Ketamine for dressing changes

[apaisRN, RN, CRNA]

I have never used ketamine. I was a floor nurse before I was an ICU nurse, have never spent time in the ER or the OR which is where I believe it is used. I have a question for the anesthesia folks about it.

We have a MICU patient, obese, failure to wean in addition to an enormous wound on her right buttock/groin that expends almost to her perineal area. It was a nasty abscess and is healing reasonably well with a wound vac. Changing the wound vac is a b&^$#, because of the size of the wound, the location of the wound and the fact that you are basically trying to stick the dressing on musous membranes (vulva) because the wound extends right to the edge. It is supposed to be changed three times a week but is done more often because it's always leaking air. Changing it is very painful for the patient.

She is cared for by an NP who manages FTWs in our unit. This NP is EXTREMELY anti-sedation. I respect her position, that her patients can't tolerate any chance of resp depression, but she takes it overboard. Her patients often have legitimate causes of pain, and she does things like write for 25 mcg of fentanyl q12. She gets very defensive when nurses ask her to reconsider her orders. For this patient, she has ordered ketamine for these thrice-weekly dressing changes. This seems inappropropriate to me, because my understanding is that ketamine is not an analgesic, and also causes nightmares/hallucinations. This woman is getting it at least three days a week - she'll be in a constant psychotic state! Also she protests vigorously during the procedure, and is clearly in pain.

This patient weans for several hours a day on trach collar, but could be easily put back on the vent for a brief procedure.

Is this regiman appropriate? Why would someone have chosen ketamine? What might be a better option? Is the thought here that the ketamine will cause amnesia so it's okay if the dressing change hurts?

The nurses would like at the very least to give her some MSContin or something, because this enormous wound is painful all the time anyway.

[Brenna's Dad]

Ketamine is a disocciative anesthetic, but also a strong analgesic. In low doses, the analgesic effect can be very pronounced while avoiding the hallucinations etc.

It sounds like ketamine (in the appropriate doses) would be an excellent choice for this patient.

[rn29306]

I agree with Brenna's Dad about ketamine. You said perhaps the NP was against any drug that caused resp depression, and ketamine is the only drug of its kind to not cause loss of respirations. In fact, ketamine causes an increase in most patient responses, HR, BP, resp rate. It also causes excessive drooling, so have suction available or use an anitsialogue pre-op. There are two schools of thought about the use of versed to decrease the emergence delerium with ketamine. One group says to give pre-op regardless of procudure and the other group waits for the delerium to take effect and then give the versed. It would appear that she is a candidate for versed given her anxiety with the dressing changes. Two cautions with ketamine: a cardiac history or ongoing cardiac problems is a red flag as it does cause an increase in HR and BP. Also, be careful of giving ketamine to patients who have their endogenous catacholamine reserves depleted. The reason for the exictation effects of ketamine is that it causes a release in the patients own endogenous catacholamine reserves. In the patient who has their endogenous catacholamine reserves depleted, the exictation response is blunted and possibly be non-existent and a profound depressant effect may occur in the CV system. Given that she is in the unit and has daily wound changes with fear and pain, she may be in the category of having her catacholamines depleted d/t constant stress.

[loisane]

While ketamine has many properties that would be advantageous in the situation you describe, I believe it is classified as an anesthetic. It is my understanding that it would not be an appropriate drug for a non-anesthesia professional to administer.

I know that some anesthesia drugs are given in the ICU by non-anesthesia, but aren't those limited to patients who are 100% ventilator dependent? This patient does not fit that criteria.

What about an analgesic with a respiratory ceiling effect like talwin, nubain, etc.?

loisane crna

[apaisRN, RN, CRNA]

This is very interesting. I was wrong about ketamine not being an analgesic, but possibly right that it isn't a good choice.

I haven't cared for the patient personally in a couple of weeks, but my understanding is that she remains on TC for the procedure. Obviously it's RNs who are giving the drug. The patient probably has a cardiac hx - she's in her 60s with morbid obesity. I'll check tomorrow.

So ketamine causes delirium on emergence only? (This I can look up, I know.)

[UCDSICURN]

In my hospital we use Ketamine for burn patients and those with very large dressing changes, such as diarticulated hips. Those that get Ketamine are usually long term narcotics users. They must be vented and the Ketamine has to be administered by an RN that has had a docuemented inservice by anesthesia.

These patients have to be put on a rate for the dressing change and for a short time after, but so do those that we use Fentanyl and Versed on, especially for large dressing changes. We're very anti-pain here and putting someone on a rate for a while during and after a large dressing change is pretty common.

Donn C.

[TELEpathicRN]

We use ketamine for procedures/burn dsg's in our Pedi ER. Our policy states that the MD must draw the drug up and also push the drug. Most MD's go ahead with the versed pre procedure and give something to dry up secretions. I haven't seen it have a negative effect on resp status. It seems to be very effective.

[jwk]

This is very interesting. I was wrong about ketamine not being an analgesic, but possibly right that it isn't a good choice.

I haven't cared for the patient personally in a couple of weeks, but my understanding is that she remains on TC for the procedure. Obviously it's RNs who are giving the drug. The patient probably has a cardiac hx - she's in her 60s with morbid obesity. I'll check tomorrow.

So ketamine causes delirium on emergence only? (This I can look up, I know.)

If they have delirium, yes, it will be on emergence. A little versed along with the ketamine goes a long way towards preventing this. It also helps if they wake up in a quiet, calm environment.

Ketamine is a wonder drug for lots of things - until it became a scheduled drug, we used to carry it in our pocket, particularly for C-Sections. Some women get a great epidural block for their C/S, but really don't do well with all the tugging and pulling sensations they still feel. I'll start with some fentanyl and valium, but if that doesn't get them settled down, ketamine usually will. And I'm just talking about small doses - 10-20mg may be all it takes to get them to mellow out. For procedures or induction of anesthesia, it generally takes 1-2mg/kg, sometimes a little more. It can also be given IM, which is great for doing procedures on mentally handicapped kids. They mellow out after a few minutes, which then makes it easy to get an IV going and do the procedure.