Ketamine

[markneil]

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Hey guys,

In residency I never really used much Ketamine (I vaguely remember using it in long pediatric scoli spine cases but not much else for some reason...and one attending mixing it with propofol to make ketofol), and having been in private practice for more than 5 years I have rarely touched it as well. What settings do you guys use ketamine? Maybe I'm missing out. I have taken over rooms with my partners who have bolused it after induction in spine cases but haven't really seen much of a difference in pain postoperatively. I have read some stuff on low dose ketamine to decrease opioid consumption postop as well. Never had really use it in endoscopy, ortho cases, bowel cases. Anyways, maybe i'll spend the rest of my career never really using it but I would love to hear what you guys think. Is it a game changer in some cases you've done?

 

[PainDrain]

Ketamine is a very valuable medication in the correct setting. Great for awake intubations. Excellent pain adjunct in long TIVA spine cases. Shown to prevent opioid-induced hyperalgesia. Great for C-sections where the OB can’t seem to get a section done in under 3 hours and the spinal is wearing off.

Where I use it with caution is patients in shock states. Contrary to some teaching it is a cardiac depressant and will unmask hypovolemia and shock when used for induction (think catecholamine depletion).

 

[MirrorTodd]

Primarily with the chronic pain pt coming in for yet another spine surgery.

 

[GassYous]

I like to give it for the crazies when I don't like the pacu nurses

 

[Anestheezee]

Necessary in some severely autistic patients as IM injection, usually pediatric autistic combative patients needing dental restorations.

 

[usma05]

1. Awake fibers along w/ precedex and glyco and good topicaliztion
2. Multimodal pain mgmt in extremely painful postop cases or chronic pain pts in doses < 0.5mg/kg usually
3. Supplementation to prop infusion if I am worried the infusion dose needed is gonna cause respiratory depression.
4. Premed in peds pts who are > 40kg, need more for whatever reason, or can't do PO premed.

 

[Sriddymopboi]

Necessary in some severely autistic patients as IM injection, usually pediatric autistic combative patients needing dental restorations.

As a non pediatric anesthesiologist, this sounds non-ideal. When do I get the IV? Would they cooperate while awake or would I get the IV after they laryngospasm during the mask induction from their secretions?

 

[Arch Guillotti]

As a non pediatric anesthesiologist, this sounds non-ideal. When do I get the IV? Would they cooperate while awake or would I get the IV after they laryngospasm during the mask induction from their secretions?

Do IM darts for dental cases pretty often.

 

[DocMcCoy]

I used to use it all the time. Now pretty much reserved for old frail kyphoplasties in combination with a little propofol.

 

[IkeBoy18]

Do IM darts for dental cases pretty often.

How do you dose?

 

[Sriddymopboi]

Do IM darts for dental cases pretty often.

Awake or asleep IVs?

 

[Radetzky]

Shocked patients. The “catecholamine” depletion is BS imo and comes from people not realising that all induction agents drop your blood pressure and giving a full dose rather than dose adjusting. When properly dose adjusted almost never run into problems

 

[nimbus]

Shocked patients. The “catecholamine” depletion is BS imo and comes from people not realising that all induction agents drop your blood pressure and giving a full dose rather than dose adjusting. When properly dose adjusted almost never run into problems

Also easy enough to start a catecholamine infusion prior to induction.

 

[T-burglar]

The k-hole is a pretty great effect as an adjunct to something else like propofol or gas when you want to do a case MAC or with an LMA but you don’t want the patient to move.

For some reason 25 mg of ketamine on top of a propofol infusion or some gas really keeps patients from reacting to the steel. More so than a similar small dose of fentanyl. I found this out somewhat accidentally experimenting as an early career attending out in private practice.

I would use it all the time for everyone if it didn’t occasionally cause dysphoric issues in PACU

 

[ucsfgaspain]

Ketofol FTW. Keep Ketamine in under 1 mg/kg and with a little versed and no weird pacu trips. Glyco up front. Sweet MACs then.

 

[coffeebythelake]

0.5 mg/kg bolus and then 10 mg hourly.
Not a huge dose. Helps reduce opioid requirements and doesn't significantly alter wakeup or pacu stay

 

[usma05]

As a non pediatric anesthesiologist, this sounds non-ideal. When do I get the IV? Would they cooperate while awake or would I get the IV after they laryngospasm during the mask induction from their secretions?

It's a common thing to do in this patient population and works well. Anecdotally don't see the secretions as often in these situations, but sure i guess it's a possibility. These kids are likely too big for an effective PO midaz dose or won't take PO Midaz. And it's no fun to wrestle them down with 5 or 6 people (and risk staff injury). If larngyospasm were to happen from secretions (and your ignoring the possibility of it occurring during a wildly combative inhalation induction with people holding them down) then we'd give IM sux unless contraindicated (and them IM nondepolarizer). - Peds Anes

 

[usma05]

Shocked patients. The “catecholamine” depletion is BS imo and comes from people not realising that all induction agents drop your blood pressure and giving a full dose rather than dose adjusting. When properly dose adjusted almost never run into problems

It's a myocardial depressant that masks that effect by sending out endogenous catecholamines until it can't. Recognizing it and reducing the dose is the right answer, but that doesn't change the underlying physiology.

Sometimes though (traumas, prolonged extrication, massive blood loss) any dose is going to off them even with preemptive pressors on board. We can at least agree there's magically thinking in the trauma bay that tends to algorithmic thinking instead of nuance when it comes to ketamine.

 

[Arch Guillotti]

As a non pediatric anesthesiologist, this sounds non-ideal. When do I get the IV? Would they cooperate while awake or would I get the IV after they laryngospasm during the mask induction from their secretions?

Assuming they will laryngospasm isn’t reasonable.

The only times I have seen serious secretions is when a full induction dose is given which I doubt any of us do.

Dart the kid, take them to the OR, mask them down, find an IV, control the airway. It really isn’t all that complicated.

 

[coffeebythelake]

I've ketamine darted a few patients before. Secretions wasn't really an issue.

 

[DocVapor]

I've mixed a vial of ketamine in with some sprite and let a large, young but violently-demented patient sip it down to chill him out before I went after him with an IV needle. Just needed to wait long enough. I was the hero that day because no staff got injured like had happened before with attempted IM darts.

 

[coffeebythelake]

I've mixed a vial of ketamine in with some sprite and let a large, young but violently-demented patient sip it down to chill him out before I went after him with an IV needle. Just needed to wait long enough. I was the hero that day because no staff got injured like had happened before with attempted IM darts.

2 hour wait?

 

[Radetzky]

It's a myocardial depressant that masks that effect by sending out endogenous catecholamines until it can't. Recognizing it and reducing the dose is the right answer, but that doesn't change the underlying physiology.

Sometimes though (traumas, prolonged extrication, massive blood loss) any dose is going to off them even with preemptive pressors on board. We can at least agree there's magically thinking in the trauma bay that tends to algorithmic thinking instead of nuance when it comes to ketamine.

Haha yes agree with the latter.

My issue is that there’s all these studies involving the use of high doses of ketamine, beta blockade and isolated heart muscle whose findings have made their way into textbooks. But they tell us what we all know: if you give someone an induction agent, no matter which, their stroke work falls. What these studies don’t tell me is the clinical magnitude and relevance of this when appropriate doses are chosen.

 

[GassYous]

I've mixed a vial of ketamine in with some sprite and let a large, young but violently-demented patient sip it down to chill him out before I went after him with an IV needle. Just needed to wait long enough. I was the hero that day because no staff got injured like had happened before with attempted IM darts.

Now I know what I'm doing this weekend

 

[Maverikk]

I've mixed a vial of ketamine in with some sprite and let a large, young but violently-demented patient sip it down to chill him out before I went after him with an IV needle. Just needed to wait long enough. I was the hero that day because no staff got injured like had happened before with attempted IM darts.

50mg? How long did it take? Did you test with Mt Dew for speed of onset?

 

[Arch Guillotti]

50mg? How long did it take? Did you test with Mt Dew for speed of onset?

I would give a large kid more than 50 mg.

 

[secants]

How exactly are you able to get close enough to IM ketamine these peds patients? If I'm afraid of getting hit with an IV, I'm sure an IM injection will cause the same reaction?

 

[Arch Guillotti]

How exactly are you able to get close enough to IM ketamine these peds patients? If I'm afraid of getting hit with an IV, I'm sure an IM injection will cause the same reaction?

Brute force.

 

[PlayToWin]

Ketamine is a very valuable medication in the correct setting. Great for awake intubations. Excellent pain adjunct in long TIVA spine cases. Shown to prevent opioid-induced hyperalgesia. Great for C-sections where the OB can’t seem to get a section done in under 3 hours and the spinal is wearing off.

Where I use it with caution is patients in shock states. Contrary to some teaching it is a cardiac depressant and will unmask hypovolemia and shock when used for induction (think catecholamine depletion).

I’m at the busiest trauma hospital in the US. I use ketamine exclusively for inducing trauma patients .
Other that I agree with your other points

 

[Anestheezee]

How exactly are you able to get close enough to IM ketamine these peds patients? If I'm afraid of getting hit with an IV, I'm sure an IM injection will cause the same reaction?

Have an RN or assistant "check their blood pressure" in the PACU bay while you stand on the other side. Have them "take a long time" fiddling with it in a very distracting way. When the kid turns towards that then dart the contralateral shoulder. Use a large needle. There is no time to be sympathetic with a little 25g thing because you need to get the entire injectate in before they can react because you'll need 4-5 mg/kg.

In residency I teamed up with an attending for a IM injection that was large volume for a large kid. We stood on either side of him, attending tapped him on the shoulder, kid turned, then I injected half the dose on the opposite shoulder. When the kid jumped and wheeled around to swat at me the attending injected the other half of the dose on his side.

What's worse than a combative sober autistic kid getting ready for surgery is a partially sedated one, so you gotta inject quick. Also, there's frequently no time to alcohol the skin or find a spot of exposed skin. Sometimes you just have to stab through their clothes. If you can't get their shoulder and things are getting out of hand then stabbing mid-thigh through clothes is an easy target too.

I've had a 175 kg 21y severely autistic combative patient needing a chole. He was lying on his side in bed perched on his right elbow playing with his tablet. I injected into his right trap from behind which worked perfectly, unable to defend or swat me away. He took 1000 mg ketamine (10 mL of 100 mg/mL with a 18 g needle into the trap). Barely got it in in time. He got mostly sedate but enough to mask him down the rest of the way.

I've also worked WITH the kids for the IM injection. If they seem reasonable enough, you can talk frankly with them and their parents in the preop room and tell them this is just like coming to the doctor's office for a flu shot.

Would love to hear any other strategies people have used, it's fun to get creative!

 

[GassYous]

How exactly are you able to get close enough to IM ketamine these peds patients? If I'm afraid of getting hit with an IV, I'm sure an IM injection will cause the same reaction?

Turn on the baby shark and then jab them in the arm when they're not looking

 

[DocVapor]

2 hour wait?

It truthfully was around 45 minutes

50mg? How long did it take? Did you test with Mt Dew for speed of onset?

It was a concentrated vial of 500mg/10ml. Guesstimate afterwards was he probably got about 250mg.

Sprite because that was his favorite drink and what he would reliably sip on. Love the idea of testing with mountain dew after. 😂

 

[usma05]

I've mixed a vial of ketamine in with some sprite and let a large, young but violently-demented patient sip it down to chill him out before I went after him with an IV needle. Just needed to wait long enough. I was the hero that day because no staff got injured like had happened before with attempted IM darts.

Did you verify w/ pharmacy there was no interaction w/ sprite and ketamine before you mixed? 🤣

Honestly, I like this plan (PO ketamine) and have done it a lot previously mixed w/ PO versed. The problem is my current place has a sedation policy that requires anesthesia at bedside continuously until rolling back regardless of route of ketamine administration. So it's either IM ketamine or mixing precedex w/ po midaz for me. Nobody has time to wait for PO ketamine w/ that sedation policy in place.

 

[PainDrain]

It truthfully was around 45 minutes

It was a concentrated vial of 500mg/10ml. Guesstimate afterwards was he probably got about 250mg.

Sprite because that was his favorite drink and what he would reliably sip on. Love the idea of testing with mountain dew after. 😂

During my pain days we would take a 500mg ketamine vial and dilute it in a liter of fluid then run that over four to five hours for a total dose between 250-500mg. This was for severe CRPS patients. Basically you titrated to what the patient could withstand. It was very entertaining.

 

[Ashers]

During my pain days we would take a 500mg ketamine vial and dilute it in a liter of fluid then run that over four to five hours for a total dose between 250-500mg. This was for severe CRPS patients. Basically you titrated to what the patient could withstand. It was very entertaining.

I did one like that in the OR when I was a resident. The pain doc wanted the patient to try high dose ketamine, so in an hour we gave her 2grams in addition to the infusion she was on. She woke up totally lucid, and she was so sad. The first thing she said was "it didn't work."
She took compounded PO ketamine at home, so she had a high tolerance. 2g was as high as my attending was willing to go.

 

[nimbus]

I did one like that in the OR when I was a resident. The pain doc wanted the patient to try high dose ketamine, so in an hour we gave her 2grams in addition to the infusion she was on. She woke up totally lucid, and she was so sad. The first thing she said was "it didn't work."
She took compounded PO ketamine at home, so she had a high tolerance. 2g was as high as my attending was willing to go.

Anybody know the dose and duration of ketamine use it takes to cause bladder toxicity?

 

[norski]

Anybody know the dose and duration of ketamine use it takes to cause bladder toxicity?

Not a hundred percent on this. Buuut. I read somewhere that ket ingested orally or nasally on a regular basis had a much lower threshold for introducing ketamine induced cystitis than IV. I've never seen patients other than regular drug users coming in for cystectomy due to ketamine. So there's that. Anecdotal and utterly worthless, but still.

 

[drmwvr]

How exactly are you able to get close enough to IM ketamine these peds patients? If I'm afraid of getting hit with an IV, I'm sure an IM injection will cause the same reaction?

a tablet with Magic Fluids....deal with the trust issues later....dart 'em right through their clothes...then the nurses can get them undressed and ready for surgery.

 

[2Fast2Des]

I've learned that while ketamine has its uses in the scenarios described above, for routine cases though, all it does gork the patients and delays the inevitable Dilaudid. Coming out of residency I was all about multimodal ketamine and lidocaine infusions, esmolol vs fentanyl for induction, blah blah but now I have backtracked to just KISS because again, the patients will inevitably get that Dilaudid, it's really a matter of when. A good anesthetic with liberal local/block is the best technique. I still use ketamine but only on reserve for the odd scenarios when needed.

 

[PainDrain]

Anybody know the dose and duration of ketamine use it takes to cause bladder toxicity?

I read a news article on ketamine cystitis in Great Britain. Apparently ketamine is very popular and easy to get over there leading to a wave of cystitis among young Brits. I decided to look up the mechanism and apparently the metabolites of ketamine are excreted In the urine and this causes an inflammatory response in the bladder, ureters and urethra. I got the impression it wasn’t a dose related thing but a buildup of the metabolites and frequent exposure that was the culprit.

 

[GassYous]

I've learned that while ketamine has its uses in the scenarios described above, for routine cases though, all it does gork the patients and delays the inevitable Dilaudid. Coming out of residency I was all about multimodal ketamine and lidocaine infusions, esmolol vs fentanyl for induction, blah blah but now I have backtracked to just KISS because again, the patients will inevitably get that Dilaudid, it's really a matter of when. A good anesthetic with liberal local/block is the best technique. I still use ketamine but only on reserve for the odd scenarios when needed.

Ha so true
I had one attending who was all about that when it came out to the point where she was giving patients rectal tylenol and then all the residents rebelled because the patients were getting fentanyl in pacu anyway

 

[Ashers]

Ha so true
I had one attending who was all about that when it came out to the point where she was giving patients rectal tylenol and then all the residents rebelled because the patients were getting fentanyl in pacu anyway

Rectal? That sounds like a push from pharmacy to stop IV!

I used to do the lido and ketamine gtt's for a lot of patients when I was at a university, but I stopped. I do like giving PO Tylenol in preop, though. They still get narcotics, but so many are happy to drink a little bit of water.

 

[wamcp]

anyone see this earlier today? Dr. Salvador Plasencia charged, was he even a bona fide board certified anesthesiologist?

Matthew Perry's assistant among 5 people, including 2 doctors, charged in 'Friends' star's death

A prosecutor says five people have been charged in connection with Matthew Perry’s death, including the actor’s assistant and two doctors.

apnews.com

Los Angeles police said in May that they were working with the U.S. Drug Enforcement Administration and the U.S. Postal Inspection Service with a probe into why the 54-year-old had so much of the surgical anesthetic in his system.

Perry’s live-in assistant found the actor face down in his hot tub on Oct. 28, and paramedics who were called immediately declared him dead.

His autopsy, released in December, found that the amount of ketamine in his blood was in the range used for general anesthesia during surgery.

The decades-old drug has seen a huge surge in use in recent years as a treatment for depression, anxiety and pain. People close to Perry told coroner’s investigators that he was undergoing ketamine infusion therapy.

But the medical examiner said Perry’s last treatment 1 1/2 weeks earlier wouldn’t explain the levels of ketamine in his blood. The drug is typically metabolized in a matter of hours. At least two doctors were treating Perry, a psychiatrist and an anesthesiologist who served as his primary care physician, the medical examiner’s report said. No illicit drugs or paraphernalia were found at his house.

Ketamine was listed as the primary cause of death, which was ruled an accident with no foul play suspected, the report said. Drowning and other medical issues were contributing factors, the coroner said.

 

[Remxed]

Looks like one is an internist and the other is an EM doc based a quick google search

 

[usma05]

anyone see this earlier today? Dr. Salvador Plasencia charged, was he even a bona fide board certified anesthesiologist?

Matthew Perry's assistant among 5 people, including 2 doctors, charged in 'Friends' star's death

A prosecutor says five people have been charged in connection with Matthew Perry’s death, including the actor’s assistant and two doctors.

apnews.com

Los Angeles police said in May that they were working with the U.S. Drug Enforcement Administration and the U.S. Postal Inspection Service with a probe into why the 54-year-old had so much of the surgical anesthetic in his system.

Perry’s live-in assistant found the actor face down in his hot tub on Oct. 28, and paramedics who were called immediately declared him dead.

His autopsy, released in December, found that the amount of ketamine in his blood was in the range used for general anesthesia during surgery.

The decades-old drug has seen a huge surge in use in recent years as a treatment for depression, anxiety and pain. People close to Perry told coroner’s investigators that he was undergoing ketamine infusion therapy.

But the medical examiner said Perry’s last treatment 1 1/2 weeks earlier wouldn’t explain the levels of ketamine in his blood. The drug is typically metabolized in a matter of hours. At least two doctors were treating Perry, a psychiatrist and an anesthesiologist who served as his primary care physician, the medical examiner’s report said. No illicit drugs or paraphernalia were found at his house.

Ketamine was listed as the primary cause of death, which was ruled an accident with no foul play suspected, the report said. Drowning and other medical issues were contributing factors, the coroner said.

Who's the anesthesiologist in all this?

 

[2Fast2Des]

Who's the anesthesiologist in all this?

Just the usual blaming anesthesia for everything