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SpecialK users?

Discussion in 'Anesthesiology' started by dhb, Jul 30, 2006.

  1. dhb

    dhb Member
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    By reading different posts i've seen people using it in different settings.
    So how do you use it? with what frequency? what dosage?

    1mg/kg? I assume most will give some Midaz (how much, when) to avoid the "bad trips",
    do you also systematically administer atropine (or scopolamine) to counter the hypersecretion, do you sedate with more benzo?, do you use B-blockers to avoid tachycardia?

    Thanks for your feed-back on a drug that i'd like to use more often. :thumbup:
     
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  3. cchoukal

    cchoukal Senior Member
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    My one use of ketamine was in a 38 yo M with mental ******ation from CP (and, thus, quite uncooperative) who needed an ophtho EUA. We did about 3 mg/kg IM while he sat in his wheelchair, distracted by my attending. As he started to fade, we lifted him into bed and started monitors. No IV, no repeat dose needed, no adjuncts.
     
  4. jwk

    jwk CAA, ASA-PAC Contributor
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    Most recently, we're using ketamine for kyphoplasties in the radiology suite. The "usual" MAC (fent/midaz/prop) isn't always a great combination for these usually old and sick patients (apnea in prone MAC cases really sucks), and general, while making it a snap for the radiologists, has drawbacks as well.

    I give 1-2mg of midaz, get them flipped, and start dinking in the ketamine. 20mg, wait a couple minutes, another 20 if needed, then 10-20mg dinks as you go along. The radiologist uses local as well. My most recent one was a 2-level, total time about 30 minnutes, and they got a total of 100mg of ketamine
     
  5. Noyac

    Noyac ASA Member
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    Ditto, thats exactly how I use the K.

    I use it in endo (ERCP's, colonoscopies, and EGD's) I use it for heavy MAC when the surgeon isn't so good with the local. With these doses I don't give glyco b/c I don't find that they have all that much secretions with it. also, the "bad trips" are really rare at these small doses. I have not seen one. I have seen some dreams but not bad and not disturbing to the pts. I do still warn them beforehand about the possiblities of the bad dreams.
     
  6. seattledoc

    seattledoc Senior Member
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    there's a trend with some anesthesiologists at our hospital to add ~100mg ketamine to a 50ml propofol infusion. It allows considerably lower propofol dosing for MAC cases and the ketamine dose is pretty low so SE's are kept to a minimum. You don't see much apnea at all with this mix.
     
  7. supahfresh

    supahfresh un paradis du gangster
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    thats good that you are using the term specialK. we need to use more street names for all our drugs.
     
  8. dhb

    dhb Member
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    i think so too :D and maybe add some Dr Dre lyrics ;)

    ps shouldn't your location be Les Seychelles?
     
  9. nimbus

    nimbus Member
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    Exactly what I do. Works awesome. We call it ketafol around here.
     
  10. dhb

    dhb Member
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    Ketafol: nice :thumbup:

    Anybody using K for more extensive procedures?
     
  11. VentdependenT

    VentdependenT You didnt build thaT
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    I'll run 1mg ketamine per cc of propofol for mac cases. Lay em out initially with the versed and a good bolus of the propofol.

    If they are still wormy or obstructing (not centrally hypoventilating)then I'll deepen them. This allows me to throw in an airway with minimal pt resistance and usually allows for more efficient spont ventilation.

    Then, I'll cut back on my propofol use by placing on circuit mask with strap. Run 50/50 o2 nitrous through the mask, cut the propofol back and titrate prn. Flip off the prop, then flip off the nitrous, boom pt wake up fast.
     
  12. Noyac

    Noyac ASA Member
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    Thats not really a MAC then is it.
     
  13. Gern Blansten

    Gern Blansten Account on Hold
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    Not even by the loosest definition.
     
  14. CRNA01

    CRNA01 New Member

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    Does the patient arouse to stimuli? If not then it is not MAC. Funny how we walk the line. Personally I like precedex/remi. Colons and ERCPs I like propamine/ketafol 50mg/200mg at Propofol 25-50mcg/kg/min placing a nasal trumpet orally (less stimulating). Of course 2-5 mg versed up front.
     
  15. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    Both great drugs ..... unfortunately our bean-counters only see the $$$$$$$ those two drugs cost.
     
  16. MedWiz

    MedWiz Member
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    It is in fact used quite heavily in all sorts of challenging settings in the developing world or more generally, in missionary/relief work, where other medications (or rather the required/recommended monitoring equipment) may not be available: http://www.emedicine.com/emerg/topic802.htm

    So, if you intend to do such work as an anesthesiologist, it is strongly recommended to get familiar with the use of Ketamine for many (if not most) sorts of procedures/anesthesia.
     
  17. dhb

    dhb Member
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    I know that's the point, why isn't it the #1 drug for anesthesia? is it for the $? remi, precedex & propofol= more $$$?
     
  18. VentdependenT

    VentdependenT You didnt build thaT
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    aww cmon. If I give em a good jaw thrust they grimace.
     
  19. seattledoc

    seattledoc Senior Member
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    it got a bad rap for causing alot of PACU problems when people were using high doses and little/no benzos. I think the pendulum is now swinging back to more acceptance of ketamine but you'll still find plenty of people that don't use it at all.
     
  20. dhb

    dhb Member
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    Anyone using b-blockers (or other means) to counter the induced tachy?
     
  21. Noyac

    Noyac ASA Member
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    I don't really see any tachy with its use.
     
  22. Noyac

    Noyac ASA Member
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    :eek: :eek: :eek:
    precedex and remi for MAC. Your hospitals pockets must be DEEP! Thats the craziest thing I have ever heard on this forum, and I've heard some crazy crap. :thumbdown:

    Nasal trumpet orally? :confused:
     
  23. dhb

    dhb Member
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    I rotated at a hospital where they used remi-propofol drips for most of their cases (and very little gas) not exactly cheap either... socialised medicine :oops:
     
  24. CRNA01

    CRNA01 New Member

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    Its on the formulary, so I use it. yes, a nasal trumpet placed orally is more tolerable than a standard oral airway in the mac patient. Its function is only to maintain an airway through the profound soft tissue relaxation that propofol is responsible for. Give it a try in that one that you have to keep chinning that wont tolerate a hard airway.
     
  25. jwk

    jwk CAA, ASA-PAC Contributor
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    If you need an airway, it's not a MAC.
     
  26. rn29306

    rn29306 Drugs are bad, m'kay?
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    Seems rather odd that this patient has "profound soft tissue relaxation" from propofol and you have to keep giving them a chin lift - but won't tolerate a hard OA.

    Nasal airways are much better tolerated than oral, even on the way to PACU waking up. Why not just put a nasal in where it was designed to and be done with it?
     
  27. Laurel123

    Laurel123 Member
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    I love ketamine for MAC. Anywhere from 20-40 mg per 200 mg of propofol in an infusion. I have found patients to tolerate the injection of local with barely a grimace and then not even miss a breath whereas with the propofol only bolus, I usually have to do a little chin lift and watch a bit of apnea.

    Of course, I am aware that this is the almost GA form of MAC and I treat the patient as having an unprotected airway.
     
  28. Noyac

    Noyac ASA Member
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    It may be on forumlary but its still much more expensive than the other meds that will accomplish the same goal. Our health care system is in crisis if you haven't heard. Cutting costs is one way we as providers can make some sort of difference. I'm not saying don't use the stuff when necessary but do use some judgement. Its like giving zofran to every pt. Is it necessary? No. Does it increase costs? Yes.

    Ok, this is not a shot at you b/c I obviously don't know exactly how you practice but when I was supervising crna's I noticed that a lot of them gave everyone zofran without thinking. They used expensive techniques whenever they could. Now I am not saying that Doc's don't do this and I should remove the crna part of this statement but thats the ones I noticed that did it all the time. It is expensive and many cases are paid a flat rate by the insurance companies and if you can cut costs the more money the facility gets to keep. If you can show how your anesthesia practice can cut costs then you can bargain. Now the savings may start to come your way. Please don't take this the wrong way.
     
  29. jwk

    jwk CAA, ASA-PAC Contributor
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    I give most of my patients Zofran, but I don't do it without thinking. We don't keep any other anti-emetic on formulary unless you want to count reglan or phenergan (no Anzemet, Kytril, or droperidol). Some of our plastic surgeons insist on it along with benadryl and decadron. Then there's the "time is money" concept - extra time in PACU dealing with PONV is expensive, and finally, as we all know, patients HATE nausea and vomiting even more than post-op pain.
     
  30. Laryngospasm

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    No routine decadron use for PONV?
     
  31. Noyac

    Noyac ASA Member
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    Sure, I agree with the above. But as you know, not everyone needs zofran or even an antiemetic. The surgeons insisting on a med is out of line in my opinion. Do you insist that they put in 450cc implants? No, so why are they insisting you give something. They may request it.
    Oh, I use reglan. The decadron is another big one for me not just for nausea. I don't give zofran very often and I can't remember the last pt I had with nausea. Your anesthetic technique has a lot to do with the incidence of PONV. Save some propofol for the end of hte case, don't fill hte stomach with air, have them comfortable whenthey wake up, etc.etc.
     
  32. jwk

    jwk CAA, ASA-PAC Contributor
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    Lots of ways to try and avoid PONV, that's for sure. Give this, don't give that, lots of narcs and no N2O, no narcs with N2O, yada yada yada. Even patients who get straight local puke occasionally. Somehow, no one has ever developed the perfect technique for everyone - but when I do, I'll patent it, retire, and never post on SDN again. ;)

    As far as the surgeon wanting specific drugs - if we don't give it, they'll order it pre-op anyway. And the plastics folks really freak with PONV because of increased postop bleeding. One of the many joys of private practice - the surgeons are our customers as well.

    We're not sold on routine decadron use - in think most use it because it's dirt-cheap, and some still have concerns about AVN even from single doses of steroids.

    Personally I'd rather get my droperidol back, but since I don't control the hospital formulary, I'm SOL.
     
  33. VentdependenT

    VentdependenT You didnt build thaT
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    I do in the vast majority of patients. Its cheap effective and has an extremely low side effect profile.

    SOrt of sucks about the droperidol bs black box thing. Supposed to be a phenominal CHEAP PONV drug.
     
  34. dhb

    dhb Member
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    what about awake intubations? what would be your drug of choice (AIC :) ) ?
     
  35. Noyac

    Noyac ASA Member
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    Precedex
     
  36. Lizard1

    Lizard1 Member
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    Sounds good - always willing to try new stuff. What rate do you run them at (ballpark)?
     
  37. meddog1

    meddog1 Senior Member
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    Does anyone on here ever use this stuff in synergism/combination with something like scopalamine or droperidol when attempting to preserve spontaneous respirations? Any data on such a use?
     
  38. jetproppilot

    jetproppilot Turboprop Driver
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    Been done already. And I'm out on paroll. :thumbup:
     
  39. jetproppilot

    jetproppilot Turboprop Driver
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    Venty, you make me proud.

    Sounding like an attending already. :thumbup:
     
  40. Gator05

    Gator05 Resident
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    As far as droperidol's black box warning, let's not forget that zofran and its cousins cause just as much QT-prolongation.

    Anesthesiology. 2005 Jun;102(6):1094-100.Click here to read
    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15915019&query_hl=1&itool=pubmed_docsum

    By the by, there's also a lot of talk about running propofol during a case to minimize PONV. Nobody, though, seems to have much evidence on how much/how long/when. Any thoughts?
     
  41. epidural man

    epidural man ASA Member
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    Every person getting cut deserves a little ketamine.

    There is quite a bit of evidence that ketamine is great for pre-emptive analgesia.

    My favorite ketamine article is from Pain 2001. "Balanced analgesia' in the perioperative period:is there a place for ketamine?"

    What is so significant about this article is that the people that got the low dose ketamine infusion not only had less pain scores and opiod use and all that crap while in the hospital, these people reported less pain 6 MONTHS after surgery around their incision site. This, to me, is impressive. I think that if I can change someones morbidity so significantly for just a small dose of ketamine, I should do it in almost every case I do. In this well designed study, they did a load .5mg/kg ~30min before incision, and then ran an infusion of .25mg/kg/hr. I turn my infusion off 45-60 min before the case ends, otherwise you have all those problems people mention about the drug.

    Ya know, surgery hurts. I had a small mole cut off my back, and that sucker hurt for 3 to 4 days! I cant imagine having a cheveron incision across your chest/abdomen, or a large wack on your body somewhere.

    Now, a problem WE have is a large marine population that suffer from PTSD. These guys are hugely problematic with pain issues, but also waking them up from anesthesia can be very interesting (and dangerous - I had a guy try to bite me:eek:). I found that if you use ketamine (because they deserve it), then a great way to wake them up is with precedex on board - extubate with the precedex infusion running - turn it off - and they chill in the PACU for 1 to 2 hrs.

    Bottom line - read that article I reference and then start using ketamine as much as possible. I give it to who ever I can - but attendings can be butt-heads about it sometimes and not allow it.

    Oh, and one more thing - I was using it in a spine with SSEPs and the monitor chick (besides being a HOTTIE) was very THRILLED that I used it. She said it gave her great signals and she said she wished more anesthesiologists used it. I had no trouble using other agents that they usually frown upon because the signals were so great. I think I used a scoche of propofol, sevo, and sufenta.
     
  42. VentdependenT

    VentdependenT You didnt build thaT
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    for all joint cases I give 20mg ivp ketamine based on some article a pain dude gave me. I'm so damn tired right now on call doen damn cases I'm gonna friggen lose it man. Oops, did I digress?
     
  43. dhb

    dhb Member
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    Agreed, with ketamine most patient undergoing minor procedures require little to no post-op opoids (in my limited experience).
    The doses they used in the study seem a bit high to me, i like to give 20mg at induction then run a sufenta/ketamine 5-5/ml infusion at 2ml/h and they get a bag of 500cc of NS with 60mg K 2gr Mg+ over the next 24h

    What's your recipe?
     
  44. Planktonmd

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  45. Planktonmd

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    So each time you give it you take some time and think alittle bit?
     
  46. rmh149

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    When this thread was started, a year ago, zofran was still expensive. Its cheaper than dirt now. Just about everyone gets it...
     
  47. i have to admit that i dont use ketamine much and its probably due to the place i trained. They are all anti-K. I want to use it more tho.

    This has been a good thread for the discussion. Does anyone have some more recent journal article references for use of ketamine in general in anesthesia?
     
  48. Noyac

    Noyac ASA Member
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    Very nice and also very similar to my recipe. Where did you get the recipe?

    I came up with mine about 3 yrs ago when I started doing a lot of big spine cases. The surgeon even notices a difference from my anesthetic and the others. :thumbup:

    I don't run it for 24 hrs though. THe pharmacy and nursing staff are not comfortable with it. I mostly use it for the case only.
     
  49. dhb

    dhb Member
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    From reading your posts :D and from an attending who is pro-ketamine, she give 20mg + 2gr of Mg2+ plus any other stuff (decadron, Atbx) in a 50cc bag just before induction, i adapted that to make it faster: i hate waiting for the little bag to empty, and easier: i don't need several ports on the iv line.
     
  50. dhb

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    From reading your posts :D and from an attending who is pro-ketamine, she give 20mg + 2gr of Mg2+ plus any other stuff (decadron, Atbx) in a 50cc bag just before induction, i adapted that to make it faster: i hate waiting for the little bag to empty, and easier: i don't need several ports on the iv line.
     
  51. rmh149

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    Very interesting. I have very little exposure to ketamine....have used it only on those very unstable patients.

    So, on an open abdominal case it would be good to load the patient with 0.5mg/kg ketamine (after induction?), and run a gtt at .25mg/kg/hr. Then stopping the gtt about 30 minutes prior to wake up time.

    How do they wake up?

    How much narcotic would the patient need on top of the ketamine?

    How long does it last....will they be completely spaced in the PACU?
     

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