Jump to content


Photo

Ketamine Drips For Mechanically Ventilated Patients


  • Please log in to reply
19 replies to this topic

#1 kymedic25

kymedic25

    Newbie

  • Members
  • Pip
  • 6 posts

Posted 16 February 2014 - 02:42 PM

Is anyone using ketamine drips for their CCT calls for mechanically ventilated patients?

Right now, we use Propofol but I am looking for something to back up propofol in case it fails, ie septic patients, hemodynamically unstable trauma patients etc.

Thanks.

Jason
  • 0
Jason C. Sargent BS, NREMT-P, CCEMT-P
Des Moines, IA

#2 Thinking

Thinking

    Advanced Member

  • Members
  • PipPipPip
  • 92 posts

Posted 21 February 2014 - 03:50 PM

I use Ketamine occasionally for sedation of intubated patents and I like it very much in the right setting. I typically reserve it for patients who are hypotensive and where I want a better option than propofol or Midaz and Fentanyl. In my limited experience (probably only around 40-50 patients over the last 10 years or so) I have had to DC it twice and switch to another agent due to it resulting in significant hypertension, which both resolved within several minutes of discontinuation.
  • 0

#3 kymedic25

kymedic25

    Newbie

  • Members
  • Pip
  • 6 posts

Posted 24 February 2014 - 11:23 PM

I use Ketamine occasionally for sedation of intubated patents and I like it very much in the right setting. I typically reserve it for patients who are hypotensive and where I want a better option than propofol or Midaz and Fentanyl. In my limited experience (probably only around 40-50 patients over the last 10 years or so) I have had to DC it twice and switch to another agent due to it resulting in significant hypertension, which both resolved within several minutes of discontinuation.



Thanks for posting. I am attempting to get my docs here in Des Moines to look at Ketamine as a back up sedative for mechanically vented patients, if propofol and versed/fentanyl fails. Since there isn't that much info out there I am having a hard time selling it. I would love to see us or someone do a study on it from the initiation and follow the patient through the ICU etc.


Jason
  • 0
Jason C. Sargent BS, NREMT-P, CCEMT-P
Des Moines, IA

#4 medic4cqb

medic4cqb

    Advanced Member

  • Members
  • PipPipPip
  • 308 posts

Posted 25 February 2014 - 12:38 AM

Is anyone using ketamine drips for their CCT calls for mechanically ventilated patients?

Right now, we use Propofol but I am looking for something to back up propofol in case it fails, ie septic patients, hemodynamically unstable trauma patients etc.

Thanks.

Jason


Found this on the Internet... http://emcrit.org/wp...on-ketamine.pdf
  • 0

Steve A., RN, CCRN, EMT-P

"The usefulness of a cup is in its emptiness..."
- Bruce Lee


#5 medsrgw

medsrgw

    Member

  • Members
  • PipPip
  • 29 posts

Posted 07 March 2014 - 10:58 PM

Thanks for posting. I am attempting to get my docs here in Des Moines to look at Ketamine as a back up sedative for mechanically vented patients, if propofol and versed/fentanyl fails. Since there isn't that much info out there I am having a hard time selling it. I would love to see us or someone do a study on it from the initiation and follow the patient through the ICU etc.


Jason


Why would propofol "fail"??
RW
  • 0

#6 Jwade

Jwade

    Advanced Member

  • Members
  • PipPipPip
  • 1405 posts

Posted 09 March 2014 - 01:48 AM

Why would propofol "fail"??
RW



+1, Was thinking the exact same thing.

In the ICU, we will switch the patient over from versed / Fentanyl to Ativan / Fentanyl. The PharmD people get a little wigged out about metabolites etc after 3 days on versed drips. We will use ketamine occasionally depending on which trauma service is on for the week. We routinely run propofol drips on our fresh burn patients and have yet to see one "fail". Would you please elaborate.
  • 0
John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#7 medic4cqb

medic4cqb

    Advanced Member

  • Members
  • PipPipPip
  • 308 posts

Posted 09 March 2014 - 02:11 AM

+1, Was thinking the exact same thing.

In the ICU, we will switch the patient over from versed / Fentanyl to Ativan / Fentanyl. The PharmD people get a little wigged out about metabolites etc after 3 days on versed drips. We will use ketamine occasionally depending on which trauma service is on for the week. We routinely run propofol drips on our fresh burn patients and have yet to see one "fail". Would you please elaborate.


John,

Quick question for you, since you're working in a BTICU... have you and/or your trauma docs noticed any issues with propofol effecting WBCs, particularly in the burn population? I know there was some literature about propofol causing issues with white counts (acutely) in burn patients. In the past, it's caused some our docs to wean as quickly as possible and/or switch to different pharm combo, I.e.; dexmedetomidine and fentanyl. I'd love to see ketamine used more this way... Funny, as I posted about this very thing earlier, I saw a flyer for an EMS conference being held here, where our docs are going to discuss ketamine's "reemergence".
  • 0

Steve A., RN, CCRN, EMT-P

"The usefulness of a cup is in its emptiness..."
- Bruce Lee


#8 old school

old school

    Advanced Member

  • Members
  • PipPipPip
  • 1121 posts

Posted 09 March 2014 - 01:25 PM

Why would propofol "fail"??
RW


I think he was referring to situations not where propofol actually "fails", but where it's hemodynamic effects are unacceptable.


+1, Was thinking the exact same thing.

In the ICU, we will switch the patient over from versed / Fentanyl to Ativan / Fentanyl.


Ativan? Ugh.
  • 0
bring it in for the real thing

#9 medic4cqb

medic4cqb

    Advanced Member

  • Members
  • PipPipPip
  • 308 posts

Posted 09 March 2014 - 03:41 PM

Ativan? Ugh.


I agree. I'm not a big fan of an Ativan drip, prefer it as a push drug for agitation. Hemodynamic effects don't resolve as quickly and the "groggy" feeling last longer after termination depending on the pt population.
  • 0

Steve A., RN, CCRN, EMT-P

"The usefulness of a cup is in its emptiness..."
- Bruce Lee


#10 Jwade

Jwade

    Advanced Member

  • Members
  • PipPipPip
  • 1405 posts

Posted 09 March 2014 - 07:22 PM

John,

Quick question for you, since you're working in a BTICU... have you and/or your trauma docs noticed any issues with propofol effecting WBCs, particularly in the burn population? I know there was some literature about propofol causing issues with white counts (acutely) in burn patients. In the past, it's caused some our docs to wean as quickly as possible and/or switch to different pharm combo, I.e.; dexmedetomidine and fentanyl. I'd love to see ketamine used more this way... Funny, as I posted about this very thing earlier, I saw a flyer for an EMS conference being held here, where our docs are going to discuss ketamine's "reemergence".


No, we only keep them on propofol long enough to get them through the initial resuscitation and faschiotomies. Usually after 36-48 hours, they are off the propofol. Also, in the burn population, it's gonna be real hard to tell if the WBC's are being affected by the propofol anyways.

As far as Ativan, yeah, i am not a big fan either. However, as i mentioned, there are 2 PharmD assigned to every trauma service ( Blue, Green, Gold) and they round with their respective service every morning and afternoon. They are pretty adamant in getting the burn / smoke inhalation people off versed drips after 3-4 days due to the reasons i mentioned above. We keep them on some really high doses of fentanyl and will run a paralytic if necessary like my patient i currently have, severe ARDS, P/F ratio <100, Pressure control, 15 Peep, FiO2 1.0, running nitrous, literally cannot handle being rolled without dropping his sats and decompensating. RotoProne is out due to being so unstable.......

I will have to ask about DEX, have not seen it used yet. Any useful links on Ketamine would be appreciated, would love to see it used more.
  • 0
John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#11 old school

old school

    Advanced Member

  • Members
  • PipPipPip
  • 1121 posts

Posted 10 March 2014 - 05:23 PM

They are pretty adamant in getting the burn / smoke inhalation people off versed drips after 3-4 days due to the reasons i mentioned above.


I'm curious why they don't like long term versed drips?

I am aware of issues with them but it seems like there is some conflicting info out there.
  • 0
bring it in for the real thing

#12 ForeverLearning

ForeverLearning

    Advanced Member

  • Members
  • PipPipPip
  • 382 posts

Posted 10 March 2014 - 06:33 PM

I'm curious why they don't like long term versed drips?

I am aware of issues with them but it seems like there is some conflicting info out there.



Science has this study http://www.ncbi.nlm....ubmed/23989093/

Although that bears little on this forum ;)
  • 0

#13 medsrgw

medsrgw

    Member

  • Members
  • PipPip
  • 29 posts

Posted 10 March 2014 - 07:53 PM

I think he was referring to situations not where propofol actually "fails", but where it's hemodynamic effects are unacceptable.



If they can't tolerate even sedative dosing of continuous propofol, they are likely profoundly hypovolemic which should be addressed initially. Ketamine is a good drug for sedation, but initially propofol would be my choice, as John mentions.
RW
  • 0

#14 old school

old school

    Advanced Member

  • Members
  • PipPipPip
  • 1121 posts

Posted 10 March 2014 - 11:34 PM

Science has this study http://www.ncbi.nlm....ubmed/23989093/

Although that bears little on this forum ;)


Yeah, I am well aware of the many potential issues with versed.

Versed is a hot topic in the anesthesia/CC world right now, which is why I was curious if there were specific things that John's unit was concerned about in their population.


If they can't tolerate even sedative dosing of continuous propofol, they are likely profoundly hypovolemic which should be addressed initially. Ketamine is a good drug for sedation, but initially propofol would be my choice, as John mentions.
RW


I completely agree. I would probably never choose ketamine over propofol for maintenance sedation. Or for most anything else, really.
  • 0
bring it in for the real thing

#15 Jwade

Jwade

    Advanced Member

  • Members
  • PipPipPip
  • 1405 posts

Posted 11 March 2014 - 01:34 AM

I'm curious why they don't like long term versed drips?

I am aware of issues with them but it seems like there is some conflicting info out there.


The PharmD i spoke with mentioned metabolite buildup after 3 days. I am back on thursday and will ask for some additional in depth reasoning from them. I simply had no time today with my train wreck patient i was glued to all day.

I will say the PharmD's do have a lot of influence on the multi-disciplinary rounds, and for the most part the attending Trauma / Critical Care Surgeons value their input and go with their advice.

Can you elaborate on what controversy versed has going in Anesthesia these days?
  • 0
John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#16 old school

old school

    Advanced Member

  • Members
  • PipPipPip
  • 1121 posts

Posted 11 March 2014 - 07:39 PM

Can you elaborate on what controversy versed has going in Anesthesia these days?


Midazolam is associated with significantly more delirium than other sedatives when used for long term sedation maintenance. It's not so much a controversy as just an issue that seems to be getting some more attention these days, probably due to the increased awareness of the problems associated with ICU delirium.

When I asked why your pharmacists don't like it I was wondering if there was something specific about the burn population that makes them dislike it. Metabolite build up is a potential issue with long term infusion of many drugs; I was curious if there was a problem using midazolam with the lower levels of serum protein in burn patients resulting in a higher free serum level, or possibly the platelet aggregation or cortisol suppression problems that can occur. Clearance of the active glucuronide metabolite 1-hydroxymidazolam can be reduced in any patient with impaired renal function, I wonder if there is anything specific to burn patients?

With most surgical patients the idea is usually to get them off the sedation as quickly as possible, but with burn patients there is a fairly long period where you have little choice but to use a lot of drugs to keep them comfortable, so I can see where these issues might be more important in that population.
  • 0
bring it in for the real thing

#17 Gila

Gila

    Advanced Member

  • Members
  • PipPipPip
  • 588 posts

Posted 11 March 2014 - 08:33 PM

Midazolam is interesting as the parent molecule is hydrophilic. As you might guess it undergoes phase 1 bio transformation via cytochrome-P450 enzymes. There are three major metabolites but one one is typically significant. In any event, hydrophilicity favours good clearance assuming hydrophilicity. Therefore, in spite of it's hydrophilicity, there is also a phase 2 conjugation reaction in the liver. This is typically what we see with midazolam, good clearance and a short t1/2. However, for reasons that I cannot fully appreciate, some patients who receive prolonged infusions experience marked changes in midazolam pharmacokinetics. As I stated, I'm not fully in the know and most of what I'm currently studying revolves around fairly intuitive and easy to derive toxicokinetic/pharmacokinetic models. I'd venture to guess renal and hepatic issues in the sick patient and perhaps saturation kinetics and first order to zero order conversion may be part of what is going in. However, there seems to interesting findings such as an increased apparent volume of distribution, suggesting sequestration in other compartments.

To recap, there are concerns with long term midazolam infusions, specifically with altered pharmacokinetics. I know a few evidence hounds may begin barking at me and I admit that I'm not in the vicinity of my resources but perhaps I can post links when I have access to a proper computer?
  • 0
Christopher Bare
"Non fui, fui, non sum, non curo "

#18 Gila

Gila

    Advanced Member

  • Members
  • PipPipPip
  • 588 posts

Posted 11 March 2014 - 08:35 PM

Please forgive any typographic or grammatical error.
  • 0
Christopher Bare
"Non fui, fui, non sum, non curo "

#19 Jwade

Jwade

    Advanced Member

  • Members
  • PipPipPip
  • 1405 posts

Posted 13 March 2014 - 05:02 PM

Midazolam is associated with significantly more delirium than other sedatives when used for long term sedation maintenance. It's not so much a controversy as just an issue that seems to be getting some more attention these days, probably due to the increased awareness of the problems associated with ICU delirium.

When I asked why your pharmacists don't like it I was wondering if there was something specific about the burn population that makes them dislike it. Metabolite build up is a potential issue with long term infusion of many drugs; I was curious if there was a problem using midazolam with the lower levels of serum protein in burn patients resulting in a higher free serum level, or possibly the platelet aggregation or cortisol suppression problems that can occur. Clearance of the active glucuronide metabolite 1-hydroxymidazolam can be reduced in any patient with impaired renal function, I wonder if there is anything specific to burn patients?

With most surgical patients the idea is usually to get them off the sedation as quickly as possible, but with burn patients there is a fairly long period where you have little choice but to use a lot of drugs to keep them comfortable, so I can see where these issues might be more important in that population.



Spoke to the PharmD this morning. In response to Versed, he said there is well documented studies that show negative outcomes with the extensive metabolite buildup from long term infusions. He further stated, a couple of other studies have shown in the Traumatic Burn Patient anything that can potentially lead to MODS is discontinued as soon as possible, which due to the unique problems associated with burn patients, this becomes even more important. He also mentioned the studies that show increased frequency of ICU delirium.

For example, my train wreck burn guy is on bi-level, Nitric, severe ARDS, now has ventricular irritability due to his poor oxygenation status and cannot even tolerate being turned to his side with a foam wedge. Last thing they want to do is keep him on something that may add another organ to his list of problems. Anyways, that's the explanation I got.

Thanks for the info on the versed.
  • 0
John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#20 onearmwonder

onearmwonder

    Advanced Member

  • Members
  • PipPipPip
  • 571 posts

Posted 18 March 2014 - 12:53 PM

These should help guide you in your clinical practice: http://www.neurocrit...support-enls... And this too: http://emupdates.com...n-continuum/... Typical doses are 1-4mg/kg/hr. Start at 1mg/kg/hr and see what your PT needs. Adding some fentanyl will help as well. Ketamine alone hasn't been proven yet to be as effective as a combo.

Matt
  • 0