Ketamine

[pardus]

I had a wisdom tooth ripped out as a 40yr old. General anesthesia, Ketamine and an opiate I now forget. I was aware they were working on me but I was having a GREAT time!
I remember being PISSED when I came out of it because I was enjoying it so much.

 

[Jerry Barrett]

Yes in most cases I would chose Ketamine over Morphine and definitely Fentanyl as it doesn't knock out the respiratory drive .. in most cases it will increase BP and respiratory drive. I'll look for some papers but we have been using it on the road in Western Australia for many years now with great success.

 

[Jerry Barrett]

• Title: Safety and efficacy of intranasal ketamine for acute postoperative pain
• Author/Creator: Christensen, Kyle ; Rogers, Elizabeth ; Green, Geoff A. ; Hamilton, Douglas A. ; Mermelstein, Fred ; Liao, Edward ;Wright, Curtis ; Carr, Daniel B.
• Subjects: Intranasal administration ; Ketamine ; Analgesia ; Postoperative pain ; Dental pain
• Is Part Of: Acute Pain, 2007, Vol.9(4), pp.183-192 [Peer Reviewed Journal]
• Description: Background Subanaesthetic doses of ketamine are analgesic. Intranasal administration offers a non-invasive route for systemic drug delivery. We evaluated the safety and analgesic efficacy of intranasal ketamine in treating moderate-to-severe, acute postoperative pain in the molar extraction model.
  Methods Intranasal ketamine (10 mg, 30 mg, and 50 mg) and placebo were evaluated in a randomised, double-blind, single-dose, parallel study in 40 patients undergoing removal of 2–4 impacted third molars. Analgesic efficacy was assessed over a 3 h period following drug administration. Safety was evaluated through adverse event reporting, vital signs, pulse oximetry, nasal assessments, and a standard dissociative side effects questionnaire.
  Results Ketamine delivered intranasally was well tolerated. Statistically significant analgesia, superior to placebo, was observed with the highest dose tested, 50 mg, over a 3 h period. Rapid onset of analgesia was reported (<10 min), and meaningful pain relief was achieved within 15 min of the 50 mg dose. The majority of adverse events were mild/weak and transient. No untoward effects were observed on vital signs, pulse oximetry, and nasal examination. At the doses tested, no significant dissociative effects were evident using the Side Effects Rating Scale for Dissociative Anaesthetics.
  Conclusion Intranasal ketamine may offer a safe, nonopioid, well-tolerated, needle-free analgesic with efficacy in moderate-to-severe acute pain.
• Language: English
  
  
• Identifier: ISSN: 1366-0071 ; DOI: 10.1016/j.acpain.2007.09.001
• This is a great study that uses IN route, no sharps, no IV access...perfect for any conflict zone...

 

[kaja]

Thanks Jerry!

Regarding ketamine I would be worried about possible psychological /PTSD problems when not used with benzodiazepines.... The idea of being shot in combat and then given ketamine kind of scares the shit out of me...

To clarify- I'm not against ketamine, but just want to play a little devils advocate here to get more informations/opinions for when I'll try to get it approved for field use for me/ our SOPs. For civilian mass-casualty and disaster response the ketamine is our to-go analgetics, but not so much for military/ field use by non-doctor personnel.

 

[Jerry Barrett]

Right on Kaja I can see where you are coming from and understand. I guess with prolonged use of Ketamine I may be worries but for one off analgesic use I would see no problem at all, instead of having a flat casualty you quite often get a helping hand. Ketamine works so very differently than opioid s in so much as it just confuses the brain into thinking that the pain is someother sensation....it doesn't fuck with the CNS too much. A functional casualty in a fire fight is better than a flat one, also if you get heavy handed with the dosing you still maintain the airway!!

 

[bublik]

I really appreciate this thread and input from all b/c I was hesitant to use ketamine early on in my training. I grew increasingly comfortable w/it after a stint at Landstuhl...used it lots since and I think it's a fantastic drug, for many reasons, when used appropriately. I do premedicate w/benzos b/c patient feedback dictates varying experiences.

I took care of one guy that had a horrible, nightmarish experience w/ketamine (major burns, years and years of surgeries) and he specifically asked that I not use ketamine so that was a no brainer. He did fine w/anesthesia and woke up a-ok but there's no way I'd subject him to something that was bad juju for him.

During the same timeframe I took care of 5 or 6 different guys who'd received ketamine ONLY after initial injury and they loved it (one felt like he was in a video game, another thought he was flying, the stories are great when they have a good experience). I premedicate w/benzos but if I was a high speed type and ONLY able to carry one drug it'd be ketamine. Luckily that's not the case but lots more bang for the buck than w/morphine. I can't remember the last time I gave morphine to a patient but I have access to everything else so it'd be last in a controlled setting.

There are those in my world who aren't major ketamine fans but I think it's a fantastic option for field medicine (insert appropriate training and all disclaimer shenanigans here). The only clinical difference I see on a daily basis is that in larger doses (even w/versed) postoperative females tend to cry more take from that what you will but it hasn't stopped me from using it in smaller doses...you know how we girls are...boohoohoo. No one likes a crying patient in the recovery room, poor form even if the patient doesn't remember it.

 

[SPLAT]

LOVE KETAMINE for trauma sedation / pain management. Have used it several times in combination with Versed and have never had any re-emergence issues. Sent it both IV and IM...IM route works surprisingly fast. I had one patient who's vehicle was hit by a train and he was effectively FUBARed, traumatic crush / leg amp BTK, FX pelvis & femur, hypotensive, screaming in pain, altered and trying to fight with what strength and appendages he had left....Ketamine IV followed by small dose of Versed and it was a nice calm flight. No additional drop in BP following administration, screaming and thrashing stopped. I read a study recently which stated even the effects of the ICP increase from Ketamine have been way over blown and there is current literature that suggests Ketamine may be neuroprotective in head injuries. I will try to find that article again and post it here for the masses. Good stuff IMO

 

[amlove21]

I read a study recently which stated even the effects of the ICP increase from Ketamine have been way over blown and there is current literature that suggests Ketamine may be neuroprotective in head injuries. I will try to find that article again and post it here for the masses. Good stuff IMO

That would be awesome. I hope you find it.

I have also been pleasantly surprised with ketamine's effectiveness IM, even in hemodynamically challenged patients.

 

[bublik]

The info from TCCC and Defense Health Board supports use in regard to ICP concerns:

"Ketamine has traditionally been contraindicated in patients with headinjury due to a belief that it
may increase intracranial pressure (ICP).
38
The FDA approved package insert also notes that an increase in intracranial cerebrospinal fluid pressure has been reported after administration of ketamine and advises extreme caution when using ketamine in patients with increased ICP.
35

In vitro and animal studies suggest that ketamine may in fact have neuroprotective properties due to it being an N-methyl-D-aspartate antagonist.
38, 39, 40, 41
Additionally, recent studies suggest thatketamine may be safe for brain injured patients.
38, 42, 43, 44, 45
However, these studies had small sample sizes and primarily examined ketamine administration in combination with other anesthetics or sedatives. Because many of these ketamine studies are limited to procedural sedation in pediatric populations and none address ketamine use in pre-hospital, austere environments, the generalizability to tactical settings is limited. The consensus opinion of the Board members who are subject matter experts in neurosurgery and neurotrauma reaffirmed that the quality of the studies suggesting that ketamine can be used safely in those with head injury is insufficient and that these results are not generalizable to casualties with head injuries. The DHB concludes that this literature contains low-level evidence that may not be applicable, and recommends that until large randomized controlled trials examining the use of ketamine alone demonstrate that ketamine does not increase ICP, ketamine should not be used in patients with significant TBI (penetrating brain injury or head injury with altered level of consciousness)."

 

[surgicalcric]

I was pleasantly happy with its results once I was on a drip. The initial administration of 100mg IO did little for me though.

Crip

 

[TLDR20]

I was pleasantly happy with its results once I was on a drip. The initial administration of 100mg IO did little for me though.

Crip

Did you receive Fentanyl or Morphine POI?

 

[surgicalcric]

I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.

 

[bublik]

Thank you for sharing your experience. If you don't mind me asking, do you know how long were you on a ketamine drip?

As a CRNA I've used it plenty in various settings and routes, yet never needed it myself as I've only ever had a spinal for a lower extremity surgery. The majority of prolonged experience was in the ICU when I was a nurse. I don't hear a lot of negative feedback in general nor do I hear much about longer infusions (other than for complex regional pain syndrome) so I'm curious if you have feedback. Any and all info appreciated.

 

[surgicalcric]

Thank you for sharing your experience. If you don't mind me asking, do you know how long were you on a ketamine drip?.

I was on a propofol and ketamine drip for 9 days.

 

[amlove21]

I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.

I really, really dislike the fentanyl pops. I have never given them to a patient that has said anything BUT "well, it took the edge off, not much though." Just not impressed.

 

[SPLAT]

Good to know...we were looking at the fentanyl pops as an option for pain management POI for SWAT. We do a lot of REMOTE mountain terrain, counter narc ops with long evac times. Looking for a little more than "took the edge off".

 

[TLDR20]

I received two 800mcg lollipops and 10mg MS IM at the POI that took the edge off however I remember the events from wounding to the OR at Tarin Kowt.

Did you guys have the intranasal ketamine at that point?