Moderator EMEDPA Posted July 17, 2021 Moderator Share Posted July 17, 2021 A nice pearl from one of my CRNA friends: 1 cc ketamine 50 mg/ml in a 1 cc insulin syringe. each 0.1 cc contains 5 mg of ketamine. titrate to appropriate pain response. recently had a guy with intractable renal colic resistant to high dose fentanyl, dilaudid, IV tylenol, IV toraol, IV lidocaine 100 mg over 10 min (https://rebelem.com/iv-lidocaine-for-renal-colic-another-opioid-sparing-option/) 30 mg of ketamine and he was pain free. This is a great drug and I keep discovering new uses for it like treating anxiety on bipap with 0.1 mg/kg instead of ativan. Bonus: you get bronchodilation too. 1 2 Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 17, 2021 Moderator Share Posted July 17, 2021 I’ve also been using a lot of ketamine infusions. Like 0.5mg/kg in 100cc given over 6 hours once daily. Works like a charm to reduce opioid use. love the lidocaine use. I’ve never seen that before. Definitely will give that a try. 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 17, 2021 Share Posted July 17, 2021 2 hours ago, EMEDPA said: A nice pearl from one of my CRNA friends: 1 cc ketamine 50 mg/ml in a 1 cc insulin syringe. each 0.1 cc contains 5 mg of ketamine. titrate to appropriate pain response. recently had a guy with intractable renal colic resistant to high dose fentanyl, dilaudid, IV tylenol, IV toraol, IV lidocaine 100 mg over 10 min (https://rebelem.com/iv-lidocaine-for-renal-colic-another-opioid-sparing-option/) 30 mg of ketamine and he was pain free. This is a great drug and I keep discovering new uses for it like treating anxiety on bipap with 0.1 mg/kg instead of ativan. Bonus: you get bronchodilation too. Sometimes you need higher doses of ketamine to get a patient to tolerate BiPap. I had a patient a few weeks ago with hypercarbia and confused, hx of alcohol and benzo abuse, weighed about 50 kg, who 30 mg of ketamine would only keep her calm for about 45 min. After that, she was back to pulling off her BiPap. Her IP doc finally tried Zyprexa PO which did work - though this was several days later and I think the hypercarbia had probably resolved. 1 Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 17, 2021 Share Posted July 17, 2021 8 hours ago, ohiovolffemtp said: Sometimes you need higher doses of ketamine to get a patient to tolerate BiPap. I had a patient a few weeks ago with hypercarbia and confused, hx of alcohol and benzo abuse, weighed about 50 kg, who 30 mg of ketamine would only keep her calm for about 45 min. After that, she was back to pulling off her BiPap. Her IP doc finally tried Zyprexa PO which did work - though this was several days later and I think the hypercarbia had probably resolved. I'll take dexmedetomidine over ketamine. I've seen a decent amount of agitation and weird hemodynamics with ketamine. Think it works ok as an induction agent and low dose for pain (or to take down an agitated delirium patient) but really avoid it on my respiratory folks. The increased secretions always worry me as well in both my NIPPV and my vented people. I (wrongly) thought the lido for renal colic had gotten debunked. Will have to yell at my wife for lying to me. 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 17, 2021 Share Posted July 17, 2021 I've not had success with lidocaine for renal colic. I wish I had Ofirmev (IV acetaminophen), but the system doesn't have it in their formulary. I don't have dexmedetomidine either. I have seen a bit of emergence reactions with ketamine, but overall, have had good success with it. Never have experienced the weird hemodynamics or increased secretions. I have had folks with unexpected resistance, worst was the psyche patient that broke a window in a psyche room door with a chair trying to get to me that 500 mg of ketamine only slowed down but didn't put under. 2 Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 17, 2021 Share Posted July 17, 2021 It's funny, dex is the ketamine of the upstairs. The K resistance is a real thing. Have my students tell stories regularly re: 280lbers who go down like a tranq'd rhino after 250 IM while a little 120lber takes 500. 1 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2021 Author Moderator Share Posted July 17, 2021 I have had fairly good results with the IV lido infusion for renal colic. My patient the other day was the first who did not get at least partial relief. The IV tylenol is ok, but not a panacea. It seems maybe 50% of folks get some relief with it. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2021 Author Moderator Share Posted July 17, 2021 1 hour ago, MediMike said: It's funny, dex is the ketamine of the upstairs. The K resistance is a real thing. Have my students tell stories regularly re: 280lbers who go down like a tranq'd rhino after 250 IM while a little 120lber takes 500. recently gave someone a total of 30 IM zyprexa and like 8 of IM ativan and it took the 500 of ketamine to put them down. and it was a methed out lady who weighed maybe 150 lbs. Quote Link to comment Share on other sites More sharing options...
MediMike Posted July 17, 2021 Share Posted July 17, 2021 2 hours ago, EMEDPA said: recently gave someone a total of 30 IM zyprexa and like 8 of IM ativan and it took the 500 of ketamine to put them down. and it was a methed out lady who weighed maybe 150 lbs. Ugh. There's a local ED doc at an outlying hospital who's ICU I cover, he has started using phenobarbital on a lot of patients then ends up intubating due to ALOC. So now they're intubated AND hypotensive with these creepy blown pupils. Know that FOAMEd has been screaming about it's use in ETOH withdrawal but man... it's side effects are no joke. Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 17, 2021 Moderator Share Posted July 17, 2021 6 hours ago, MediMike said: I'll take dexmedetomidine over ketamine. I've seen a decent amount of agitation and weird hemodynamics with ketamine. Think it works ok as an induction agent and low dose for pain (or to take down an agitated delirium patient) but really avoid it on my respiratory folks. The increased secretions always worry me as well in both my NIPPV and my vented people. I (wrongly) thought the lido for renal colic had gotten debunked. Will have to yell at my wife for lying to me. I would love precedex. I brought it up to the committee, but it was shot down 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted July 18, 2021 Share Posted July 18, 2021 On 7/17/2021 at 2:39 PM, EMEDPA said: methed out This - the one I had that it took 500 mg of ketamine & 20 mg Geodon to put down was meth as well. I've seen a lot of temporary paranoia from meth. Makes me wish for the old days of simple to manage opiate ODs. Titrate narcan to the patient's ability to walk to the ambulance. Quote Link to comment Share on other sites More sharing options...
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