Ketamine

[jili]

I am looking for another RN (not advanced practice) who has given Ketamine for conscious sedation. I am being challanged by a CRNA and need some back up. Especially in Michigan, there is no law or nurse practice act that list specific drugs that an RN connot give.

[outlierrn]

I given it a number of times for procedural sedation (we don't call it conscious anymore, go figure). Usu for peds, IM or IV, sometimes with an atropine chaser. I'm an ASRN in California with plenty of experience in ER. We don't consider it a big deal, routine sedation precautions of course.

[traumaRUs, MSN, APRN]

I live in IL and Ketamine is sometimes used for children's sedation. We used to use it a lot but rarely give it nowadays. Fentanyl, versed and nitrous are more easy to titrate and you don't have the awakening issues that you do with Ketamine. If your CRNA is challenging this issue, ask him/her to show you the policy or state statute from the board of nursing.

[neneRN, BSN, RN]

In FL, where I'm at, RNs cannot push Ketamine, Brevitol, or Diprivan because they are considered general anesthesia. Not saying it isn't done, but technically, nope, not allowed.

[tridil2000, MSN, RN]

i've given it in nj iv to mostly kids in the ed as 'conscious sedation.' and yes, atropine is given as well.

we had this mentally challenged adult once who really needed a ct of the head after a fall. we couldn't hold him down to get a line in him so i gave him haldol im and ativan im. about 30 minutes later he was still crazy, so we tried ketamine im. it took a second dose to get him sedated, but we finally got the ct, and of course it was negative. i recovered him monitored, o2 etc and even placed a hep lock!

oh, and ketamine needs to be locked and counted with narcs too.

[Focker, CRNA]

Can you tell us more about the situation? How was this CRNA involved? What type of patient did you give it to? Is the CRNA "challenging" you because you misused the drug or simply because you used it at all?

It doesn't really matter what your state says, each hospital has to meet certain standards set by the state, but after that, the hospitals can add different regulations of their own. So it comes down to what your hospital policy states. As another poster states, it is pretty common for hospitals to limit administration of drugs like propofol, etomidate, ketamine etc. to a "qualified anesthesia provider."

[andhow5, BSN, RN]

I'm in Indiana and I've used Ketamine as a drug for "conscious sedation" several times. Of course, I follow my facilities P&P's for the conscious sedation, and there is always me (the RN), RT, the EDMD, and usually a tech in the room while this is going on.

I've never had to chase ketamine with another drug. In fact, when I've given it, I've never had to linger in the room because the patient's Aldrete scores pop right back to baseline within 5-8 minutes (at least, it has been that way every time I've used it).

In fact, the quickest I've ever had a patient bounce back was a dislocated ankle that EMS had treated with 4mg of morphine - I expected the patient to snooze for quite awhile. I did all my baseline vitals pushed the med, and watched the patient fall asleep.

The doctor popped the ankle in place, I glanced at the monitor to document the rhythm, and then the patient asked, "When are you going to start?"

We all jumped like we had been shot!

The only other med I've ever used for a conscious sedation is Versed. I really don't like how long my patients take to come around after using it.

Just check your facility's P&P for which medicines you use and you should be fine!

[outlierrn]

Lots of variation obviously, I've pushed brevitol and propofol before, and for some strange reason out facility doesn't require wasting ketamine, brevitol yes, go figure.

[NotReady4PrimeTime, RN]

Lately it seems ketamine is the flavour of the month at our place. We've even run it as an infusion to "augment" long-term sedation for several kids, but we're really anaesthetizing them to make up for being chronically short-staffed. (I HATE to do that... they're so psychotic while on it! One minute they're totally zonked and the next somebody drops a clipboard and they're dislocating their shoulders trying to get the restraints off. And that's WITH 4mcg/kg/min of midaz going!) In our facility it may be administered by a "specially trained RN", meaning all of our ICU staff. We are required to count and waste, a change in our practice that has caused no end of grief... many discrepancies due to the multi-dose vials and sloppy practice mostly.

[rgroyer1RNBSN, BSN, RN]

I am looking for another RN (not advanced practice) who has given Ketamine for conscious sedation. I am being challanged by a CRNA and need some back up. Especially in Michigan, there is no law or nurse practice act that list specific drugs that an RN connot give.

:balloons: I have given ketamine, versed, propofol, and a few others we use them all the time in the E-R for stuff like dislocations and endoscopy's.

Now we use etomidate almost every other day when where intubating usually the protocol at our facility for intubation is the following-

Benadryl

Sucs or Pavillion

Etomidate

Versed 0.5 to 2 IV

Lidocaine

Atropine

thats generally are RSI procedure I push it at least 2 or 3 times a week

then after the RSI and intubation are over we start them on a propofol drip and titrate it to maintain sedation.

Sometimes are docs will use an opiate with the RSI instead of versed alot of them use all those and some MS (Morphine) or Fentnyll, now on some procedures like endoscopies we do something like-

Benadryl

Versed

Morphine or Meperidine

Phenegran

hope that helped

Sincerely,

Rod RN, BSN

St.Louis, MO

[Nitecap]

If a state says a RN or certain provider cant give a drug then it doesnt matter if that hospital says it ok. The RN cannot give it if the state says no, that mean State Board of Nursing ect.

Im a RN and CRNA student. Really i think it depends what kind of dose you are giving. If you are giving a small stun dose for say a burn debridment than it may be safe for a RN to give. Its a great drug for such procedures as it causes profound amnesia, sedation as well as analgesia something benzo do not.

The issue hear is RN's giving larger and larger doses or repeated stun doses throughout the procedure to equal almost an induction dose of general anesthesia. In this instance we have to ask ourselves who is hear to manage the airway or adverse effects of this drug. The Pediatrician or burn RN or IM MD ect arent proficient enough to manage the airway. Really to manage anesthestics you have to immensely understand their mechanisms of actions as well as therapeutic and advese effects. As a RN in the ICU believe me I had no idea how half the drugs I used daily worked and would have provided better care if knew half of what I know now.

Ketamine can be a great drug or dangerous drug. Of couse a antisialagogue (antisecretion) drug must be given b/c the ketamine causes increased oral secretions from cholinergic effects which can lead to airway issues. As well ketamine increases release of Norepi storescausing HTN and possibly increases in HR. This can be detrimental to a pt with CAD, and fixed cardiac output ect. Increasing their HR and BP may cause a major CV event. In this case who will Manage the pt? The pedi or Burn RN? Who will be there with a box full of drugs to counter the adverse effects that come along with the therapeutic effects? The RN?

Also if the patient is catecholamine depleted say with chronic CHF compensation giving the Ketamine can actually cause profound hypotension as their are no norepi stores to release and counter the actual hypotensive effects of the ketamine.

Also one peson above claimed as awake issue. ketamine causes a catatonic state where the pt may have coordinated yet purposeless mvmt. even at doses large enough to induce general anesthesia. It is common to see arm as well as head mvmt as well as extraocular mvmts and nystagmus. This does not mean the pt is awake though it may appear so. this can cause issues in the provider that believes the pt is awake so gives another dose. Then along come more side effects. So Ketamine may not be the drug of choice if you are trying to keep a PEDI pt still for a procedure with risk for error or innacuracy s/t mvmt.

Also in the glycoma pt Ketamine increase Intraocular pressure as well in the head injury of Neuro Pt Ketamine can increase Cerebral blood flow, increase cerebral metabolic demand for o2 and increase ICP.

Ketamine again is a great drug for the right pt in the right situation. The problem lies in a few areas.

1- Both MD's and RN's not understanding the full scope of actions and side effects of the drug. Sorry but a GI or Rad MD usually knows little about anesthetics.

2- Wrong dosing s/t lack of knowledge of how to assess the dept of anethesia. Glasco may not be enough as the eyes may be open and pt moving even the pt is mentally asleep.

3-How much drug the person is giving. Doses equal to anesthesia induction doses should be administer by anesthesia personell or someone qualified to handle the adverse effects and airway.

4-RN's training with the Drug. I believe RN's should be at the very least inserviced by anesthesia on procedural sedation with ketamine or propofol.

Believe me Im all for expanded scope of practice for all RN's yet that RN should fully understand all the details of the drug they are giving. Its lack of knowledge that gets people is trouble when they adminster a drug and an adverse effect arises and they have no clue why or how to treat it.

Ketamine no propofol can be reversed like opiods and benzo. When its in its in and all you can do is manage the pt and wait for it to metabolize.

[mmcdon78]

Usually only use Ketamine for Pedi Procedural Sedation (IM or IV), preceeded by Atropine.

Ketamine is occasionally used by our MD's for RSI in asthma patients