Questions about Ketamine & Propofol Case

[MmacFN]

Ok

So i had a call the other day where an ER physician at a very small facility, had intubated an adult asthmatic. Apparently the asthmatic was altered so the intubation ensued.

In anycase, just to confirm why diprivan shouldnt be used in the ER they gave these meds for induction to a basic asthmatic.

50 mg of propofol (Why?)

on propofol drip @ 19cc/hr (seems high to me)

Also, 180 of succs (why propofol then??)

and a dose of ketamine (cant remember dose) (isnt it ketamine OR propofol?)

In anycase, I do realize that the induction dose of propofol is 1-2.5 mg/kg and this patient was around 60 Kg so the doc went on the low side, but i just dont see why he would take the risk in the ER when we could easily use etomidate and succs? After all he used succs AND ketamine along with propofol!! The reason i say that is both the aspiration risk, as well as the issue that came up directly after the induction which was profound hypotension (systolics of 70-80). Then he called us. Helpful eh?

So, I arrive to find a patient who is still very hypotensive (80-85 systolic with a map of about 59-65), on a major propofol drip and intubated due to asthma. So im seeing a patient who was so severely decompensating that they became hypoxic enough to be altered (therefore in a ventilation perfusion mismatch) and then, as if to add insult to injury is now hypotensive to the point where the coronaries are barely filling as a result of medication. Anywho, i wasent thrilled.

Now here is where the ketamine issues arise. I have never given ketamine but for peds in the ER in very small doses for procedure. Even then, its a RARE case it seems. When i walked in this physician asked me if i could take a ketamine drip. Which, i could. Not feeling very good about all the other meds this pt already got and my realitive lack of comfort with the drug as a drip, i decided i would not allow the ketamine drip and said so to the doc. I also asked him why he wanted it in the first place and he said because of the asthma.

Now im farmiliar with ketamines H2 effects causing bronchodilation. I realise this theoretically, makes it the best induction agent for asthmatics. However, i have never heard of it being used as a drip for adults for the purpose of asthma. Have any of you?

Also, ketamine would have made sense only assuming that it was done with say succs. I dont see the point of propofol, succs and ketamine then the pt be placed on a propofol AND ketamine drip?? It dosent make sense to me at all, any of you seen this?

My other concerns relate to the effects ketamine has. Increased HR and increased contractility which = increased MVO2 demand. Now this might be OK if the patient wasent already so severely compromised, but with a hypotensive, hypoxic and now on the verge of cardiac ischemia, increasing the MVO2 demand without fixing the hypotension was senseless? While the ketamine might work against the propofol hypotensive effects, i think it would be disasterous to use it in this situation.

Secondly, the pts HR was already 130 because of continuous SVNs and hypotension, just another reason not to give ketamine. I will also add to that the fact that long before the physician decided to intubate he had given 4 of MS and 4 of ativan..... the ativan is typically contraindicated based on its sedative effects on an asthmatic in extremis, but i have read some studies suggesting asthma can be a combination of disease and anxiety so maybe there could be a case made for that (though i wouldnt give it) but i can see absolutely no benefit of the MS in this case.

Anywho , after taking over management of the patient i ended up D/C'ing the propofol drip and giving fentanyl and vecc for the ride. Her pressure came back in about 5 minutes with a fluid bolus. HR came down to 120. Then i gave solumedrol and put her on a mag drip along with continuous in line SVNs.

Her vent settings on arrival was 10 of PEEP (yes, my jaw dropped. Peep in asthma is conrotroversial and has no evidence to back it up) a TV of 700 on 100% and I:E of 1:4 as well as a rate of 12. Well.... i changed all of that.

Once i got her and placed her on my vent her ETCO2 was 60. Yes, thats what i actually said, SIXTY!!!!! They did not have ETCO2 so they had no idea how bad she really was. I changed her I:E times to 1:7, increased the frequency to 20 and dropped the TV to 400 about the lower side of the range (6-8 cc/kg in asthmatics). in about 5 min her CO2 was now 35-40 and sats 99%. After a couple of minutes i dialed back her rate to 15 and everything stabalized at those numbers.

So.... does anyone have any real explanation for the actions fo this doc that i may be oblivious to?

[WntrMute2]

I can't really answer your questions directly but a couple of your statements require exploration:

1)"Also, 180 of succs (why propofol then??)" Patients need hypnosis not just paralysis for intubation Intubating someone w/just sux is really inapropriate except in exreme cases. So the propofol bolus/gtt was indicated (the gtt for sedation p/ intubation.) We can debate the dose and whether generic propofol is the best agent for the job.

2)"The reason i say that is both the aspiration risk," This makes no sense, the choice of induction drugs has no effect on aspiration.

3) "So, I arrive to find a patient who is still very hypotensive (80-85 systolic with a map of about 59-65)" A MAP of 60 is NOT considered very hypotensive. Unless you know the LVEDP you can't say the coronaries weren't filling.

4) "Anywho , after taking over management of the patient i ended up D/C'ing the propofol drip and giving fentanyl and vecc for the ride. Well, you took all of her sedation away, since when is fentanyl (except in extreme doses and even then that is questionable) a sedative? Cardiac anesthesia was done with huge doses of fentanyl or sufentanil with high rates of recall.

5) A decrease in HR from 130 to 120 is a major accomplishment?

6) I submit, there is less of a serious question here than you want to prove how clever you are.

Sorry

[MmacFN]

wow.

Thanks for being so pessimistic. Let me answer your concerns/questions.

Also, 180 of succs (why propofol then??)" Patients need hypnosis not just paralysis for intubation Intubating someone w/just sux is really inapropriate except in exreme cases.

Yes I know, I RSI daily. What i said was why have all of those drugs. You could simply use succs and etomidate, succs and versed, succs and ketamine etc etc etc. There was no need to use succs, ketamine AND propofol.

So the propofol bolus/gtt was indicated (the gtt for sedation p/ intubation.)

Ugh. No, it was a bad choice. The patient became hypotensive with the bolus the physician pushed to a systolic of 80. A MAP of 55-60 and a systolic of 80 are minimum requirements for end organ perfusion and coronary perfusion. A propofol drip was contrandicated in a patient with hypotension such that there was no room to play with numbers. There are better choices.

"The reason i say that is both the aspiration risk," This makes no sense, the choice of induction drugs has no effect on aspiration.

You are thinking in the OR. This is a "well lit scene" with a very inexperienced family practitioner at a rural "ER/Clinic". The last time he intubated was over a year previous per his own admission and this took 4 attempts. There is a higher risk of aspiration with propofol than with a paralytic (from my perspective) when your not an experienced intubator. Secondly, a patient in extremis should always been intubated using paralytics simply because studies have shown that of all the IV induction agents, paralytics have proven to increase success rates in the crash airway than any other type of induction (ie: propofol) where you have to muck around with dose ranges.

"So, I arrive to find a patient who is still very hypotensive (80-85 systolic with a map of about 59-65)" A MAP of 60 is NOT considered very hypotensive.

Again your thinking OR. I worked CVICU i know it isnt horrible. However, this is a patient in extremis already severely compromised and most likely headed to cardiac ischemia. Clearly, this blood pressure is increasing the risk of mortality in a pt in extremis. Ive watched pts code with a BP like this who wernt managed quickly.

Well, you took all of her sedation away, since when is fentanyl (except in extreme doses and even then that is questionable) a sedative?

Uh huh. So you would have left the propofol on a patient with a BP of 80 systolic and let her code. Strong work. Or would you have also given versed to a patient with a systolic od 80 and watched as her pressure dropped further? Sorry, you dont get sedation when your hypotensive and in extremis, this is absolutely contraindicated in pts in extremis. Secondly, the fentanyl is what kept this paitent "high" so they could tolerate it after we got her BP back to normal (which was 100% due to the propofol), then i gave her versed.

A decrease in HR from 130 to 120 is a major accomplishment?

Wow. Are you even used to taking care of sick patients? Decreasing the HR of an asthmatic, however minor, has a direct relation to absolute MVO2 demand. Add to this the fact that she needed inline SVNs which would keep her HR up, she was hypotensive and compensating with an increase in HR and that she was hypoxic enough to be altered and intubated, YES a decrease in 10 is signifigant and trending in the right direction.

I submit, there is less of a serious question here than you want to prove how clever you are.

I was asking questions that related to an actual case. I thought it might be interesting but if your going to be an as* about it i wont bother posting anymore and the forum can go back to how it was, dead.

BTW: the recieving pulmonologist was thrilled at how we managed this patient after hearing how we found her. Did i do a good job? Your DAMN right i did and it all related to my own interest in study and keeping up with research and practice. I dont need any validation from this list as to how "clever" or "good" i am.

[WntrMute2]

"I was asking questions that related to an actual case. I thought it might be interesting but if your going to be an as* about it i wont bother posting anymore"

Cool

[Pete495]

The use of ketamine is very contraversial, so I won't get into that too much. Suffice it to say if a patient is crashing, I wouldn't look to give ketamine, giving its propensity to cause so many other side effects and know what else is going on. How can you evaluate your patient if they are hallucinating from the ketamine is my point of view. except the ketamine, the meds for induction seemed appropriate.

I'm not aware of literature that says propofol causes aspiration, but you can enlighten me if you find any. There's a higher risk of aspiration the longer it takes to intubate somebody, or if a patient is has a difficult airway, is morbidly obese, diabetic, pregnant, or has a full stomach. Generally pts. are difficult intubations when they are considered a 'trauma' patient also. I suspect this doc used ketamine because he didn't want to snow the patient with propofol, and the pt. had asthma, which probably a poor choice. don't know why etomidate wasn't used. probably cuz it's hard to draw up (j/k).

A MAP of 60 is sufficient from my point of view, esp. if the patient is non cardiac and on diprivan, but in your situation, I would have done the exact same thing if my pressure was in the crapper. It was probably right to get the pt. off of the propofol, and fentanyl is used very commonly for sedative purposes even though the tolerance to it is reached pretty quickly, and it requires increasing doses. I don't think the SVN was making your patients heart rate high. It was probably related more to what was going on, and poss. the ketamine. that's why I wouldn't give it in an emergency. I've given a lot of SVN's, and rarely see such an increase in HR. After changing the sedation, I would have given the fluid, and brought down the PEEP(causes hypotension and decreased cardiac output), and just rode it out.

[sc17]

It is obvious from the questions asked that you don't really understand what you are talking about.

"There is a higher risk of aspiration with propofol than with a paralytic (from my perspective) when your not an experienced intubator."

This is crazy. The point is to use propofol for sedation/hypnosis, and sux for paralysis for intubation. The two are not exclusive and using one without the other (or a different combination of sedative and paralytic)is likely to cause problems either way. The poster seems to think propofol by itself is a substitute for etomidate and sux together or sux by itself. I saw this in our ER when we tubed somebody with propofol and sux and the ER attending said "gee, why did you push the propofol before the sux? I"ve never seen it done that way." We said :Are you f'ing kidding me?

One reason for choosing ketamine in this severe asthmatic may be for its bronchodilating properties, so this is appropriate in this situation.

[MmacFN]

sc17

I think you misunderstood what i was saying.

This is crazy. The point is to use propofol for sedation/hypnosis, and sux for paralysis for intubation. The two are not exclusive and using one without the other (or a different combination of sedative and paralytic)is likely to cause problems either way. The poster seems to think propofol by itself is a substitute for etomidate and sux together or sux by itself. I saw this in our ER when we tubed somebody with propofol and sux and the ER attending said "gee, why did you push the propofol before the sux? I"ve never seen it done that way." We said :Are you f'ing kidding me?

Propofol is used for induction and intubation in various places WITHOUT a paralytic. Its written right in the anesthesia books I have as an option for intubation as opposed to succs. This physician used Succs, Propofol AND ketamine for induction. The actual timing of meds given was Ketamine --> Succs --> Diprivan which is inappropriate. I discussed with with some CRNAs and a pulmonologist in my ACLS class today and they all agree this was sheer stupidity. Their choice should have been succs and etomidate. They all agreed that the dose of propofol was low for induction but that it could have been a choice for induction alone at correct doses or used as a sedative, though none would have chosen it for either in this patient. They also agreed that ketamine could be a replacement for etomidate in asthma, but not in this particular case.

One reason for choosing ketamine in this severe asthmatic may be for its bronchodilating properties, so this is appropriate in this situation.

No it absolutely wasent. The patient was hypotensive and tachycardic, not to mention mismanaged with a ETCO2 of 60. Adding a med that would increase HR, Increase BP ergo increase MVO2 demand in a patient in such extremis is absolutely negligence. Everyone involved in the review of this case agreed both with my tx, reasoning and those conclusions. You show here that either you didnt bother to read the case or you "dont really understand what you are talking about"

[MmacFN]

Here is an Idea.

When you see my name on a post dont read it, i wont be reading anything you write since your response to this post shows lack of understanding an knowledge outside of what/where you currently work and, most importantly, lack of respect.

After all the questions you have asked on this forum over your membership, im sure you would have enjoyed being treated in the way you treat others. Love the professionalism.

"I was asking questions that related to an actual case. I thought it might be interesting but if your going to be an as* about it i wont bother posting anymore"

Cool

[MmacFN]

hey pete thanks for the reply :)

The use of ketamine is very contraversial, so I won't get into that too much. Suffice it to say if a patient is crashing, I wouldn't look to give ketamine, giving its propensity to cause so many other side effects and know what else is going on. How can you evaluate your patient if they are hallucinating from the ketamine is my point of view. except the ketamine, the meds for induction seemed appropriate.

The whole thing was surreal. I would not have given ketamine for the induction either in such a sick patient. After talking to the two CRNAs and the pulmonologist they also felt this was contraindicated.

I'm not aware of literature that says propofol causes aspiration, but you can enlighten me if you find any. There's a higher risk of aspiration the longer it takes to intubate somebody, or if a patient is has a difficult airway, is morbidly obese, diabetic, pregnant, or has a full stomach.

I agree. I did not make myself very clear with how i wrote that at all. What i meant to say was that the risk of aspiration was high especially for an inexperienced intubator. What i write came out totally wrong.

I suspect this doc used ketamine because he didn't want to snow the patient with propofol, and the pt. had asthma, which probably a poor choice. don't know why etomidate wasn't used. probably cuz it's hard to draw up (j/k).

I have no idea why he didnt try etomidate, however, its never worth it to ask after the fact in these situations.

A MAP of 60 is sufficient from my point of view, esp. if the patient is non cardiac and on diprivan, but in your situation, I would have done the exact same thing if my pressure was in the crapper. It was probably right to get the pt. off of the propofol, and fentanyl is used very commonly for sedative purposes even though the tolerance to it is reached pretty quickly, and it requires increasing doses.

Thanks! Im ok with the pressure but not so much in a patient this sick. The fentanyl seemed like a good idea for initial sedation until the pressure came back then i gave versed doses en route with fentanyl.

I don't think the SVN was making your patients heart rate high. It was probably related more to what was going on, and poss. the ketamine. that's why I wouldn't give it in an emergency. I've given a lot of SVN's, and rarely see such an increase in HR. After changing the sedation, I would have given the fluid, and brought down the PEEP(causes hypotension and decreased cardiac output), and just rode it out.

Well, thats the thing, its always hard to tell. I have had many pts HR shoot into the 140's with continuous SVNs but ive also seen ketamine shoot up the HR as well. Could have been either one for sure. But the HR stayed pretty high (120) after ketamine was long gone so it seemed more likely to be the SVN since once the pt was normotensive the HR was still 120's.

I have always been taught that PEEP > 5 is contraindicated in asthmatics. I decided to see how she would do without it and it seemed to be fine.

It was a good call and alot of fun.

Thanks alot for the comments!

[WntrMute2]

From Barash, Clinical Anesthesia:"Ketamine has well-characterized bronchodilatory activity. In the presence of active bronchospasm ketamine is considered the iv induction agent of choice. Ketamine has been used in subanesthetic doses to treat persistent bronchospasm in the operating room and ICU. It is also used with midazolam to provide sedation and analgesia for asthmatic patients. (pg.337)....The incidence of these reactions (hallucinations, nightmares, altered short-term memory and cognition) is dose dependent and can be reduced by co-administration of benzodiaziapines, barbituates or propofol. (pg 337). So according to Barash, one of the major texts of anesthesia, the ketamine, sux, propofol routine seems appropriate. BTW, etomidate inhibits the release of cortisol for 8-24 hrs. maybe the doc figured the patient might need their own stress hormones. Just a thought. Sorry for the earlier remark but anytime someone says if I'm not treated with respect I'm going home. Well, they asked for it.

[Pete495]

Can't argue with Barash. There's no doubt about Ketamine's bronchodilating effects. I think the question is do you use it in a rapid sequence w/ sux, and do you use it with hemodynamically unstable patients. In some instances, the ketamine could be beneficial because it does increase your heartrate and blood pressure, however as Mike said I believe, it increases your myocardial work load, which would contraindicate it in heart patients.

Personally, just my opinion, but I still think it was a poor choice because

1) The patient is already altered, and Ketamine causes hallucinatory effects, and how does one evaluate the pt. while in an emergency room if the pt. is halllucinating.

2) Heart rate will already be increased with asthmaticus. why potentiate it

3) Ketamine's bronchodilatory effects do not outweigh hemodynamic instability and the use of other drugs which can counter histamine release or facilitate intubation with minimal histamine release in the asthmatic patient.

just my extra 2 more cents. not trying to step on anyone's toes.

From Barash, Clinical Anesthesia:"Ketamine has well-characterized bronchodilatory activity. In the presence of active bronchospasm ketamine is considered the iv induction agent of choice. Ketamine has been used in subanesthetic doses to treat persistent bronchospasm in the operating room and ICU. It is also used with midazolam to provide sedation and analgesia for asthmatic patients. (pg.337)....The incidence of these reactions (hallucinations, nightmares, altered short-term memory and cognition) is dose dependent and can be reduced by co-administration of benzodiaziapines, barbituates or propofol. (pg 337). So according to Barash, one of the major texts of anesthesia, the ketamine, sux, propofol routine seems appropriate. BTW, etomidate inhibits the release of cortisol for 8-24 hrs. maybe the doc figured the patient might need their own stress hormones. Just a thought. Sorry for the earlier remark but anytime someone says if I'm not treated with respect I'm going home. Well, they asked for it.

[MmacFN]

Hey Wntr

N/p man, i just want to learn more, not be attacked. I guess i didnt expect someone as sarcastic as i am to respond

Now THIS is the kind of information i am looking for! Thank you! It is entirely possible this doc knew exactly what he was doing, but it seemed very unusual from my perspective, after all, what do i know about operating room anesthesia (that'd be 0)?

How about ketamine drips? Have you ever seen or heard of one? I have not, nor has anyone i know including some PICU RNs. Is this also something used in this way?

Have you ever used this sortof combo in your practice? How about using propofol for the initial induction by itself? Ive read about it, and seen it in the OR but never in the ER or ICU.

The info on etomidate is excellent. I had read that and it makes sense. There are so many things to consider when using multiple agents and then trying to take the clinical picture into account, very exciting!

Thanks again, i forsee us being sarcastic much more

From Barash, Clinical Anesthesia:"Ketamine has well-characterized bronchodilatory activity. In the presence of active bronchospasm ketamine is considered the iv induction agent of choice. Ketamine has been used in subanesthetic doses to treat persistent bronchospasm in the operating room and ICU. It is also used with midazolam to provide sedation and analgesia for asthmatic patients. (pg.337)....The incidence of these reactions (hallucinations, nightmares, altered short-term memory and cognition) is dose dependent and can be reduced by co-administration of benzodiaziapines, barbituates or propofol. (pg 337). So according to Barash, one of the major texts of anesthesia, the ketamine, sux, propofol routine seems appropriate. BTW, etomidate inhibits the release of cortisol for 8-24 hrs. maybe the doc figured the patient might need their own stress hormones. Just a thought. Sorry for the earlier remark but anytime someone says if I'm not treated with respect I'm going home. Well, they asked for it.