    If the surgeon has specific suggestions related to the details of the anesthetic you should take them into consideration and do your best to accommodate him as long as the plan seems reasonable to you, but the moment you sign that record the plan becomes your's not his, and you are the one who will be liable if anything goes wrong.
    So, it's perfectly OK to do what the surgeon asks you to do as long as you feel that his way is something that you agree with based on your knowledge and training, but it can't be "standing orders" because you still have to ask yourself the question every time: Is this appropriate for this specific patient? and proceed only if the answer is yes.
    Now, If you are a CRNA then it's different because you approach things differently and your role is different.
    Is this logic "Ego Driven?" I don't think so.
     
  38. jetproppilot

    jetproppilot Turboprop Driver
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    :lol::lol:
     
  39. Planktonmd

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    :confused:
    Was my statement really funny?
     
  40. mille125

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    very interesting post trinity..


    what happens if ketamine is contraindicated in a particular patient? What is the plan then? As you know ketamine has many contraindications. If he does enough of these cases he will eventually get a patient in whom you cannot use ketamine.


    I think that his standing orders show blatant disrespect for the specialty. If he has a technique that works, he should simply talk to the anesthesia attendings. It could go something like this, "Dr. Anesthesiologist...in my experience I have found that many of my patients benefit from NMDA antagonism. Please consider ketamine when indicated clinically. Thank you."


    I would be much more likely to follow his wishes and at the end of the day he would win my respect.


    This reminds me when I was a resident in the neurosurgery room. We had a very arrogant but very very technically good neurosurgeon. He was usually right about most things and is obviously very smart. However, on this particular day he was on the wrong side of an argument with me and later my attending. He retorted near the end of the case, " You guys should remember that the patients come to this prestigious hospital to see me not you." What an SOB...
     
  41. mille125

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    very smart words......if you administer ketamine or any other drug on his list and an adverse effect occurs, you better believe that the surgeon is going to distance himself from you as fast as possible......
     
  42. dhb

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    :confused: which ones?
     
  43. mille125

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    this information is available in any anesthesiology text. if you are practicing and dont know this then I am scared for your patients...

    just off the top of my head..
    Contraindications to ketamine (most are relative)
    1) Hypertension (systemic and pulmonary)
    2) Increased ICP
    3) Cardiac Ischemia
    4) Severe preeclampsia
    5) Hyperthyroidism (releases thyroid hormone)
    6) Eye (open eye injury) and neurosurgery (brain surgery) in general
    7) Any cardiac condition or pulmonary condition were increased PAP would be detrimental
    8) Vascular aneurysms
    9) Schizophrenia
    10) Those at high risk of postop delirium...
     
  44. Idiopathic

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    On a related note, how do you deal with the surgeon who wants you to give 30mg/kg solumedrol when the SSEPs go out on a C3-C4 laminectomy?

    I mean, its fairly well established that there is no benefit and definite harm with high dose steroids...how do you react to this 'order', especially if you are a resident?
     
  45. dhb

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    :rolleyes: come down from your ivory tower once in a while
     
  46. mille125

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    lol
     
  47. urge

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    I have never seen meaningful BP changes (more than 5mmHg) after ketamine. If needed, I would give it in any of the above scenarios without hesitation.
     
  48. dhb

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    exactly :thumbup:
     
  49. SleepIsGood

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    The neurosurgeon at my institution uses DSSEP's not the SSEP etc. He claims that this is the 'best' and is going to become the gold standard. Anyone else's neurosx use DSSEPs?
     

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