Pre/post anesthetic suggestions?

[futuredo32]

---

Members don't see this ad.

I'm a psychiatrist and I have heard that some patients have quit smoking when the CRNA or anesthesiologist told them they would have no desire to smoke when told this before and after anesthesia. Any truth to this? If so could it possibly help with anxiety or other disorders? My apologies in advance if this is the dumbest question ever asked here.

 

[coffeebythelake]

Never heard of this before.

 

[Psai]

General Anesthetics to Treat Major Depressive Disorder: Clinical Relevance and Underlying Mechanisms. - PubMed - NCBI

Nice review article in a&a that just came out this year that suggests how general anesthesia may help depression

 

[futuredo32]

Thanks, I have heard about ketamine.

 

[anbuitachi]

Never heard of the smoking thing

 

[coffeebythelake]

General Anesthetics to Treat Major Depressive Disorder: Clinical Relevance and Underlying Mechanisms. - PubMed - NCBI

Nice review article in a&a that just came out this year that suggests how general anesthesia may help depression

read with interest in the summary that "Indeed, equipotency of general anesthesia alone in comparison with electroconvulsive therapy under general anesthesia has been demonstrated in several clinical trials." do you happen to have a full electronic copy of this article?

 

[Mman]

I'm a psychiatrist and I have heard that some patients have quit smoking when the CRNA or anesthesiologist told them they would have no desire to smoke when told this before and after anesthesia. Any truth to this? If so could it possibly help with anxiety or other disorders? My apologies in advance if this is the dumbest question ever asked here.

I'm too lazy to look it up, but there have been studies showing attempts at quitting during a hospitalization, even for elective surgery, have a higher success rate than other attempts.

 

[DocVapor]

I'm too lazy to look it up, but there have been studies showing attempts at quitting during a hospitalization, even for elective surgery, have a higher success rate than other attempts.

In this same vein, I feel like we have a great opportunity to get people to actually start using their CPAP as well. Whenever I have the time to discuss a patient's sleep apnea and how it effects not only the anesthetic plan but their whole physiology in general, I do. Then afterwards if I have a chance i discuss with them just how easily they actually obstructed. It seems like when there's enough of an actual "Oh, so this actually DOES cause real problems" they are more receptive to giving it a solid effort. I've had multiple stubborn old men thank me for the information, and their wives just love it to. If nothing else, I think it's great PR for the hospital and our field.

 

[Noyac]

I would love to put people to sleep strictly to induce smoking abstinence. Unfortunately, I think it is total BS.

Btw, crna’s say some weird sh/t to pts. Every once in a while there seems to be some support in something like the Journal of Nature or some other non scientific magazine. That is not what I read routinely for my medical practice.

And, welcome to the forum. Keep these questions coming. They are great reprieve from the usual A-line debate.

 

[Psai]

I would love to put people to sleep strictly to induce smoking abstinence. Unfortunately, I think it is total BS.

Btw, crna’s say some weird sh/t to pts. Every once in a while there seems to be some support in something like the Journal of Nature or some other non scientific magazine. That is not what I read routinely for my medical practice.

And, welcome to the forum. Keep these questions coming. They are great reprieve from the usual A-line debate.

If they have an artery, it needs a line.

 

[IMGASMD]

If they have an artery, it needs a line.

If there is an empty orifice, I must fill it.
Also if there is a broken bone, I must fix it.

 

[DeadSpace]

When I ask if they smoke they say that they used to but have quit. When I press for when they quit it turns out it's usually since this admission. I give a few sentences about smoking, airways, and anesthesia. I'd be very surprised to hear any of them care or change their lifestyles based on this.

 

[Planktonmd]

I think general anesthesia is like hitting the reset button on your brain and a good reboot frequently fixes things in a mysterious way !
That's pretty much what electro-convulsive therapy does, a hard reset.
As for the smoking cessation if you combine a reset with the placebo effect of telling the patient that when he wakes up he will not want to smoke you might be on to something.

 

[Urzuz]

Btw, crna’s say some weird sh/t to pts. Every once in a while there seems to be some support in something like the Journal of Nature or some other non scientific magazine.

Not to be confused with the journal named Nature, one of if not the most prestigious science journal in the world.

 

[futuredo32]

Btw ketamine clinics for depression are " the latest and greatest" . Currently there are few and done by anesthesiologists and cash only. I've never sent a patient but one of my former attendings was always raving about them. Not a bad way to make a ton of cash currently.

 

[IMGASMD]

Hey OP what state are you in? I can drive to where you are.

When I was doing some research at one of the ivory towers, my PI was approached by psychiatry to do some research with them. They were infusing doses they weren’t comfortable with. Maybe up to 100mg (?) at a time. Long and behold.... saw the psychiatrist somewhere gave a talk about it recently.

 

[deleted162650]

Btw ketamine clinics for depression are " the latest and greatest" . Currently there are few and done by anesthesiologists and cash only. I've never sent a patient but one of my former attendings was always raving about them. Not a bad way to make a ton of cash currently.

My group opened our own ketamine clinic a bit over a year ago. It's going well, and it seems like most of the patients are seeing benefits - enough to keep coming back for boosters after their initial series. We also have a chronic pain protocol. Many insurance plans are actually paying for the infusions, which came as a surprise to us. I think currently we are doing around 70ish infusions per month.

 

[futuredo32]

Hey OP what state are you in? I can drive to where you are.

When I was doing some research at one of the ivory towers, my PI was approached by psychiatry to do some research with them. They were infusing doses they weren’t comfortable with. Maybe up to 100mg (?) at a time. Long and behold.... saw the psychiatrist somewhere gave a talk about it recently.

Michigan. I am not involved w a ketamine clinic. I wouldn't. I wonder about the long term dangers of repeated small doses of ketamine.

 

[Mman]

Michigan. I am not involved w a ketamine clinic. I wouldn't. I wonder about the long term dangers of repeated small doses of ketamine.

To be fair, I also worry about the long term dangers of inadequately treated depression.

 

[anbuitachi]

My group opened our own ketamine clinic a bit over a year ago. It's going well, and it seems like most of the patients are seeing benefits - enough to keep coming back for boosters after their initial series. We also have a chronic pain protocol. Many insurance plans are actually paying for the infusions, which came as a surprise to us. I think currently we are doing around 70ish infusions per month.

How did you even get this going? were you getting referrals or did you post signs everywhere advertising ketamine infusions and its benefits

Actually i just googled it. Apparently there are a bunch of ketamine clinics in NYC..
And it looks like they are either anesthesiologists/pain docs, or psychiatrists.. i guess as expected.
The first result on google showed they charge 475$ per infusion session
Interesting stuff. A bit more reading shows their infusions lasts about 1 hr, and patients typically leave 15-30 min after (doesn't have to be accompanied by someone), and if they get bad dissociation, they can get medications that end the dissociation within a minute.. (i wonder which med they are referring to)

 

[deleted162650]

How did you even get this going? were you getting referrals or did you post signs everywhere advertising ketamine infusions and its benefits

Actually i just googled it. Apparently there are a bunch of ketamine clinics in NYC..
And it looks like they are either anesthesiologists/pain docs, or psychiatrists.. i guess as expected.
The first result on google showed they charge 475$ per infusion session

We started off partnered with the hospital which does a good bit of psychiatric care. We also do our own marketing.

And $475/infusion is cheap.

 

[anbuitachi]

We started off partnered with the hospital which does a good bit of psychiatric care. We also do our own marketing.

And $475/infusion is cheap.

Yea i was thinking about how you must need several infusions to go at once to even cover the cost of staff/equipment and make ok salary.. I guess they must have a lot of patients to make it worthwhile

 

[deleted162650]

A bit more reading shows their infusions lasts about 1 hr, and patients typically leave 15-30 min after (doesn't have to be accompanied by someone), and if they get bad dissociation, they can get medications that end the dissociation within a minute.. (i wonder which med they are referring to)

Versed. We try not to give it because the literature shows it may negate the benefits of the ketamine. Very rare to have someone have a bad trip.

 

[IMGASMD]

@SaltyDog also interested if you guys give anything for bad dissociation?

Edit: answered. I was tad slow.

 

[deleted162650]

Yea i was thinking about how you must need several infusions to go at once to even cover the cost of staff/equipment and make ok salary.. I guess they must have a lot of patients to make it worthwhile

We max out at 4 infusions going at a time. Right now we are doing around 3-4 infusions per day M-F. It's a supplement to our regular OR work and a means of diversification. We aren't getting filthy rich off it - yet.

 

[anbuitachi]

Versed. We try not to give it because the literature shows it may negate the benefits of the ketamine. Very rare to have someone have a bad trip.

Interesting. what about propofol instead of versed? any literature showing that negating its affects?

We max out at 4 infusions going at a time. Right now we are doing around 3-4 infusions per day M-F. It's a supplement to our regular OR work and a means of diversification. We aren't getting filthy rich off it - yet.

3-4 infusions per day? That's not many at all but i figured it'd be hard to get it off the ground and have a lot of patients.. probably hard to afford for most people and not a large patient pop
Though i guess if it was a standalone clinic, 1 anesthesiologist would be able to handle 3-4 infusions alone, no need for even other staff.. still a good 1.5-2k before overhead. not bad

 

[deleted162650]

Interesting. what about propofol instead of versed? any literature showing that negating its affects?



3-4 infusions per day? That's not many at all but i figured it'd be hard to get it off the ground and have a lot of patients.. probably hard to afford for most people and not a large patient pop
Though i guess if it was a standalone clinic, 1 anesthesiologist would be able to handle 3-4 infusions alone, no need for even other staff.. still a good 1.5-2k before overhead. not bad

Don't know about the propofol.

Clinic is staffed by 1 doc and a nurse. Usually cases in the am and ketamine in the afternoon. I think patient population is the limiting factor. There are only so many severely depressed people out there that have exhausted all other options and have the money to spend (although insurance is kicking in for many). We have been increasing the number of infusions pretty much every month since inception though. We do have a few people that travel pretty far to see us.

 

[Noyac]

I think general anesthesia is like hitting the reset button on your brain and a good reboot frequently fixes things in a mysterious way !
That's pretty much what electro-convulsive therapy does, a hard reset.
As for the smoking cessation if you combine a reset with the placebo effect of telling the patient that when he wakes up he will not want to smoke you might be on to something.

I always assumed ECT caused a massive release of serotonin and dopamine.
Maybe GA does this to some degree but definitely not the same level.
I’m pretty sure you are speaking somewhat tongue in cheek though.

 

[futuredo32]

To be fair, I also worry about the long term dangers of inadequately treated depression.

Agree.
It's just ketamine is new and no long term studies. I take good care of my patients and see mostly the worried well and do a lot of psychotherapy and therapy seems the most beneficial with patients with depression in my limited experience. As a patient I won't take a "new drug" that hasn't been out for at least 3 months, for patients only new drugs if all else failed. I actually am hoping for a miracle and will be applying for a second residency in FP next fall.

 

[IMGASMD]

Agree.
It's just ketamine is new and no long term studies. I take good care of my patients and see mostly the worried well and do a lot of psychotherapy and therapy seems the most beneficial with patients with depression in my limited experience. As a patient I won't take a "new drug" that hasn't been out for at least 3 months, for patients only new drugs if all else failed. I actually am hoping for a miracle and will be applying for a second residency in FP next fall.

FP? Family practice? Unless you meant forensic psychiatry?

 

[futuredo32]

FP? Family practice? Unless you meant forensic psychiatry?

Family practice. I picked the wrong pony. It's a long shot but I would rather try next fall and fail than not. I will apply next fall and the fall after and then just try to make lemonade out of my lemons

 

[anbuitachi]

Agree.
It's just ketamine is new and no long term studies. I take good care of my patients and see mostly the worried well and do a lot of psychotherapy and therapy seems the most beneficial with patients with depression in my limited experience. As a patient I won't take a "new drug" that hasn't been out for at least 3 months, for patients only new drugs if all else failed. I actually am hoping for a miracle and will be applying for a second residency in FP next fall.

But it's ketamine. You wouldn't want ketamine?

 

[Noyac]

But it's ketamine. You wouldn't want ketamine?

Well not until I was at least out in the boonies.

Not that I know what that is like.

 

[futuredo32]

But it's ketamine. You wouldn't want ketamine?

LOL NO. illicit free. I worked way too hard for my license. This group is fun. Too bad I'm not an anesthesiologist

 

[Mman]

Agree.
It's just ketamine is new and no long term studies.

Ketamine has been in regular use since the Vietnam War and is on the WHO list of essential medicines. Are there long term studies on it? Of what? While I would personally not use it, I also don't have crippling depression and there are plenty of studies of how bad that is long term.

 

[Aether2000]

J Clin Psychopharmacol. 2018 Aug;38(4):380-384. doi: 10.1097/JCP.0000000000000894.
Maintenance Ketamine Therapy for Treatment-Resistant Depression.
Archer S, Chrenek C, Swainson J.
Abstract
BACKGROUND:
Previous studies have demonstrated ketamine to have a rapid antidepressant effect in some patients with treatment-resistant depression (TRD), but the effect is unfortunately not sustained in the long term. In this study, we report on the clinical use of ongoing maintenance ketamine infusions in a group of patients with TRD, beyond an acute course of 6 to 8 ketamine infusions.

METHODS:
This retrospective case series reports on 11 patients with TRD who received maintenance ketamine infusions, defined as treatments beyond an initial series of up to 8 infusions. Charts were reviewed to collect data on response to treatment and side effects.

RESULTS:
All 11 patients in this case series were noted to have a reduction in their Beck Depression Inventory II (BDI-II) score after an acute course of treatment and a lower median BDI-II during their maintenance treatments than their baseline BDI-II. At the study end point, 4 patients were continuing maintenance ketamine and 1 patient had transitioned to maintenance intranasal ketamine. Four patients discontinued ketamine due to loss of effect and 1 due to side effects, and the reason for discontinuation was not noted for the remaining 2 patients. No major adverse events were noted in these patients receiving maintenance treatments, and it was well tolerated overall.

CONCLUSIONS:
Maintenance ketamine treatments may be an effective way of maintaining treatment response in some ketamineresponders. Future research is required to determine optimal length of treatment in those who respond to ketamine and to track adverse effects over a longer time.

 

[anbuitachi]

I wonder what doses are t hey doing these at...

 

[narcotics999]

J Clin Psychopharmacol. 2018 Aug;38(4):380-384. doi: 10.1097/JCP.0000000000000894.
Maintenance Ketamine Therapy for Treatment-Resistant Depression.
Archer S, Chrenek C, Swainson J.
Abstract
BACKGROUND:
Previous studies have demonstrated ketamine to have a rapid antidepressant effect in some patients with treatment-resistant depression (TRD), but the effect is unfortunately not sustained in the long term. In this study, we report on the clinical use of ongoing maintenance ketamine infusions in a group of patients with TRD, beyond an acute course of 6 to 8 ketamine infusions.

METHODS:
This retrospective case series reports on 11 patients with TRD who received maintenance ketamine infusions, defined as treatments beyond an initial series of up to 8 infusions. Charts were reviewed to collect data on response to treatment and side effects.

RESULTS:
All 11 patients in this case series were noted to have a reduction in their Beck Depression Inventory II (BDI-II) score after an acute course of treatment and a lower median BDI-II during their maintenance treatments than their baseline BDI-II. At the study end point, 4 patients were continuing maintenance ketamine and 1 patient had transitioned to maintenance intranasal ketamine. Four patients discontinued ketamine due to loss of effect and 1 due to side effects, and the reason for discontinuation was not noted for the remaining 2 patients. No major adverse events were noted in these patients receiving maintenance treatments, and it was well tolerated overall.

CONCLUSIONS:
Maintenance ketamine treatments may be an effective way of maintaining treatment response in some ketamineresponders. Future research is required to determine optimal length of treatment in those who respond to ketamine and to track adverse effects over a longer time.

Time to open ketamine clinic?