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Post by katevaughn on Mar 29, 2018 16:47:41 GMT -5
This month’s journal club is presented by Kristen Horsman. She chose a very interesting article that looks into the use of Ketamine to help prevent chronic postsurgical pain. Many of our colleagues use Ketamine for our spine cases but this article draws attention to the possibility of using it for many more cases. This will stimulate great discussion regarding multimodal analgesia. Feel free to also delve into other multimodal approaches you use on a daily basis so we can all learn from each other. Enjoy! Here is a link to the article. Questions to encompass within your response: 1. Do you ever use ketamine as part of your anesthetic? Why or why not? 2. What cases, patient characteristics, comorbidities, etc. do you use it for? What doses of bolus/drip administration do you typically use for these cases?
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Post by LarSharVeA Bennett on Apr 5, 2018 9:51:13 GMT -5
I unapologetically love ketamine! In general, I use it to decrease the amount of narcotics, thus, decreasing the associated side effects. After most cases, I frequently check back to see how often patients require anti-emetics and pain medication; my findings are less with the use of ketamine.
I routinely use ketamine for IV drugs user, typically at 10mcg/kg/min. Understanding that ketamine works well for skin and bone pain, I also use it for spine, orthopedic, and cases that involve skin grafting. Recently, I have began using it for thyroid and parathyroids. As you know, because of nerve monitoring, we do not have the liberty of paralyzing those patients, however, I have experienced profound hyperalgesia because of high dose remifentanil. To combat this, I give ketamine 50mg a few minutes prior to incision (Nagelhout & Plaus suggests lidocaine or ketamine to mitigate remifentanil associated hyperalgesia). I found that the ketamine bolus obviates going above 0.1mcg/kg on Remifentanil, there is no bucking on incision, and there's a railroad tracking trend of vitals.
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Post by BrittneyKeating on Apr 15, 2018 12:03:31 GMT -5
1.) I do use Ketamine in my practice, but honestly speaking, I probably underutilize this great drug. The research and clinical discussion revolving around the phenomenon of central sensitization, activation of C fibers, wind up and the association with chronic pain is not new. Yet, the use of ketamine, and other NMDA antagonists are likely underutilized in many patient populations. This article mentions the use of N20 as another NMDA antagonist, and the use of other antinociceptive, non-narcotic medications such as gabapentin and pregabalin, which offer beneficial pain-relieving effects. As a whole, I believe our department utilizes these drugs frequently with big spine/orthopedic cases, and as part of ERAS protocols (specifically the use of gabapentin with ERAS), but there seems to be room for improvement so to speak, to expanding the use of these drugs in certain populations considered “high risk” for chronic post-surgical pain.
2.) I typically utilize ketamine for big spine/orthopedic cases, and large abdominal cases which are not part of the ERAS protocols (as dictated by the protocol). Additionally, I find this drug to be most useful for patients with a history of substance abuse, or for patients who have chronic pain and are prescribed high doses of narcotic pain medication. I think the idea of using ketamine in patients undergoing thyroid and parathyroid surgery to reduce the dose of remifentanil, as LaSharVea mentioned, is a great idea and is something I may consider utilizing in my own practice. The article mentions the use of ketamine in the post-operative period, which I think is an area where huge improvements and change can occur at our institution. As it stands currently, I believe that only patients who are seen by APS and are in the ICU are eligible to receive ketamine post-op. However, it would be interesting to see how many patients have “risk factors” for chronic post-surgical pain (such as radiation/chemotherapy, depression, length of surgery, etc.), but aren’t seen by APS, or are not in the ICU, and therefore miss the opportunity to receive ketamine as part of their post-op management.
I have heard some providers not using ketamine in patient’s who are septic or are considered catecholamine depleted. Yet, other providers use ketamine for induction with these patient populations. The article mentions catecholamine depletion as a potential side effect of ketamine. Just curious about others thoughts regarding the use of ketamine in patient’s who are either septic or catecholamine depleted.
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Post by Wai-Ling Lo on Apr 28, 2018 17:08:47 GMT -5
1. Yes, I use Ketamine as part of my anesthetic. I really appreciate the synergistic effect of Ketamine with propofol in sedation cases. I can achieve deep sedation with less respiratory suppression and a more stable hemodynamic status.
2. I use it a lot for obese patients and patients with history of chronic pain, substance abuse, PTSD and depression. The cases can be endoscopy, CVIL cases (TEE), or spine cases. For sedation cases, I titrate in 50mg (plus or minus depends on pt's response) IV bolus prior to procedure start and combine that with propofol infusion (~50mcg/kg/min), patients usually get through colonoscopy or TEE without much hemodynamic or respiratory issues. The dissociation feeling is usually transient. As for general surgery for chronic pain pts, I have tried 0.05-1mg/kg/hr infusion with pretty good pain control during wake up. Unfortunately that we are having Ketamine shortage and there is no Ketamine in Endo suite any more, so inconvenient!!
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Post by Chuck Eder on Apr 29, 2018 21:30:07 GMT -5
1. Yes, I use Ketamine occasionally. Mostly in the EP lab and Endo. It great to use when you are providing sedation for TEE and endoscopy procedures.
2. Patients that are obese, elderly, and sick hearts are usually good candidates when undergoing sedation for procedures. Typically, 30 - 50 mg IV can provide adequate sedation for these cases. I rarely use Ketamine infusions, however I may try some of the prior recipes posted in future cases. I enjoy reading some of the different uses that providers use in their daily practice.
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Post by darolyn on Apr 29, 2018 22:16:42 GMT -5
1. I typically use ketamine for patients where I want to maintain their BP, in patients with low EF and if they have pulmonary hypertension. These are patients who I would not want to use propofol solely. Also would use ketamine in patients who are OSA (most of our patient population, right?). Recently I have used ketamine in patients with LVAD who were having endoscopy performed.
2. I have used ketamine for patients undergoing painful procedures (think burn patients who are having a 'release' of their scar tissues) as it is great for decreasing the need for narcotics. However I have mostly used ketamine (bolus) in endo with the cardiac patients. I rarely use an infusion. I may start with a bolus of 40mg IV and then supplement with low low low dose of propofol infusion (longer procedures) and additional bolus of ketamine of 10mg IV as needed.
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Post by Jessica Switzman on Apr 30, 2018 7:04:52 GMT -5
I do use ketamine in C-sections when I need to supplement the epidural. I also use ketamine for patients who have addiction and or on a lot of pain medication. It is also good for pts with OSA, burn dressing changes and sometimes endoscopy.
I mostly bolus and rarely use a drip. I usually start with a bolus of 40-50 mg and rarely use more than 100mg. As with any drug it has its pros and cons. I find it interesting to read about ketamine being used for depression and other mood disorders.
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Post by klinden on Apr 30, 2018 20:25:05 GMT -5
I rarely use ketamine because of the dysphoric effects postop. I have had several pts who have requested to not have a repeat of their last anesthetic which included ketamine.
I do use it for trauma pts who are awake and have low blood pressure.
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Post by mdougla5 on Apr 30, 2018 20:38:00 GMT -5
1. I occasionally use ketamine as part of my multimodal approach for anesthetic management. My goal in using ketamine is for reducing the incidence of chronic post surgical pain (CPSP) and to decrease opiate consumption.
2.I use Ketamine in those patients who are obese with suspected OSA and/or have a history of chronic opiod consumption and hyperalgesia. In the Outpatient setting, our goal is to have fast turnover and fast discharges home or to the floor. As a result, our use of narcotics is minimal to decrease the changes of a patient having respiratory depression and a longer than anticipated perioperative course. A few weeks ago, I used 5-6 20mg IV Ketamine boluses to supplement the opoids given to a obese chronic pain patient. Once her pain was within a tolerable range, she was discharged home without any adverse physiologic effects.
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Post by chrisdiem on Apr 30, 2018 20:57:56 GMT -5
1.) Do you ever use ketamine as part of your anesthetic? Why or why not? —Yes I as well as my colleagues above, routinely use ketamine in a variety of different clinical situations. I use in sedation cases combined with propofol to provide deeper level of sedation while better maintaining hemodynamics and decreasing respiratory depression. I also, use as an analgesic adjunct in chronic pain patients or larger procedures to decrease opiate requirements and provide a multimodal analgesic. Have also used it as a primary induction agent in trauma or unstable patients.
2. What cases, patient characteristics, comorbidities, etc. do you use it for? What doses of bolus/drip administration do you typically use for these cases? —For sedation cases I use it for patients that have depressed cardiac function, obesity or OSA that tend to obstruct more easily, or for cases where I know I need a deep level of sedation. When it is a longer case I just put ketamine into the propofol vial. I mix 100mg ketamine into 100ml vial propofol to make it a 10-1 ratio. This makes infusion rates easy because of you run them both in mcg/kg/min the ketamine is 1/10th the rate of propofol. For TEEs usually just bolus 10-30mg in divided doses. As an analgesic adjunct I use different doses for different clinical situations. Our neuro colleagues, for big backs, bolus 1mg/kg then like to do 10mcg/kg/min then drop back to 5mcg/kg/min and then turn off completely far in advance of the end of the procedure. When I am using it myself, for a chronic pain patient and different procedure I do 0.5-1mg/kg bolus before incision and then infusion at 0.1-0.25mg/kg/hr and even keep it running for emergence. Evidence supports that the analgesic effects of ketamine are present these lower doses and I feel it beneficial to keep it on as long as possible. I also like to use Magnesium 2gm along with the ketamine for additional NMDA action, +/- nitrous depending on patient. I also have friends that work in other institutions where they use the lower dose of ketamine for big spines and even take patients to the NCCU, extubated with ketamine still infusing. One other unusual use it to treat severe dyskinesia related to Parkinson’s disease. I small dose usually 10-20mg ketamine will completely stop even severe dyskinesia in a patient with Parkinson’s disease. I have used this technique on two occasions after attending a conference and it is amazing how well it worked.
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Post by BGardner on Apr 30, 2018 21:03:35 GMT -5
1. I occasionally use Ketamine but probably not as much as I should or would like to, especially now that it is unavailable due to shortage. Also, the more we learn about this drug the more I think we are finding it an important part of our anesthetic armamentarium especially for chronic pain and big surgeries where patients are most at risk for CPS. 2. I use it mostly in endo for cardiac cripple patients with low EF and in EP for the same populations by giving boluses 10-20mg up to 50mg or low dose drip which I need to use more to get more comfortable with using regularly.
LarSharVeA- I love the idea to bolus prior to thyroid incision!
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