substitutes for IM ketamine "darts"

[BeatriZZ]

Now that we are in the midst of a ketamine shortage what have people used for substitutes for those developmental delay patients that refuse to cooperate for an IV.
I'm talking full grown adults, and in ambulatory surgery center where we need to d/c them quickly.
I just tried IM versed but it took forever to work and we still had to wrestle the guy, though I probably didn't give enough ( 5mg for a ~90kg autistic guy)
Are you all using diphenhydramine? haldol? What dosages? Do they wear off in a timely manner post-op?
In residency we always used ketamine for these cases

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[NITRAS]

I’m not anesthesia but my friend told she woulfd have them drink Versed with a juice box chaser....

 

[AdmiralChz]

Bring back the sux races!

... in all seriousness, though, I’d worry how long a big IM slug of Haldol would last in the ASC setting. Maybe try to push the PO versed as much as possible?

 

[Hoya11]

Now that we are in the midst of a ketamine shortage what have people used for substitutes for those developmental delay patients that refuse to cooperate for an IV.
I'm talking full grown adults, and in ambulatory surgery center where we need to d/c them quickly.
I just tried IM versed but it took forever to work and we still had to wrestle the guy, though I probably didn't give enough ( 5mg for a ~90kg autistic guy)
Are you all using diphenhydramine? haldol? What dosages? Do they wear off in a timely manner post-op?
In residency we always used ketamine for these cases

First attempt: PO versed. 40mg for an adult. No i do not worry about the 20ml volume. Then I put an IV in the hand and more versed and/or propofol IV immediately. TIP: If they come with an aid or caretaker or parent, let the parent guide how to give it, syringe or cup, whatever ritual they have established to take meds at home, they can help with this.

Second attempt (if ketamine not available): IM versed 0/1-0.2mg/kg. Honestly I would have given your guy almost 20mg IM. Versed you will find is very forgiving and these people usually have seizure histories and are not in a rush to return home/to facility within minutes after surgery.

I find it hard to believe that you are doing these cases in a surgery center, as in not part of a hospital (like day surg area of a big hospital), sounds like a terrible idea as these cases are challenging enough when you are not in a rush.

When we have people come to our ASCs who are mentally disabled for pre-op screening, we refer them to the hospital. Not worth the headache.

 

[dannyboy1]

I find it hard to believe that you are doing these cases in a surgery center, as in not part of a hospital (like day surg area of a big hospital), sounds like a terrible idea as these cases are challenging enough when you are not in a rush.

When we have people come to our ASCs who are mentally disabled for pre-op screening, we refer them to the hospital. Not worth the headache.

This. Surgicenters are for making money quickly and easily. Send them out.

 

[cchoukal]

Case reports of intranasal dexmedetomidine, 200 µg per nostril. I have used it a couple of times, and although it takes several minutes to work, it does seem to work well.

 

[propadope]

Doing these cases without ketamine sounds like a nightmare.

 

[BeatriZZ]

Thanks for the tips Hoya.
Does your versed only come in 1mg/cc concentration? Ours does, and pushing 20cc IM would take awhile and I didn't want him to get pissed and swat at me.
Will try to PO versed but what if your patient refuses to drink or spits it out?

 

[BigRedBeta]

TIP: If they come with an aid or caretaker or parent, let the parent guide how to give it, syringe or cup, whatever ritual they have established to take meds at home, they can help with this.

This is huge and probably the single most important lesson anyone can take from their peds rotations at any point in their career (3rd year clerkship, any residency program that makes you see kids even if only for a week, whatever)...you are never the expert in the room with a developmentally delayed patient. Probably doubly true in anesthesia when there are medications and needles involved. Tell the parents/caregivers that y'all are on the same team and however they want to go about it, you'll work with will create a lot of trust.

Intranasal meds are super helpful - in various settings have had good luck with versed, fentanyl, and most recently dex that route. The biggest issue will probably be getting the atomizers either stocked or from pharmacy

 

[WholeLottaGame7]

First attempt: PO versed. 40mg for an adult. No i do not worry about the 20ml volume. Then I put an IV in the hand and more versed and/or propofol IV immediately. TIP: If they come with an aid or caretaker or parent, let the parent guide how to give it, syringe or cup, whatever ritual they have established to take meds at home, they can help with this.

Second attempt (if ketamine not available): IM versed 0/1-0.2mg/kg. Honestly I would have given your guy almost 20mg IM. Versed you will find is very forgiving and these people usually have seizure histories and are not in a rush to return home/to facility within minutes after surgery.

I find it hard to believe that you are doing these cases in a surgery center, as in not part of a hospital (like day surg area of a big hospital), sounds like a terrible idea as these cases are challenging enough when you are not in a rush.

When we have people come to our ASCs who are mentally disabled for pre-op screening, we refer them to the hospital. Not worth the headache.

Whewww 40mg is a lot. I typically don't go over 20, even for adults. 40mg of midaz is going to take awhile to setup and then lasts for awhile; no way you're getting them out of an ASC quickly, especially if a short case. Above 40kg I'll just add PO ketamine (obviously not a solution here).

You can also do intranasal midaz or precedex, still takes a little while to set up and is going to have a long tail.

I'll third the "ask the parents the best route" if it's a developmentally delayed adult. Also, will add that if you can tell PO is going to be the route early on, I will often discuss the plan briefly with the parents and then excuse myself prior to the med being given so that it seems like it's coming from the parent and not the scary medical provider.

Sometimes you can also just EMLA the target and distract them. Or have parent come back and let them breathe some nitrous first.

Lots of techniques, really just depends on their state.

 

[dhb]

Now that we are in the midst of a ketamine shortage

Time to stock up on some PCP from your SOCMOBing friends.

 

[Hoya11]

Thanks for the tips Hoya.
Does your versed only come in 1mg/cc concentration? Ours does, and pushing 20cc IM would take awhile and I didn't want him to get pissed and swat at me.
Will try to PO versed but what if your patient refuses to drink or spits it out?

Versed for IM is 5mg/ml. I use 4ml on a 5cc syringe and a 20g needle. Sounds cruel, but try doing it with a 25g it takes forever to push into the muscle.

 

[propadope]

These patients often have a prn order for a sedative from their institution or home, usually ativan. You can get a sense from the caregivers as to what kind of effect the dose has. Although ativan is long acting so is a massive dose of versed. It could be an option to consider.

Triazolam is another possibility. Short acting and much easier to give PO than midaz. Onset and bioavailability is improved if given sublingual

 

[AdmiralChz]

Sometimes you can also just EMLA the target and distract them.

For the few I’ve truly had to do a Ketamine dart on, there is NO WAY I’m going near them with an angiocath needle without sedation even with the best EMLA in the world. That’s asking for trouble, some of these adults can be huge and extremely strong.

 

[propadope]

Whewww 40mg is a lot. I typically don't go over 20, even for adults. 40mg of midaz is going to take awhile to setup and then lasts for awhile; no way you're getting them out of an ASC quickly, especially if a short case. Above 40kg I'll just add PO ketamine (obviously not a solution here).

You can also do intranasal midaz or precedex, still takes a little while to set up and is going to have a long tail.

I'll third the "ask the parents the best route" if it's a developmentally delayed adult. Also, will add that if you can tell PO is going to be the route early on, I will often discuss the plan briefly with the parents and then excuse myself prior to the med being given so that it seems like it's coming from the parent and not the scary medical provider.

Sometimes you can also just EMLA the target and distract them. Or have parent come back and let them breathe some nitrous first.

Lots of techniques, really just depends on their state.

I agree about not giving more than 20mg midazolam PO. 40mg seems like a massive dose

 

[deleted9493]

4mcg/kg of Precedex in apple juice at least an hour before OR time.
Also,
Lorazepam .05mg/kg in apple juice at least an hour before OR time

Both result in a prolonged recovery time, much like a stout dose of IM ketamine but are even more forgiving from a side effect profile. Intranasal administration, to me, is not ideal for the linebacker-sized autistic patient...onset is too long after what will be viewed as a confrontational moment.

Give 'em one of the above cocktails as soon as they walk in the door--no such thing as too soon.

 

[fakin' the funk]

Now that we are in the midst of a ketamine shortage what have people used for substitutes for those developmental delay patients that refuse to cooperate for an IV.
I'm talking full grown adults, and in ambulatory surgery center where we need to d/c them quickly.
I just tried IM versed but it took forever to work and we still had to wrestle the guy, though I probably didn't give enough ( 5mg for a ~90kg autistic guy)

- Agree that doing these cases at an ASC seems to run counter to the principles of an ASC.

- Also, you can't make **** shine. You've been given a crap situation with an autistic patient and no availability of your drug of choice; it's not reasonable to expect a quick discharge. Adapt to the situation.

- You could try the classic ED "5 and 2" of 5 IM Haldol and 2 IM Ativan. Would probably be semi snowed still after 1-2 hours.

Case reports of intranasal dexmedetomidine, 200 µg per nostril. I have used it a couple of times, and although it takes several minutes to work, it does seem to work well.

I have my doubts about giving a long-acting intranasal drug to combative DD patients in a "quick discharge" type of scenario...

 

[midazzoler]

I agree about not giving more than 20mg midazolam PO. 40mg seems like a massive dose

I'm not opposed to 40 mg of PO Versed but, regardless of size or age, the pharmacy refuses to give me more than 20 mg PO. I gotta supplement or find a way to get more pull than the pharmacy.

 

[deleted162650]

I gotta supplement or find a way to get more pull than the pharmacy.

Did you tell them your screen name?

 

[WholeLottaGame7]

I'm not opposed to 40 mg of PO Versed but, regardless of size or age, the pharmacy refuses to give me more than 20 mg PO. I gotta supplement or find a way to get more pull than the pharmacy.

You didn't get that name by giving up that easily. Keep trying!

 

[somedumbDO]

Case reports of intranasal dexmedetomidine, 200 µg per nostril. I have used it a couple of times, and although it takes several minutes to work, it does seem to work well.

works in kids 2-4 mcg/kg takes a SOLID 45 min to work. it still isnt as good as a nice K hole....

 

[propadope]

Has anyone tried IM precedex and versed?

http://www2.pedsanesthesia.org/meetings/2013winter/posters/uploads/373--NM-293.pdf