mediport case

[cfdavid]

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Do you guys use Ketamine for mediport insertion cases? If so, what dose do you use? Assuming you'll still be running a propofol infusion that is. So, mostly this will be used for analgesia in lieu of narcotics.

 

[W222]

Do you guys use Ketamine for mediport insertion cases? If so, what dose do you use? Assuming you'll still be running a propofol infusion that is. So, mostly this will be used for analgesia in lieu of narcotics.

Do not use it and would not. The last thing you need is a patient freaking out and tripping their head off while doing this type of case. I only use ketamine awake in a few instances and when I do its always combined with a benzo. I have had to many people freakout on special K. Plus, the ketamine may increase secretions and combined with the propofol you could have a salivating AND obstructing patient.

 

[cfdavid]

Do not use it and would not. The last thing you need is a patient freaking out and tripping their head off while doing this type of case. I only use ketamine awake in a few instances and when I do its always combined with a benzo. I have had to many people freakout on special K. Plus, the ketamine may increase secretions and combined with the propofol you could have a salivating AND obstructing patient.

What about a dose of, say 0.2 mg/kg? That's pretty low, and one I've seen quoted as being an "analgesic dose" versus that of sedation or certainly induction....

I don't have enough experience with the drug, but I wonder if you could avoid that dissociation at that dose.

Also, which instances DO you use ketamine?

 

[Multifidus]

I use or have used it in few instances:

1. Tourniquet pain in regional cases with the patient sedated on propofol. I give small boluses of 10mg at a time up to a max of 50 mg or so. Works wonders. Much better than opioid in these instances because with the latter you invariably will require high enough doses to cause respiratory depression in your patient with an unsecured airway.

2. C-sections with a patchy epidural or a mom who just can't bare the tugging. Same dosing as above. I don't do this often, but it works well.

3. In residency, had an attending use it for big spine surgeries in patients with chronic pain. He would give a bolus of about 1mg/kg with induction with propofol. Then run them on an infusion of about 20mcg/kg/min until exposure achieved, then drop to 10mcg/kg/min for the majority of the case, then to 5mcg/kg/min and usually off at least an hour before the end of the case.

4. Of course, there is the classic teaching of tamponade or severe asthma...

5. Great in TIVA cases. Mix Ketamine 50mg (0.5ml) with Propofol 49.5ml. Run your infusion somewhere from 80-120 mcg/kg/min (based on standard propofol concentration). Your ketamine will be running at 1/10th the propfol dose (ie when Propofol is 100mcg/kg/min, ketamine dose is 10mcg/kg/min). Again, get rid of the ketamine about an hour before the end of the case to minimize side effects.

I always give versed to these patients at the beginning of the cases.

 

[pgg]

I'm a big fan of ketamine, but ports and permacaths and portacaths can be done under local and not much else. Some of the people here look at me funny for using as much as I do.

1 or 2 of midazolam.
~50 mg propofol and ~200 mcg alfentanil ... wait for them to get all glassy eyed.
Surgeon has about 30-60 sec of stunned time to go to town with a bunch of local.
Say a few reassuring words to the patient after that, and say "local to the surgeon" as needed.
Maybe another bit of propofol/alfentanil when the surgeon does the tunneling.

The gen surg who does 90% of our ports is lightning fast and generous with local though. When IR does them, ick - I wind up doing nasal cannula generals more often than not with that guy.

 

[Gasworks]

100 mcg of fent and as much dip as the pt will tolerate. If you are that worried about the pt just go straight local. You can tent the drapes over their face to increase fio2 just don't hypoventilate them too long. If a pt is so frail that you are worried they'll die from a dip infusion you'll most likely drive them into prolonged delirium from the ketamine. We had a vascular room where I trained where the maximum you were allowed to give was 1mg of versed and 50mcg of fentanyl. The motto there was that it was better for the pt to complain than to not complain at all.

 

[sevoflurane]

1 or 2 of midazolam.
~50 mg propofol and ~200 mcg alfentanil ... wait for them to get all glassy eyed.

👍


Pretty much what I do... except that I end up using all the alfenta to stun their tongue while tunneling.

 

[Oggg]

What is a dip infusion?

 

[RussianJoo]

for sedation cases i've heard of people mixing 20mg of ketamine into 20ml of propofol, (Ketafol drip) others run the propofol drip and bolus ketamine 5 to 10mg at a time for desired effect (i.e. resp rate, HR). Haven't really used it that much in the main OR yet, but i've used a ton of it in OB.

 

[pgg]

What is a dip infusion?

I assumed Diprivan (propofol)

 

[jwk]

for sedation cases i've heard of people mixing 20mg of ketamine into 20ml of propofol, (Ketafol drip) others run the propofol drip and bolus ketamine 5 to 10mg at a time for desired effect (i.e. resp rate, HR). Haven't really used it that much in the main OR yet, but i've used a ton of it in OB.

Why so much in OB?

 

[Idiopathic]

Why so much in OB?

because they do sections either with inadequate blocks or they allow them to wear off.

 

[RussianJoo]

because they do sections either with inadequate blocks or they allow them to wear off.

well i guess both is the correct answer also a lot of the sections occur under epidurals bolused with Nesacaine. My post was what other residents do in the main OR for sedation cases. I personally have only used ketamine for c-sections. And our sections typically take 3 to 4 hours, cause i guess it's july. I love it when the ob asks how much longer they have on a spinal when we're already 3 hours into the c-section. But I've had to give only 5 to 15mg totally. but still a lot i guess.

 

[pgg]

well i guess both is the correct answer also a lot of the sections occur under epidurals bolused with Nesacaine.

True chloroprocaine doesn't last as long as lidocaine, and you don't get as much out of epidural narcs with it, but you're still allowed to redose it. Why switch to ketamine unless the epidural itself is crappy?

My post was what other residents do in the main OR for sedation cases. I personally have only used ketamine for c-sections. And our sections typically take 3 to 4 hours, cause i guess it's july. I love it when the ob asks how much longer they have on a spinal when we're already 3 hours into the c-section. But I've had to give only 5 to 15mg totally. but still a lot i guess.

Oh my god, it hurts to read that. Painful flashbacks. I remember routinely doing CSEs for repeat sections in residency, because the risk that a 15 mg bupiv spinal would wear off was so high. I remember putting in spinals for hips, then watching the orthopods look at the films for 45 minutes before even scrubbing.

Counting my blessings now, I am.

 

[W222]

Why so much in OB?

We use it for vaginal repairs in women without neuraxial blocks. Give some midaz while rolling back to the OR, hit them with some ketamine and thats all they need.

 

[Arch Guillotti]

well i guess both is the correct answer also a lot of the sections occur under epidurals bolused with Nesacaine. My post was what other residents do in the main OR for sedation cases. I personally have only used ketamine for c-sections. And our sections typically take 3 to 4 hours, cause i guess it's july. I love it when the ob asks how much longer they have on a spinal when we're already 3 hours into the c-section. But I've had to give only 5 to 15mg totally. but still a lot i guess.

5-15 mg doesn't seem like a whole lot to me.

This is July of your CA-1 year, correct? How have you used a ton of anything yet?

 

[RussianJoo]

5-15 mg doesn't seem like a whole lot to me.

This is July of your CA-1 year, correct? How have you used a ton of anything yet?

yep 20 days in. Well it seems like a ton to me. We stay pretty busy here in my program, they really like to work us, I mean July 1st I was on my own, the attending was there for 5min during induction, a senior resident would come for emergence but that's about it. It's probably not the best way to teach us but at the same time they don't really teach us.

 

[Idiopathic]

so you are using chlorprocaine, which wears off very rapidly and has diminishing returns, as primary anesthetic for surgeons that routinely take 3+ hours for cesarean section? thats atrocious planning. ive used it sparingly in my career, usually only for emergent sections, i would never select it for things like arrest of labor or failure to progress.

another thing - we learned here that if you just place the spinal for primary cesarean, and dont give anyone an option to have an epidural catheter/CSE, that cesarean sections which routinely used to take close to 3 hours, now take about half that time.

 

[cfdavid]

So, I've done a few more mediport cases (no no, that's not all we're doing......). Ketamine does seem to work nicely. Local just doesn't seem to cut it (even with versed ofcourse). So, the propofol infusion seems like a great way to go, with a little (35mg over maybe 2-3 boluses) Ketamine seems to have worked out very well the whole 2 times I've used it this way....
This is compared to a propofol infusion with narcotics...