What is your Ketofol regimen?

[Outrigger]

Does anyone have any good recommendations for ketofol infusion dosing for patients with spinals? There are a fair number of LE surgeries in my practice and a large number of morbidly or even super morbidly obese patients which can be difficult to sedate on propofol necessitating the frequent use of oral airways.

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[GassYous]

If they're old I give 15 of ketamine for the spinal and run the prop at around 25
If they're not I give 30 of ketamine upfront with 2 of versed and run the prop around 50-75

They have perfect pain control you don't need much sedation. I just give em enough to keep them quiet.

 

[DrOwnage]

I regularly give ketamine and prop infusions with most of my ortho/LE spinal cases. I usually give 2 of versed for the spinal, when they lay down I give 0.2 of glyco with the FM on, start the prop infusion at around 70 mcg/kg/min, bolus 20-30 of propofol with some lido. Then give 10-20 of ketamine with that. I give around 10mg of ketamine every 45 minutes after that unless procedure is going to stop in less than 30 minutes. Works really well and patients are happy. I also don't use pillows during these MACs, I get a warm blanket instead and make sure their neck is extended properly. All of the pillows seem to flex the patient's neck a little bit.

I also do this regimen with a little touch of fentanyl here and there for cases where the surgeon is using local like carpal tunnel releases.

 

[dabears505]

If I use it, I put 50mg in a 50cc syringe filled with propofol. 2 versed for spinal, then bolus 5 cc of the mix and run at 75

 

[nimbus]

Why do you need ketamine if you have a spinal?

 

[sevo00]

Why do you need ketamine if you have a spinal?

wondering this as well. After placing spinal I don’t give them anything besides propofol gtt. No meds prior to spinal either, maybe versed if their super anxious

 

[sevo00]

For MAC cases with NO block or spinal, I mix 2 vials of propofol(400mg) , 100mg lido, and 100mg ketamine in a 50cc syringe then run it at 100mcg/kg/min. Prior to starting infusion give versed and Glyco

 

[dhb]

Why are you doing spinals with your GAs?

 

[GassYous]

wondering this as well. After placing spinal I don’t give them anything besides propofol gtt. No meds prior to spinal either, maybe versed if their super anxious

Half my patients have depression and anxiety

 

[deleted697535]

Why do you need ketamine if you have a spinal?

Exactly.
ketamine, glyco, fentanyl? with a spinal?
Why not just propofol? they have great dreams and leave happy.
whats wrong with oral airways?

I do a scope list about 30 scopes once or twice a month. Never used anything other than propofol

 

[Justice4all]

Only time I ve done ketofol is with the obese OSA patients. Usually allow for a lower rate. 20mg for 200 propofol. Works well.

 

[Katheudontas parateroumen]

Agree that if spinal as your primary anesthetic you won’t need any sedation or just a prop drip would be enough for most cases. Precedex is good if you have it gives just enough as well. But ketofol is a great combo to put them out n deep sedation. If I am gonna use it I squirt 100mg of ketamine into a 100cc bottle of propofol and just run the ketofol drip at 30-50mcg/kg/min. If your patient is 100kg, at 50mcg/kg/min prop you’re getting 0.3mg/kg/hr of ketamine which is plenty for either.

 

[DrOwnage]

I've noticed my patients enjoy the ketafol more, and have better dreams. Under 30 of ketamine for a 2 hour procedure is nothing and I believe it leads to less obstruction and movement during stimulating portions (when they're swaying back and forth from the hip gun). I also have never had one dysphoric patient with small doses of ketamine. All part of a balanced anesthetic, just like using decreased amount of propofol when precedex is added as an adjunct as part of a balanced MAC.