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]
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:
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!
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>