As a non user of Ketamine, I've stayed out of the clinical debate, but I
do think this is an important point that has been pointed out by a
number of people already . We should set our own standards, not be led
by others...hang on, these standards we are debating HAVE been set by
our own (Royal)College! How did that happen?
Simon
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
Sent: 20 November 2009 09:45
To: [log in to unmask]
Subject: Re: Ketamine
But, as pointed out earlier, I think "keeping anaesthetists happy" might
be
missing the point. Shouldn't we be responsible for our own standards,
using
a drug which anaesthetists rarely if ever use, on our own patients and
in
our own departments?
AF
----- Original Message -----
From: "Adrian Boyle" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, November 20, 2009 9:30 AM
Subject: Re: Ketamine
> I'm aware that I am lucky having lots of juniors, being in a big
centre. I
> am not sure we enough safety data to really advoacate a single
operator &
> sedationist. This often means the 'operator' takes no more than 10
> minutes to do the procedure, so I don't see this as resource heavy.
It
> also keeps the anaesthetists happy (or quiet at least)
>
> I think Ray and Andrew should publish their single operator data, this
> would be a useful addition to the debate. The question comes down to a
> question of risk and how much risk is acceptable. There is an tiny
risk to
> ketamine sedation, as we all know, but I suppose hard numbers would
help.
>
> Adrian
>
>
> On Thu, 19 Nov 2009 21:51:04 -0000
> Adrian Fogarty <[log in to unmask]> wrote:
>> 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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