So do I when in the field or in resus.... with adults
Ray
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Rowley Cottingham
Sent: 19 November 2009 23:03
To: [log in to unmask]
Subject: Re: Ketamine
Yes, a typo. In adults I tend to use 25mg increments to effect.
Sent from my BlackBerryR wireless device
-----Original Message-----
From: Adrian Fogarty <[log in to unmask]>
Date: Thu, 19 Nov 2009 21:51:04
To: <[log in to unmask]>
Subject: Re: Ketamine
I couldn't agree more. We use ketamine regularly for children's lacerations,
which are almost exclusively facial. The operator is therefore right there
at the airway listening for all those interesting airway sounds: secretions
and phonation being the common sources with ketamine, while snoring is
exceptionally rare (each require a different response).
We tend to do wounds which can be fixed within the 10-minute operating
window, so 3-4 sutures is the norm. Therefore it is easy to stop to listen
and observe, or intervene if and when necessary. There seems no point in
having a "sedationist" standing further away with their hands in their
pockets. After all, we are not scrubbed up with our hands in the patient's
chest or abdomen, neither are we overly preoccupied with the business of
surgery itself. It's perfectly easy to "multitask" in such cases.
I would take issue with Rowley's doses, however. We use 4mg/kg im as we feel
a higher dose is safer than a lower dose (serious complications such as
laryngospasm occur with light sedation rather than heavy sedation), though
one would tend to use half that for iv, but 0.1 to 0.3mg/kg sounds
homeopathic, so I presume it's a typo.
AF
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, November 19, 2009 7:45 PM
Subject: Re: Ketamine
>I have now used ketamine regularly for over 20 years, both in and
> pre-hospital. It's greatest problem is that it is called an anaesthetic
> and
> therefore naturally anaesthetists think of it as their preserve. In truth,
> it's a drug hardly any anaesthetists use in hospital.
>
> It's an ED and pre-hospital drug in the UK. It does not give true
> operating
> conditions except in high doses (4-10mg/kg). It induces a dissociative
> state
> where reflexes are well preserved and the risk of loss of airway and
> apnoea
> is minute; 0.03% in the initial studies in the 70s. Sialorrhoea is the
> major
> complication and certainly in children use of glycopyrrolate or atropine
> can
> be considered.
>
> Ketamine has been extensively used in the third world for single operator
> surgery such as sections because of this safety profile.
>
> The risks that require additional operators for 'traditional' opiate and
> benzodiazepine analgesia that may need urgent attention (loss of airway,
> vomiting and apnoea) are not there. It is as wrong to think of ketamine as
> a
> sedative in the same way.
>
> So if the risk is not there, neither is the need to be vigilant for it. I
> am
> obviously not advocating a laissez-faire approach, but certainly an
> operator
> and one assistant is adequate for the doses of ketamine we use (0.1 to
> 0.3mg/kg).
>
> The risks rise when it is combined with other agents such as midazolam or
> propofol.
>
> There is a vogue for ketamine with midazolam to improve muscle relaxation,
> and it can be a useful combination - so long as you have access to the
> airway. It is certainly not wise in the trapped patient with windscreen by
> face. However in the ED resus setting with relatively short procedures and
> low dosages in use it is still quite reasonable and safe to have two
> people
> present.
>
> BW
>
> Rowley
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Adrian Boyle
> Sent: 19 November 2009 18:45
> To: [log in to unmask]
> Subject: Re: Ketamine
>
> We always have two docs and a nurse. My feeling is that
> the sedationist has to be just sedating and nothing else.
> We do most IV, reserving IM for the impossible to
> cannulate or get near. In practice this means one
> (usually the SHO) does the procedure and the other
> sedates, usually the SpR or Consultant. The advantage of
> IV is a quicker recovery. I giess we need to be squeaky
> clean about this, and I can imagine the anaesthetic
> bleating that we are nearly as bad as endoscopy.
>
> adrian
>
>
> On Thu, 19 Nov 2009 18:21:46 -0000
> Ray McGlone <[log in to unmask]> wrote:
>> The College Guidance on Ketamine came out earlier this
>>year. It includes the
>> following...
>>
>>
>>
>> 5. At least three staff are required: a doctor to manage
>>the sedation and
>> airway, a clinician
>>
>> to perform the procedure and an experienced nurse to
>>monitor and support the
>> patient,
>>
>> family and clinical staff.
>>
>>
>>
>> Since the early 90's we have been using low dose i.m.
>>ketamine at Lancaster
>> with a doctor and nurse with no critical incidents.
>>
>>
>>
>> I asked the advice of Steve Green the USA Ketamine
>>expert and his response
>> was...
>>
>>
>>
>> "In the USA the ASA and AAP guidelines both dictate 2
>>doctors for deep
>> sedation, but yet moderate sedation can have just 1
>>doctor and a monitoring
>> nurse. They don't mention ketamine specifically and
>>where it should best
>> fall, and as you no doubt know the dissociative state
>>doesn't formally meet
>> the definitions of either deep or moderate sedation.
>>That being said, at
>> Loma Linda from the 1980s on we have never required 2
>>doctors and quite
>> commonly the only doctor is the one doing the procedure
>>(although always a
>> procedure that could be quickly interrupted). Requiring
>>2 doctors is
>> prohibitive in many EDs where only a single doctor is
>>available."
>>
>>
>>
>> Of course the College of Anaesthetists were insisting on
>>two doctors for a
>> Bier's Block for years........ which was not normal
>>practice in Emergency
>> Medicine.
>>
>>
>>
>> What is your practice for ketamine?
>>
>>
>>
>> Ray McGlone
>>
>> Lancaster.... where it is still raining!
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
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