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ketamine/versed->propofol

Discussion in 'Emergency Medicine' started by roja, May 26, 2008.

  1. roja

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    So, we almost never have patients that recieve propofol in the ED. Its gas limited other than post intubation management.


    Tonight, we had a really bad posterior shoulder dislocation with a wierd fracture. Ortho resident wanted it to go to the OR but because it was the weekend, several attendings told him: get gas and give propofol after aspirating the 'clot'.

    So, we get gas (we haven't given the guy anything as well know in this 270 lb big guy, that ketamine/versed or fentanyl/versed is just not going to cut it).

    They give ketamine/versed which doesn't work, the guy is hopping around and screaming. Then they give propofol (about 5 minutes after the ketamine/versed). Guy stops breathing, sat drops to 85% but he is bagged through. Not such a big deal for us but the gas attending is cussing a storm about case needing to be in the OR, intubation ,etc. Know, to some degree, we all agree. but it wasn't possible.


    So, anyone with experience with propofol immediately on top of ketamine/versed?
     
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  3. NinerNiner999

    NinerNiner999 Senior Member
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    Actually, I have mixed Ketamine and Propofol together and it is pretty effective (I've even put them in the same drip). My guess is the versed never adequately cleared systemically and the propofol sedated just enough for the respiratory depression of the benzo to take control...
     
  4. GeneralVeers

    GeneralVeers Globus Hystericus
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    It was the propofol that stopped the guy breathing. Nice thing about it is that you turn it off and within 1-2 minutes the patient is usually awake and breathing again.

    Why not just use Etomidate? I've never had an issue startingo ut with 10mg initial dose.
     
  5. docB

    docB Chronically painful
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    I used to use etomidate exclusively. I had problems from time to time with the myoclonus that happens but other than that no big issues. We've moved away from etomidate in favor of propofol and I have grown to really like it. Etomidate is supposed to be much more of an induction agent than a sedative although the same can be said of propofol. Etomidate also is supposed to cause serious adrenal suppression if it's redosed. I occasionally need more time and I really like how you can just keep tham down as long as you need with propofol as opposed to adding in benzos at the end or redosing etomidate.
     
  6. BatmanMD

    BatmanMD Senior Member
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  7. psychbender

    psychbender Cynical Member
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    January 2007 issue of Annals of Emergency Medicine; "A Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the Emergency Department"

    Link will work only for those with a subsciption to Annals
    http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS019606440602004X.pdf
     
  8. Jeff698

    Jeff698 EM/EMS nerd
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    How do you mix and dose ketafol? I read that article but it uses different concentrations than we have available.

    I've been a heavy user of propofol for procedures for the past three years. We use it all the time and have great luck with it but we have one physician dedicated to pushing drug/managing the airway and another to the procedure.

    I'm going single coverage in July and the hands off benefits of ketamine appeal to me.

    Anyone have any suggestions on dosing with this combo? How about redosing?

    Thanks and take care,
    Jeff
     
  9. BADMD

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    I've found that the myoclonus is rate dependent. I have my nurses slow down the push and patients rarely shimmy and shake.

    I have found that etomidate is great agent for converting vtach. I had one patient with vtach that converted before I shocked him, right after he got the etomidate push. There was a second case, a few weeks before mine, where the exact same thing happened as well.

    As for the propofol, I'm afraid of inducing general anesthesia and needing to ventilate my patient. I just don't have enough experience using it to really be certain that I won't need to control ventilation. Fortunately, I usually only need procedural sedation for procedures that can be performed under the timeframe that etomidate provides. I'm know that the gas passers don't like etomidate for this purpose, but then maybe they should help us out with using other agents....
     
  10. Apollyon

    Apollyon Screw the GST
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    Get ready for the invasion - someone linked to this thread in the anesthesia forum. There's some very reasonable people in there (mmd, jet, noyac, venty), but there's also some dogmatic types, and I believe that those in the second group are the ones who are going to bark.
     
  11. BADMD

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    I hope anyone who fusses will have something useful to add and not just say "Get an anesthesiologist." 'Cause my hospital isn't going to do that.
     
  12. EctopicFetus

    EctopicFetus Keeping it funky enough
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    I used ketafol a number of times with great success. Used it last night actually. I tend to mix it in a 1:1 ratio and usually give between 0.6 -0.7 mg/kg of each, redose of about 0.2 mg/kg.

    Silky smooth. The advantage is that you use lower doses of each with less respiratory issues.
     
  13. dchristismi

    dchristismi Gin and Tonic
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    I will have to go read that article...

    I prefer propofol, especially for those very painful orthopedic procedures. Easy to titrate, (I do it manually, so when they start to resist, another 0.5 mg/kg usually takes them back down), wears off quickly, and we always have 2 docs at bedside, plus RT and capnography. I have used ketamine in adults with good results, although what the patient decides to do during the procedure is anyone's guess. (I had a lady sing the Star Spangled Banner at the top of her lungs once.) I do like ketamine in kids, but will have to read the article. I'm going to a double-covered place, but like to keep my options open.

    I think that if I needed a steinman pin, I would want propofol. I try to extend that courtesy to my patients when possible.
     
  14. docB

    docB Chronically painful
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    Interesting. I've found propofol to be effective for DTs. I've had several patients with refractory DTs who I've intubated in preparation for starting a benzo drip and while waiting for the drip to come from pharmacy I've started propofol. It has actually stabilized the seizures, BP and tachycardia on its own.
     
  15. BADMD

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    There is some literature that supports this. Propofol seems to work fairly well for DTs. One of the neuro guys I work with thinks that propofol is a double edged sword when it comes to seizures (I can't for the life of me recall the evidence -- he did an update for our Grand Rounds on contemporary seizure management.) The NMDA antagonism of propofol seems to be quite effective for refractory seizures and the benzo agonist portion works well for the earlier phase of seizures.
     
  16. bartleby

    bartleby Senior Member
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    Propofol, when treated with respect, is nearly impossible to beat for brief, painful procedures. You shouldn't be using it if you aren't prepared to mask ventilate or, failing that, insert an LMA to bag the patient through until the effect passes. People wake up quickly with a smile on their face and are asking to be discharged by the time they come back from their post reduction films. I wouldn't work anyplace I couldn't use it..
     
  17. bulgethetwine

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    I don't care if they do bark. It ain't gonna change what I'm doing.

    And to think that jetprop is one of the 'reasonable ones' is just ridiculous.
     
  18. drewpydog

    drewpydog Member
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    When I started my job a year ago, I said, "I want propofol and an ultrasound machine." Neither of which I have gotten. I've learned to live without them - I use etomidate frequently, ketamine for all the pediatrics, and enough fentanyl/versed to be comfortable with it. I still lust after an ultrasound, though.
     
  19. n2b8me

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    Where I trained we did not have propofol so I did not have any experience. Now I have been using it for 5 years with pretty good results. Mostly for shoulder and hip dislocations, usually with only myself, the RN and sometimes an RT. I usually dose in 20mg boluses every 15-20 seconds. The most I need is usually about 100-150mg in average sized adults. Occasionally I use for I&Ds for difficult patients. I prefer etomidate when intubating 20mg IVP.
    I used to use etomidate exclusively for procedural sedation: 10mg IVP, but looking back, it had more unpredictable results: some people going deeper than others, and lasting longer than propofol.
     
  20. leviathan

    leviathan Drinking from the hydrant
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  21. Apollyon

    Apollyon Screw the GST
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    He's always, always been a stand-up guy whenever I've seen. And he treats other people with respect. His sarcasm is lost on some folks, sometimes, though.
     
  22. roja

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    I couldn't find where they linked to our thread but oh well. It was gas who gave the meds. I haven't really seen it used much.

    I wasn't to wigged out about the not breathing either. The guy hadn't eaten in over 6 hours, was easily baggable and we all knew that the propofol wouldn't stick around long. I was a little startled that the gas attending was freaking out.

    There are some very reasonable guys over in anesthesia forum. they recognize the reality of concious sedation and volume.
     
  23. Egon

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    ... could have reversed the benzo with flumazenil if it was still on board and the pt may have started breathing again.

    I have to review our procedural sedations and we did over 100 last year with propofol without any complications. Our protocol is that we do ASA I and II cases, anything ASA III only if emergent, like a cardioversion. Otherwise anesthesia is supposed to do the ASA III cases. Just make sure to titrate the dose up as needed and not start too high it can really decrease cardiac output, but this is mainly in the pt with comorbidities.

    We use ketafol a bit as well, but the sedation will last longer.

    Using fentanyl with the etomidate will help prevent myoclonus...
     
  24. roja

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    I have to confess a nervousness about flumazenil. It was so dogmatically taught that this could throw someone into 'withdrawal' if they were an 'unknown' addict.

    Does anyone have any good literature on the incidence of 'withdrawal' when flumazenil is given?
     
  25. Apollyon

    Apollyon Screw the GST
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    My mentor in residency told me that, when he was a resident, he saw it used in a kid, and this kid seized and died. That's enough for me.

    I share your trepidation.
     
  26. wook

    wook Just a hairy situation
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    Interesting article from Anesth Analg 2005; 101(3):705-9 titled, "Magnesium sulfate pretreatment reduces myoclonus after etomidate." It talks about pre-treatment with magnesium for anesthesia. It was a study comprised of 77 patients with a magnesium (2.48 mmol or 6.0246 mg if I did the math correctly), ketamine (0.5 mg/kg), ketamine (0.2 mg/kg), and control group. They found that 76% of the magnesium group did NOT develop myoclonic movements vs 28% of the ketamine 0.5 mg/kg vs 36% of the ketamine 0.2 mg/kg vs 28% of control who did NOT develop myoclonus (P < 0.05). They concluded that 2.48 mmol administered 90 seconds before induction was effective in reducing etomidate induced myclonus while ketamine does not.

    I've used magnesium (500 mg) before induction and procedural sedation since reading this and have seen a substantial drop in the myoclonus. My numbers aren't large enough to be a study, but it is interesting.



    Wook
     
  27. docB

    docB Chronically painful
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    Seems cool but it might necessitate checking a Mg before the procedure. I don't usually check any labs routinely before procedural sedation and it would slow me down to do so.
     
  28. gutonc

    gutonc No Meat, No Treat
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    Actually, his conversion isn't quite right, 2.48 mmol of MgSO4*Heptahydrate which is the injectable form works out to around 600mg of Mg.

    The likelihood that someone w/o renal failure would become Mg toxic w/ a single dose of <1g of Mg seems small to me. The bolus dose for prevention of seizures in pre-eclampsia is 4-6g and then they tack on another 1-2g/h up to something insane like 18-20g.

    Of course, then you have to trust the patient when they tell you that they don't have renal failure and since most patients are either liars or idiots that may not be a risk you want to take.
     
  29. docB

    docB Chronically painful
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    Although I do give my alcoholics a gram of mag without checking so I imagine I could do it for the sedation patients. I still won't go back to etomidate over propofol though.
     
  30. roja

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    But I hate using 'that one time' to justify my own nervousness.

    :scared::D
     
  31. BADMD

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    I did a mini lit review on this topic when I was looking at the evidence for a commercial methamphetamine treatment system.

    What I found was really mixed. Patient selection seems to be the best way to minimize seizures and status epileptics. All the studies are small and had very different inclusion and exclusion. Here are a selection and not meant to be comprehensive.

    Gueye, AEM, 1996 27(6) - N=35. Divided into Group A and B. A - Likely BZD overdose only, n=4. All awoke, no adverse events. B- everyone else. 9 showed improvement. 22 didn't. 5 had seizueres.

    Ritz, Intensive Care Medicine, 1990, 16(4) - N=23. RCT, 13 given flumazenil. 6 of 13 improved. 10 of 10 did not. No adverse events.

    Hojer, BMJ 1990 8,301(6764) - N=105, RCT. No seizures. About 2/3 of patients had a UDS + for BZDs.

    Pediatric Emergency Care 2006 22(3) - Case series. 3 kids intubated for status epilepticus. Flumazenil was used to facilitate extubation. All 3 returned to SE.

    These are basically representative of what I found: Small trials that showed a few seizures or no seizures, larger trials with more careful selection showing no seizures, and horror story case reports that, in retrospect, suggest questionable decision making based on known risk factors for post flumazenil seizures.

    Spivey has done the most work on IDing risk factors. In 2 papers published in 1992 and 1993 respectively, he documents what he believes to be risk factors for seizures post flumazenil: multiple IV benzos, benzos for seizures, proconvulsant co-ingestion, major sedative-hypnotic withdrawal, or myoclonic jerking.

    Basically, anyone with a history of seizures or taking a proconvulsant drug (TCA, antipsychotic, multiple other) should definitely not get flumazenil. When it comes to someone with an isolated benzo overdose or benzo abuse, I don't think the evidence is that clear. There is even a small body of literature using flumazenil as a mixed agonist-antagonist for the treatment of benzo or alcohol withdrawal (Saxon 1997, Gerra 2002).

    So, take it for what it is worth...
     
    #30 BADMD, Jun 2, 2008
    Last edited: Jun 2, 2008
  32. roja

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    THANKS! you rock
     
  33. Apollyon

    Apollyon Screw the GST
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    And therein lies the rub - the "emergence phenomenon" - terrifying to regular folks - is exactly what the people who abuse "Vitamin K" seek.

    Yep.
     
  34. emergiQ

    emergiQ Killer Whale Trainer
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    I think etomidate is a great drug when you are (near) certain you won't need multiple doses. I would have avoided it in this monster for exactly that reason. I don't want to debate etomidate and adrenal insufficiency (real/not real, does it happen with even a single dose, blah blah blah) but I think avoiding re-dosing of etomidate is a reasonable compromise with the dogmatic among us.

    Not sure I'd assume he stopped breathing just from the prop. I use it pretty regularly in the ICU and the ED and hardly ever do I have apnea. Perhaps very transient hypopnea, but nothing serious. I bolus with an initial 20 to 40 mg (2-4cc) depending on size of the patient, then titrate a cc or two at a time for the duration of the need.

    I'd say it is at least equally likely that it was the slow leeching onset of the benzo, and truth in the universe is probably that it was the additive effect -- polypharmacy -- of all the agents used (not that polypharmacy could be avoided - what is one supposed to do when the first choice fails!?).

    Huh. Just realized I responded to a years-old thread. Oh well (shrug). Still my current usage of propofol.
     

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