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]

Pete495 says: "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....Personally, just my opinion, but I still think it was a poor choice"

But you are arguing with Barash and every other textbook out there. Ketamine is the perfect drug in the unstable status asthmatic. And you are worried about the mental altered state of the patient? Lets get her to survive and then we'll worry about that. Barash also clearly addresses the phsycotropic effects and how to mitigate them (BZD, barbs, propofol). This is a typical error in judgement. Since one has little experience with something it should be avoided DESPITE CLEAR EVIDENCE TO THE CONTRARY. It is the drug of choice. Try defending another choice during M&Ms or even in court. Find me some literature to back up your position.

MmacFN says:

How about ketamine drips? Have you ever seen or heard of one? Yes I use them for sedation occasionally in the elderly w/ hip fractures. Isobaric tetracaine and midazolam usually but occasionally, ketamine with its hemodynamic, analgesic and respiratory effects will allow a comfortable patient without oversedation.

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.

I'm not sure of your question here. What combo are you asking about? I intubate w/all induction drugs, ketamine the least as there are pretty well defined uses, but I do sedate with it. It is also a wonderful analgesic @0.2mg/kg.

[MmacFN]

hey!

when i asked this below i had meant using propofol with the ketamine and succs. Is this something you use often?

Also, do you ever use propofol all by itself for intubation? Or are you always adding something else?

Thanks for the ketamine dose that was my next question!

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.

I'm not sure of your question here. What combo are you asking about? I intubate w/all induction drugs, ketamine the least as there are pretty well defined uses, but I do sedate with it. It is also a wonderful analgesic @0.2mg/kg.

[WntrMute2]

Usually I just use 1 induction agent plus muscle relaxant plus fentanyl. On big cases like AAAs valves etc. I might do a narcotic induction w/ sufentanil. I have given combinations before but that is usually begun w/ STP and if the patient isn't deep enough w/ a single dose (400 mg.) I'll draw up propofol or etomidate as those don't require mixing like STP. I am not the worlds greatest propofol fan but I use it frequently as an induction agent in outpatient cases. Almost never "alone" if I'm going to intubate. A muscle relaxant is usually called for to place an ETT. Propofol alone with a little narcotic for LMA placement or for mask cases.

[Pete495]

Well, there is also the simple plan of JUST NOT USING IT. Seems pretty simple, but it works. The reasons textbooks don't tell you when and when not to use it is because clinical judgement is in the hands of the provider.

Pete495 says: "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....Personally, just my opinion, but I still think it was a poor choice"

But you are arguing with Barash and every other textbook out there. Ketamine is the perfect drug in the unstable status asthmatic. And you are worried about the mental altered state of the patient? Lets get her to survive and then we'll worry about that. Barash also clearly addresses the phsycotropic effects and how to mitigate them (BZD, barbs, propofol). This is a typical error in judgement. Since one has little experience with something it should be avoided DESPITE CLEAR EVIDENCE TO THE CONTRARY. It is the drug of choice. Try defending another choice during M&Ms or even in court. Find me some literature to back up your position.

MmacFN says:

How about ketamine drips? Have you ever seen or heard of one? Yes I use them for sedation occasionally in the elderly w/ hip fractures. Isobaric tetracaine and midazolam usually but occasionally, ketamine with its hemodynamic, analgesic and respiratory effects will allow a comfortable patient without oversedation.

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.

I'm not sure of your question here. What combo are you asking about? I intubate w/all induction drugs, ketamine the least as there are pretty well defined uses, but I do sedate with it. It is also a wonderful analgesic @0.2mg/kg.

[MmacFN]

cool

thanks again for all the info wntr!

[WntrMute2]

Well, there is also the simple plan of JUST NOT USING IT. Seems pretty simple, but it works. The reasons textbooks don't tell you when and when not to use it is because clinical judgement is in the hands of the provider.

Actually, Pete, the texts are telling you to use it when terms such "it is the drug of choice in X situation." are being used. You are right that the literature doesn't say you must use a particular drug. But "drug of choice" is pretty strong language for a text and seems pretty clear to me and most others. Especially as a student,(Not that there is anything wrong with being a student mind you) arguing against without some experience to the contrary seems weak. Give me some peer reviewed articles or texts to the contrary.

[gaspassah]

i was going to put my 2 cents in earlier but i thought i would let things die down a little.

i have 2 techniques where i use propofol and ketamine together.

in a 100 cc bag a saline i add 200 mg propofol, 100 mg ketamine and 100 mcg of fentanyl and drip it though a micro drip to desired effect. i used this one just the other day for a cold knife conization. worked really well.

second one is 1 mg of ketamine to every cc of propofol and run it on an infusion pump at propofol doses. have used this one in conjunction with paracervical blocks when doing d and c's and this new ob thing where they put a coil in the fallopian tube under hysteroscopy for sterilization.

both of these techniques are for mac cases and work well for me. \

and i understand neither of these constitutes an induction scenario.

as for intubation,

1. i'll sometimes use propofol only after a mask induction on kids,

2 i rarely if ever don't use a paralytic in an OR pt (adult),

3 I often refrain from paralyzing in icu or a code. and if it's a pt that has been down i won't use prop either.

just a caution about paralytics.

for the pt BREATHING IS ALWAYS GOOD! meaning paralyze only when conditions warrant it.

once you paralyze, you own the airway until....

spontaneous breathing resumes (depends on the agent for length of time)

secured airway is achieved

pt dies.

paralytics are dangerous and should only be handled by ppl with good airway skills.

[MmacFN]

Hey GP

Nicely said.

i was going to put my 2 cents in earlier but i thought i would let things die down a little.

i have 2 techniques where i use propofol and ketamine together.

in a 100 cc bag a saline i add 200 mg propofol, 100 mg ketamine and 100 mcg of fentanyl and drip it though a micro drip to desired effect. i used this one just the other day for a cold knife conization. worked really well.

second one is 1 mg of ketamine to every cc of propofol and run it on an infusion pump at propofol doses. have used this one in conjunction with paracervical blocks when doing d and c's and this new ob thing where they put a coil in the fallopian tube under hysteroscopy for sterilization.

both of these techniques are for mac cases and work well for me. \

and i understand neither of these constitutes an induction scenario.

as for intubation,

1. i'll sometimes use propofol only after a mask induction on kids,

2 i rarely if ever don't use a paralytic in an OR pt (adult),

3 I often refrain from paralyzing in icu or a code. and if it's a pt that has been down i won't use prop either.

just a caution about paralytics.

for the pt BREATHING IS ALWAYS GOOD! meaning paralyze only when conditions warrant it.

once you paralyze, you own the airway until....

spontaneous breathing resumes (depends on the agent for length of time)

secured airway is achieved

pt dies.

paralytics are dangerous and should only be handled by ppl with good airway skills.

[Nitecap]

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?

On the contrary to what others have said ketamine is an excellent drug if the pt is crumping. With your asthmatic it causes catchol release which can have some beta agonist effect causing some vasodilation. Also is has minimal resp depressant effects which is good for your pt that is already resp compromised. Which the crapy BP despite ketamine increasing demand we arent getting supply anyways and ketamine will increase your pressure to hopfully perfuse the vital organs. NOt to mention Ketamine has analgesic effects which makes it good for a tamponading pt in which the chest is being cracked at the bedside.

As far as the Sux its the quickest on and off so just in case he couldnt get the airway he could buy 6-7min vs 30min with another drug. Also if this guys airways are closing off the suxs may assist with cord tone and allow the cords to be in a better position assisting your intubation. Sux does cause so histamine release I have seen it first hand.

Whether Sux, propofol, ketamine or etomidate your airway is compromised so aspiration will be an issue with all of these potentially though propofol has some antiemetic effects.

Not sure the rationale on his choice of vent settings or drips. Lets just say ER docs dont start as many drips and vents as some other docs.

I have seen many give smaller dose of 2 diff agents to decrease side effects but this really just sounds like this doc really didnt know what the hell to do when the crap was hitting the fan. I mean if the pressure is in the toilet its common sense to turn of the propofol. ITs not like this guys chest was open and post intubation we are worrying about awareness. You dont have to be sedated to be on a vent if vitals arent allowing sedation. Good job by turning off the propofol though if your gave a big vec dose and were only pushing tiny fent doses not enough to snow them d/t pressure then that could be questioned since the pt is paralyzed but maybe mentally intact.

The ativan was a larger dose and the morphine causes histamine release and if the doc knew this guy had asthma that could be questioned.

BAck to the ketamine though. IT is an excellent drug for the right person in the right situation.