For some reason, I seem to be the ketamine queen in our er. The docs have started to use it on kids for extensive lacs or reductions when the kids are really (really, really) uncooperative or we are just not able to get them to be still for the tx. First time, it scared the holy *** out of me!. I looked it up before giving it, but still........... this fat little two year old went from screaming at the top of his lungs, and flailing all over the place, to this tranquil little (well, fat) kid laying limply on the stretcher with his eyes jerking back and forth. looked like he was watching tennis or something. can you say nystagmus (sp?). I got the doc because the mom was freaking out (causing me to try to look like I was NOT freaking out). He takes one look at the kid and says, "oh...he's just hallucinating" Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
anyway, now I have administered it to three or four kids, and to my knowledge, none of the other nurses in the department have had this "wonderful learning opportunity" the kids come out of it fine, and I've had no problem. I have been following our iv conscious sedation protocol, but am wondering if I should be doing anything else? the protocol was written for adults, and all the little ketamine people are kids. I don't do peds! (I do that at home in my off time). anybody else have protocols specifically for ketamine or peds ivcs?
When did we stop talking about the pharmacology and safe administration of ketamine and start throwing flames? I apologize if I unintentionally offended you, I just have strong feelings about safe practice. I refuse to stoop to your level of immaturity and respond to your personal attacks on me.
For the CRNAs and student nurse anesthetists, I did a nice case today with propofol, ketamine and alfenta drip for sedation on a difficult eyelid case. The surgeon wanted the patient deep for part of the case, then wide awake enough to open her lids, then back to sleep. It was a little tricky, because the surgeon was impatient, but went well. I think general anesthesia is much easier than sedation, but this patient needed to be awake at times.
A few years ago fentanyl was ONLY used in the OR, now it is given by for pain by nurses without specialized training.
Conscious sedation was not done outside of the OR until a few years ago. It is now a fairly common practice and is safely done every day both in the hospital and in free standing surgical centers.
Times change and nursing scope of practice evolves, nurses have a responsability to keep up to date on current practice and standards.
When did we stop talking about the pharmacology and safe administration of ketamine and start throwing flames? I apologize if I unintentionally offended you, I just have strong feelings about safe practice. I refuse to stoop to your level of immaturity and respond to your personal attacks on me.
For the CRNAs and student nurse anesthetists, I did a nice case today with propofol, ketamine and alfenta drip for sedation on a difficult eyelid case. The surgeon wanted the patient deep for part of the case, then wide awake enough to open her lids, then back to sleep. It was a little tricky, because the surgeon was impatient, but went well. I think general anesthesia is much easier than sedation, but this patient needed to be awake at times.
holy moly...........just wanted to know if there were specific PEDIATRIC conscious sedation guidelines that were, in any way, different from the ones that are oriented to adult patients. Of course we get consent, oral airway/BVM at bedside, cardiac monitoring, oximetry, iv (usually once ketamine starts to work), 02, crash cart. Last hospital I worked at, we even were required to have a respitory therapist at bedside when IVCS was initiated (I liked that). I think I misspelled respitory. anyway.....?
i frequently used "conscious sedation" - is there really such a thing
conscious sedation means the individual should still be awake and able to
follow commands...but the majority of the time this is not the case....
i personally remember being in charge one nite...when the director of our ED (big dummy) wanted to reduce and 81y/o female's thumb...he gave her a small dose of etomidate...
usually a pretty stable drug cardiac wise...it snowed her, dropped her RR and BP - so he lays her flat....huge mistake...she then aspirates prior to waking up....
all we are saying is that these drugs are highly dangerous...and although times change and nurses are doing more than ever...is it worth your license when a court of law decides you were giving a med that you weren't really supposed to be giving?? reading a drug book excerpt doesn't at all give you all the ramifications of these meds...
i truly know of what i speak...i was in your shoes...i used to think..so, we'll just bag em.....WRONG...
if you are able to efficiently bag (which at times is very difficult) - how do you know how much pressure (mm hg) you are exerting?? too much and you will force air into the esophagus...then they will aspirate.....
the patients seen in an ED are always considered full stomachs...this means they haven't usually fasted etc... they will always require RSI -- which you cannot do w/ conscious sedation gone wrong...when it has gone wrong you are already too deep in it....
it is not a matter of "territory" it is a matter of patient safety and professionalism.
i frequently used "conscious sedation" - is there really such a thing
conscious sedation means the individual should still be awake and able to
follow commands...but the majority of the time this is not the case....
i personally remember being in charge one nite...when the director of our ED (big dummy) wanted to reduce and 81y/o female's thumb...he gave her a small dose of etomidate...
usually a pretty stable drug cardiac wise...it snowed her, dropped her RR and BP - so he lays her flat....huge mistake...she then aspirates prior to waking up....
all we are saying is that these drugs are highly dangerous...and although times change and nurses are doing more than ever...is it worth your license when a court of law decides you were giving a med that you weren't really supposed to be giving?? reading a drug book excerpt doesn't at all give you all the ramifications of these meds...
i truly know of what i speak...i was in your shoes...i used to think..so, we'll just bag em.....WRONG...
if you are able to efficiently bag (which at times is very difficult) - how do you know how much pressure (mm hg) you are exerting?? too much and you will force air into the esophagus...then they will aspirate.....
the patients seen in an ED are always considered full stomachs...this means they haven't usually fasted etc... they will always require RSI -- which you cannot do w/ conscious sedation gone wrong...when it has gone wrong you are already too deep in it....
it is not a matter of "territory" it is a matter of patient safety and professionalism.
so what exactly do you CRNA's (or CRNA students) propose? Are you suggesting the EVERY ER in the US is using unsafe practices? Do you have a lobbying group that works to remove medications from the list of those allowable in an ED setting?? If so, then you have the obligation to work to remove these meds from our access. Personally, I would LOVE it to have a CRNA/anesthesiologist rush right in every time we had to give conscious sedation.( I can see THAT happening, we cant even get them over for an intubation on a hard to intubate patient) It would certainly make my job easier and allow me to be an ER nurse.....
so what exactly do you CRNA's (or CRNA students) propose? Are you suggesting the EVERY ER in the US is using unsafe practices? Do you have a lobbying group that works to remove medications from the list of those allowable in an ED setting?? If so, then you have the obligation to work to remove these meds from our access. Personally, I would LOVE it to have a CRNA/anesthesiologist rush right in every time we had to give conscious sedation.( I can see THAT happening, we cant even get them over for an intubation on a hard to intubate patient) It would certainly make my job easier and allow me to be an ER nurse.....
L
if you get right down to it...
much of what we do in the ER is "highly dangerous" but we are in an unteniable (sp?) position...
kind of like the icu pts being boarded...
many of the gtts we have to manage are "highly dangerous" and we have limited exposure...but what is the alternative?
we are ALL trying to give quality care...
but until ALL "conscious sedation" patients are taken to ORs or same-day surgeries with CRNAs...
and ALL icu patients are taken to icu units with CCRNs...
and ER nurses are allowed to take care of the acutely injured/ill patient...
we are ALL going to have to try to do the best we can...
we all try to do the best we can....bottom line. We, as ER nurses do not have the luxury of being in the OR suite, in a controlled environment taking care of ONE patient at a time. We have to do what we have to do. After 9 years, I have the gift of experience on my side when hanging critical drips and pushing critical meds.
I often see RN's with little experience giving meds that they are not familiar with, just last week I heard one of our RN's (who is thought to be a prodigy) out of school 3 years, telling her orientee (who has NO previous nursing experience) that you "just push every drug over 2 minutes, that is the rule of thumb" I had to walk away....
back to the topic, I would love to see the day when CRNA's did ALL conscious sedations, it would make me a happy girl :rotfl:
hey...you all are preaching to an ED nurse....i am well aware of the situations we are put in...what i am telling you now with the small amount of in depth knowledge i have gained..is that yes...it is unsafe...
it is your life...practice as you wish....but i would check the inserts and make sure it doesn't say "to be administered by anesthesia provider" because it's your butt....and i wish you all well and hope that it never comes to a point where you do have to defend yourself.
hey...you all are preaching to an ED nurse....i am well aware of the situations we are put in...what i am telling you now with the small amount of in depth knowledge i have gained..is that yes...it is unsafe...
it is your life...practice as you wish....but i would check the inserts and make sure it doesn't say "to be administered by anesthesia provider" because it's your butt....and i wish you all well and hope that it never comes to a point where you do have to defend yourself.
I dont really have to worry about it because we dont give Ketamine all that often anyway... I will remember to call Anesthesia the next time we do give it though, that will get a huge laugh I am sure. :rotfl: :rotfl: OMG! what do we do after 5:00pm when Anesthesia goes home?????
VEETACH, I think you have serious issues. Every time I have seen you reply to someone who might not agree with you you just attack them. I am a CRNA with 3 yrs ER experience and 1 year ICU experience. In the ER I worked in anesthesia related drugs were given by qualified personnel. What is being said is not that you should not be giving those drugs but you had better watch your butt when a patient aspirates or dies on your bed even though you did nothing wrong. Your RN, and mine, behind the name more than likely will not cover you when the lawyer comes a knocking. Unless you have had training just for this more than likely even the hospital will not be able to cover you because this falls out of your scope of practice, period. Doesn't bother me that you give the medication, you do what you want. I just like to keep my distance from anything that could potentially be a lawsuit against me.
VEETACH, I think you have serious issues. Every time I have seen you reply to someone who might not agree with you you just attack them. I am a CRNA with 3 yrs ER experience and 1 year ICU experience. In the ER I worked in anesthesia related drugs were given by qualified personnel. What is being said is not that you should not be giving those drugs but you had better watch your butt when a patient aspirates or dies on your bed even though you did nothing wrong. Your RN, and mine, behind the name more than likely will not cover you when the lawyer comes a knocking. Unless you have had training just for this more than likely even the hospital will not be able to cover you because this falls out of your scope of practice, period. Doesn't bother me that you give the medication, you do what you want. I just like to keep my distance from anything that could potentially be a lawsuit against me.
I do not have an issue with anything except those people who think because things arent done the way they like them, then they are allowed to criticize how others give patient care (not knowing them at all of course). Many times on this board people have been attacked and back down and just fade off into the sunset. I wont. If you view this as "having an issue" then thats your opinion. I have not attacked anyone, only responded to rude condescending posts to me by a fellow CRNA of yours.
I have repeatedly said the we do not give Ketamine in our ER on a routine basis. I was attacked when I originally responded to this topic and have been flamed numerous times since then by CRNA's. who has the problem here?
Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
yoga crna
530 Posts
Vee,
When did we stop talking about the pharmacology and safe administration of ketamine and start throwing flames? I apologize if I unintentionally offended you, I just have strong feelings about safe practice. I refuse to stoop to your level of immaturity and respond to your personal attacks on me.
For the CRNAs and student nurse anesthetists, I did a nice case today with propofol, ketamine and alfenta drip for sedation on a difficult eyelid case. The surgeon wanted the patient deep for part of the case, then wide awake enough to open her lids, then back to sleep. It was a little tricky, because the surgeon was impatient, but went well. I think general anesthesia is much easier than sedation, but this patient needed to be awake at times.
YogaCRNA