Nausea and Vomiting

WntrMute2 · Feb 2, 2003

I have used the ketaminie/propofol combonation. Don't forget the analgesic qualities of ketamine. Used as you described, milder respiratory depression is a significant advantage.

yoga crna · Feb 3, 2003

Just a few comments about droperidol. I have seen many patients who complained about dysphoria post droperidol EVEN IN LOW DOSES. I want my patients to have a good anesthesia experience, so I avoid drop, except for the rare patient who said that it was the only thing that worked.

I am also skeptical about the use of decadron to prevent PONV. As a steroid, it has many adverse effects including delayed healing. It also causes the patient to be "jazzed up" and unable to sleep.

I hope all of you students are doing post-anesthesia follow-up. It is one of the most important tools to understanding the art and science of anesthesia.

Yoga

loisane · Feb 3, 2003

Propofol/ketamine is a great technique, from what I hear. Never have gotten a chance to try it out.

I hear it proposed for what is jokingly called a "room air general". Deep sedation for plastics, laser dermabrasion, etc for which it is difficult to impossible to provide even NC O2.

Don't forget midazolam first. Everyone I have talked to about this technique says it is crucial to give the midazolam before the drip, otherwise you get the unpleasant psych effects of ketamine.

loisane crna

smiling_ru · Feb 3, 2003

Thanks, I was under the impression that the propofol mediated the negative effects of the ketamine. We routinely pre-op with 1-2 of versed, would that be an adequate amount to mediate the effect or should I give it again once in the OR? Sorry for all the questions but there really is nothing in the literature regarding the best methods.

loisane · Feb 4, 2003

Hmmm-turns out your might have something there, smiling_ru.

I first heard about the room air general with ketamine/propofol on another CRNA BB. Those practitioners advocated midazolam, as I posted earlier. I remember there was a reference, I think it was in one of the cosmetic surgery journals.

I couldn't find where I saved the reference (I think it was a computer or two ago, file got lost). So I ventured out into cyberland to try and find it. I came across the name Barry Friedberg. Seems he has published quite a bit on it. (Friedberg, Barry. Propofol-ketamine technique: dissociative anesthesia for office surgery. Aesthetic plastic surgery. 23:70-75, 1999). There is some discussion about the technique on the site of SOBA-the society for office based anesthesia. This technique is very useful in an office setting.

His position is that midazolam is not needed, that indeed propofol does prevent ketamine induced hallucinations. So there is support for what you have heard. In his description, he sedates with propofol, boluses with ketamine, then gives the local. No further ketamine is needed, since the painful part is over.

In the "CRNA" technique I heard about before, ketamine was added to the propofol drip, and titrated for effect. This drip was continued throughout the case for continued sedation. This way might work better if the patient (and/or surgeon) wants to stay asleep throughout the case. Anecdotal evidence suggests the need for midazolam when propofol/ketamine is given in this way. But it appears we don't really know. Anybody need a research topic?

Again, I have no clinical experience with this technique. Maybe tenesma, yoga or someone else has, and can give us their opinion.

And the moral of the story is that more CRNAs need to do, and publish, research. We develop techniques, notice trends, make revisions of techniques. But it is all lost because we do not follow up with documentation. I hope our next generation makes progress in this area. (hint, hint you guys)

loisane crna

Tenesma · Feb 4, 2003

1) droperidol and dysphoria: any time you are messing with the dopaminergic receptors of the brain you run the risk of having dysphoria, anxiety, agitation, extrapyramidal symptoms or even sedation. the incidence is believed to be the same across the board for all dopaminergic drugs, which includes phenergan as well as (surprise) reglan... if you look at the package inserts (PDR) the incidence for behavior changes/dysphora/agitation between reglan and droperidol are very similar.

2) decadron and PONV: the dose used for PONV (4mg) doesn't interfere in any measurable way with wound healing... in fact look at the giant doses we give for neuro cases or maxillo-facial or plastics cases! i do agree that steroids can cause steroid psychosis, but i have yet to experience that from a single dose during anesthesia.

3) ketamine and propofol: barry friedberg has made a name for himself with ketamine and propofol.... admittedly those make a great combination for avoiding the usual stimuli for PONV, and i have used the technique.... however you have to choose your cases carefully as losing the airway can happen, aspiration can happen and often the local provided by the surgeon isn't enough to cover pain thus requiring some narcotics.

here is a quote from the study cited by loisane: "The technique

obliges the surgical team not to hurt the patient, sometimes

called "prophylactic analgesia." The operative

field must be injected with adequate local anesthesia via

tumescence, field block, nerve block, or combination

thereof. Trying to "cover" inadequate local anesthesia

with more ketamine will result in unnecessarily high total

ketamine doses with prolonged emergence as a consequence." i think this is kinda pushing it because i can have surgeons do locals with just little boluses of propofol for a deep MAC... and thus avoid any probs with ketamine...

bottom line, the best way to deal with this is to get together with a few of your buddies (CRNA/MDA) and develop a research study where you pre-select your patients with histories of PONV and administer to them a preset algorithm and then perform follow-up... who knows what kind of answers you could find.

loisane · Feb 4, 2003

Absolutely right. The key to a local mac is the local, not the mac. There are some surgeons who just don't give an adequate local, and their patients need to sleep.

Tenesma, it is interesting you note loss of airway with propofol/ketamine. I thought airway preservation was supposed to be one of the big advantages to this technique. What is the contributing factor do you think-patient too fragile, level too deep, etc? Or is it just that the addition of ketamine really doesn't make things that much different from any other cocktail we mix. Any sedation case (whether you want to call it conscious or unconscious) can take an unexpected turn to deeper than you were aiming for.

loisane crna

Tenesma · Feb 4, 2003

loss of airway ??? easy, anything that involves propofol :) (of course you can maintain an airway with propofol - but there is a blurry edge where the potential for airway loss is always there - that is why in an ideal world you never want anybody providing propofol unless they are an anesthesia provider - or the patient is already intubated)

ketamine alone maintains the airway most of the time, but not all the time...

Qwiigley, BSN, MSN, DNP, RN, CRNA · Feb 8, 2003

GREAT INFORMATION! Thanks :)

yoga crna · Feb 10, 2003

I don't wish to overdo this topic, but...in my opinion, just because you have drugs in the drawer, doesn't mean you are obligated to use them.

Yoga

Tenesma · Feb 10, 2003

but you are obligated in knowing how to use them and what the consequences are... and you should be obligated in using them if you feel that they will prevent a likely patient from experiencing PONV, because that can definitely 1) save money (shorter PACU/Recovery) 2) decrease aspiration (which saves lives) 3)make the patient happier

Qwiigley, BSN, MSN, DNP, RN, CRNA · Feb 12, 2003

I hate to vomit. I wouldn't want my patients to have to do so if I can avoid it. You know, better living through chemistry! :)