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These are all old arguments and discussions. I think this is the third cycle on this topic in the last few years! In the right hands Ketamine is the drug of choice for a number of Emergency Department scenarios, none of which Anaesthetists are as familiar with as Emergency Physicians. The emphasis in my department is on ensuring that whatever drugs are used, the procedure is done as safely as possible. One of the methods we use to ensure compliance with safety measures and that Registrars are not doing anything "feral" when the boss is not around is a rigid Team Time Out checklist, which is led by the nursing staff. Key rate limiting steps are "the consultant is aware of the patient and the proceedure" "the patient has been formally admitted to the ED" and "the doctor performing the sedation has the necessary credentials." This generates a discussion with the duty consultant about skills, knowledge, and the chosen technique, amongst other things. Of course, I work in a slightly different system, but the principles are easily translatable - as many barriers as practically possible without being overly restrictive on practice, to ensure patient safety. By following theatre proceedures we keep in-house colleagues happy! (We also use the Pre-Anaesthetic chart which on one side has the usual anaesthetic questions, airway assessment, ASA grading, etc. and on the other has an anaesthetic obs chart.) Marten Dr Marten C Howes FRCP(Glasg.) FCEM FACEM Staff Specialist Emergency Department Bunbury Regional Hospital PO Box 5301 BUNBURY 6230 Western Australia Tel: +61 +8 9722 1561 Fax: +61 +8 9722 1043 mailto: [log in to unmask] Marten ________________________________ From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Niels Merkel Sent: Sunday, 22 November 2009 1:19 AM To: [log in to unmask] Subject: Re: Ketamine I am not a consultant, and I would love to be in a work environment where consultants actually 1. had personal experience with it or at least 2. ...realised its huge benefit, and ideally... 3. ...had broad enough shoulders to stand their ground against anaesthetic resistance So far I have only been using it on adults and iv - and I think there are indications where it's just unbeatable: - 80+ year old in complete heart block with HR of 30/min and hypotensive, but still intolerant of external pacing without sedation. No way I am going to give this patient Midazolam and/or an opioid and stop their breathing! - Insertion of trauma chest drains, provided transient sedation appears clinically safe. - Moving/positioning heavily traumatised patients in the scanner - Agitated EMI patients with #NOF - to facilitate placement of nerve-stimulator guided femoral nerve blocks. They awake peacefully as their pain will be much reduced. I also feel that the answer to the debate 'haematoma block vs. Bier's block for reduction of colle's #' may well be ...25 mg Ketamine i.v - it just works. It's ironic that patients in the 3rd world often get a better deal than their 1st world counterparts for acute painful procedures - with all the medico-political issues that seem to dominate the Ketamine debate in the U.K.... In my previous workplace there were 4-5 consultant anaesthetists who used it in their own practice and were very positive about its use in the ED. However, the director of the anaesthetic department (who, of course, has never used it in its own practice)was against it. As the ED consultants favoured to sail a course of harmony with 'the anaesthetic department' (a heterogeneous group of people, as we see above) it wasn't implemented. Interesting - no debate about the potentially much more dangerous M & M though... Niels Merkel From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Mark Nicol Sent: 20 November 2009 20:11 To: [log in to unmask] Subject: Re: Ketamine I love debate around ketamine.I have introduced it in 2 hospitals.I have had great engagement and support from anaesthetic colleagues (same cannot be said of some "casualty" colleagues), not so much I think from me being FFARCSI qualified but going proactively with change management hat on: training package-powerpoint full of published literature, ALSO including reference of lack of safety with the perceived alternative midazolam,and separately reference form Australian emergency medical journal citing starvation prior to sedation is not a correlate of vomiting /not vomiting, quality assurance framework, sign off of the consultant supervised registrars experience, operational exclusion: dept so bloody busy with inadequate nursing staff to guarantee nurse supervised recovery, planned prospective audit of patient tolerance, parental satisfaction, healthcare provider satisfaction. I suspect I have given more ketamine in my 8 years at Macc. than many consultant anaesthetists...of course it would be inflammatory to ask for their log book. Another tangent to this is considering the "sedation for non anaesthetists guidelines", audit showed miscompliance with this, the guidance was then reissued under slightly different name several years later, which required of hospitals some 5 years ago to nominate 2 consultants in each trust in England to oversee the safe delivery of sedation...interestingly I know of ongoing litigation in a hospital where same patient had procedural sedation twice in 1 hospital spell, both episodes miscomplied with guidance. what may be way forward is to have web based database such that we can pool our experience, submitting into it like TARN except more cheaply: www.ketamine4kids.co.uk just a thought. mark at macc ________________________________ From: Adrian Fogarty <[log in to unmask]> To: [log in to unmask] Sent: Thu, 19 November, 2009 23:35:56 Subject: Re: Ketamine Interesting, I haven't seen that Ray. But I was intrigued the paper was entitled "predictors of emesis and agitation" yet commented on "overall airway and respiratory adverse events". My point is that some so called "adverse events", such as apnoea, are hardly events at all. They are tantamount to a normal "stage" of anaesthesia in many circumstances and are easily dealt with by a competent physician. The important adverse event is laryngospasm, and we know that occurs in light sedation and anaesthesia, in general, but rarely with deep sedation or anaesthesia. Granted, ketamine is not like other agents but in my experience one tends not to see laryngeal irritability - the precursor of laryngospasm - with deeper ketamine sedation. It's difficult to properly study, I admit, but in the absence of firm scientific evidence to the contrary, I feel much more comfortable relying on my anaesthetic nous, experience and intuition, so I prefer higher doses. But returning to your original point, I agree that there seems little point in having three staff for each ketamine case. Adrian ----- Original Message ----- From: "Ray McGlone" <[log in to unmask]> To: <[log in to unmask]> Sent: Thursday, November 19, 2009 11:13 PM Subject: Re: Ketamine Green did a recent meta-analysis and found the lower dose was not associated with more airway problems " We found that low intramuscular doses of ketamine (3.0 mg/kg) exhibited significantly fewer overall airway and respiratory adverse events, a finding at odds with a previous study that observed no such difference. There were no occurrences of either laryngospasm or apnea in the 682 children receiving lower dosing. This strongly supports the contention of McGlone et al that low intramuscular dosing is likely to be the safest overall format for ED ketamine." Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children. Green SM. Roback MG. Krauss B. Brown L. McGlone RG. Agrawal D. McKee M. Weiss M. Pitetti RD. Hostetler MA. Wathen JE. Treston G. Garcia Pena BM. Gerber AC. Losek JD. Emergency Department Ketamine Meta-Analysis Study Group. Annals of Emergency Medicine. 54(2):171-80.e1-4, 2009 Aug. Having said that it is still very safe at higher doses Needs a proper study though to be certain regarding the best dose.... Ray In Lancaster where it is still raining.... -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Adrian Fogarty Sent: 19 November 2009 21:51 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! >> >> >> >> >> >> >> >> >> >> >>