Ketamine

AlabamaBelle · Jun 18, 2009

All our syringes are luer locks. You can dilute ketamine - I have - since it's such a small dose. Might also want to consider some versed with it. Helps mitigate some of the less desirable effects of ketamine. Veterinarians use it to sedate cats and they totally spaz out coming up from it. Ketamine was used for one of my daughter's caths and she had the same reaction. Versed really helps.

Higgs · Jun 18, 2009

We dilute ketamine mixed with versed and saline in our csci bags...

Medic09, BSN, RN, EMT-P · Jun 19, 2009

Like WarEagle said, you want to watch for Emergence Reaction. I see it in maybe 20% of our pedi patients. Don't know what the real statistics are. It is typically not dangerous, but requires a lot of soothing, calming, and sometimes restraining. Can look pretty scary to the parents. They're only reassured when they see I'm not too worried. Watch for vomiting with the reaction - protect the airway. http://medind.nic.in/iad/t03/i6/iadt03i6p456.pdf As the cited article notes, 'vitamiin K' is sometimes not so popular with nurses because of the need for pretty intense care afterward. To my mind, not a big deal since after any moderate sedation we watch the patient like a hawk until they've largely recovered. It is good to know which pharm adjuncts will make life easier, though.

Ketamine is a great drug. Our docs use it quite a bit and very successfully. In third world countries it is used regularly for pretty intense procedures and surgeries, given the lack of more sophisticated anesthesia capabilities.

Guest219794 · Jun 20, 2009

On the leur lock thing- The only syrnges we have that are small enough for acurate dosing are tb sringes. Ours just have a pressure fit that you can push into a luer lock, but I ave had them stip. With the dosing so small, even a very small slip could screw up dosing.

I just tried to get into an enpc course, but it was full. Trying to get over my pedophobia. (It's really jst a healthy conservatism.)

hherrn

knowurjoe · Jun 22, 2009

From the Texas Board of Nursing Website:

Of concern to the Board is the growing number of inquiries related to RNs and non-CRNA advanced practice registered nurses administering Propofol, Ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. It is critical for any RN who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and deep sedation/anesthesia.

Moderate Sedation Versus Deep Sedation/Anesthesia

According to the professional literature "moderate sedation" is defined as a medication-induced, medically controlled state of depressed consciousness. Included in the literature from various professional organizations is the caveat that, while under moderate sedation, the patient at all times retains the ability to independently and continuously maintain a patent airway and cardiovascular function, and is able to respond meaningfully and purposefully to verbal commands, with or without light physical stimulation. Reflex withdrawal to physical stimulation is not considered a purposeful response. Loss of consciousness for patients undergoing moderate sedation should not be the goal and thus pharmacologic agents used should render this result unlikely. If the patient requires painful or repeated stimulation for arousal and/or airway maintenance, this is considered deep sedation.

In a state of deep sedation, the patient's level of consciousness is depressed, and the patient is likely to require assistance to maintain a patent airway. Deep sedation occurring in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result in a life-threatening emergency for the patient. This is not consistent with the concept of moderate sedation as defined in this position statement or the professional literature and is generally considered to be beyond the scope of practice of the

RN

.

Although Propofol is classified as a sedative/hypnotic, according to the manufacturer's product information, it is intended for use as an anesthetic agent or for the purpose of maintaining sedation of an intubated, mechanically ventilated patient. The product information brochure for Propofol further includes a warning that "only persons trained to administer general anesthesia should administer propofol for purposes of general anesthesia or for monitored anesthesia care/sedation." The clinical effects for patients receiving anesthetic agents such as Propofol may vary widely within a negligible dose range. Though reportedly "short-acting", it is also noteworthy that there are no reversal agents for Propofol.

The patient receiving anesthetic agents is at increased risk for loss of consciousness and/or normal protective reflexes, regardless of who is administering this medication. Again, this is not consistent with the concept of moderate sedation outlined in the professional literature.

Though the RN or non-CRNA advanced practice registered nurse may have completed continuing education in advanced cardiac life support (ACLS) and practiced techniques during the training program, this process does not ensure ongoing expertise in airway management and emergency intubation. The American Heart Association (AHA) cautions ACLS providers about attempting tracheal intubation in an emergency situation since "Repeated safe and effective placement of the tracheal tube, over the wide range of patient and environmental conditions encountered in resuscitation, requires considerable skill and experience. Unless initial training is sufficient and ongoing practice and experience are adequate, fatal complications may result."1 It is also important to note that no continuing education program, including ACLS programs, will ensure that the RN or non-CRNA advanced practice registered nurse has the knowledge, skills and abilities to rescue a patient from deep sedation or general anesthesia. Furthermore, it is the joint position of the AANA and ASA that, "because sedation is a continuum, it is not always possible to predict how an individual patient will respond." These organizations state that anesthetic agents, including induction agents, should be administered only by qualified anesthesia providers who are trained in the administration of general anesthesia.

Therefore, it is the position of the Board that the administration of anesthetic agents (e.g. propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice registered nurses except in the following situations:

when assisting in the physical presence of a CRNA or anesthesiologist
when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
when assisting an individual with current competence in advanced airway management, including emergency intubation procedures

Guest219794 · Jun 25, 2009

from the texas board of nursing website:
when assisting in the physical presence of a crna or anesthesiologist
when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
when assisting an individual with current competence in advanced airway management, including emergency intubation procedures

interesting. texas bon explicitly supports use of propofol and ketamine by er nurses. i am surprised that in order for it to be within the scope of an rn, the provider has to have certain qualifications, but none are specified for the nurse.

hherrn

knowurjoe · Jun 26, 2009

when assisting an individual with current competence in advanced airway management, including emergency intubation procedures

While the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.

The Board again stresses that the nurse's duty to assure patient safety [Rule 217.11(1)(B)] is an independent obligation under his/her professional licensure that supercedes any physician order or facility policy.2, 3 It is important to note that the nurse's duty to the patient obligates him/her to decline orders for medications or doses of medications that have the potential to cause the patient to reach a deeper level of sedation or anesthesia. The nurse's duty is outlined in detail in Board Position Statement 15.14 Duty of a Nurse In Any Practice Setting.