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You guys are doing blocks in the field?

Inotropes should be titrated to markers of perfusion, which (unless there is a Swann or non-invasive cardiac output monitor) is usually a thoughtful gestalt of the clinical exam, echo, labs, etc. While I recognize that nurses are capable of being thoughtful, it's a different matter from just...

In many circumstances I think that is correct.

Thanks, I'll pass it along. It is not a matter of training. Ketamine does not have a direct dose-response relationship, so "titrating" it at the bedside doesn't make sense. With the possible exception you mentioned, I don't think anybody should be sitting in the ICU partially dissociated. The...

I would sort of quibble with this. I agree that it has a wider range of safe dosing that will not cause hypotension, respiratory depression, etc. But it lacks the clear dose-response relationship of something like propofol. If a patient is agitated on low dose (subdissociative) ketamine, turning...

Who knows. They haven't been very active pursuing this, but it does mostly depend on the state, not on who created what. Agree that PAs are usually more suited to surgical work. As I understand it NPs usually need to undertake additional training to assist in the OR. True that NPs are a bit...

There's a requirement for PAs to have some form of an affiliation or supervisory relationship with a physician (in, as far as I know, every state still). In most places it means there needs to be someone you could call, or someone who looks over a few of your charts per month, or similar. In...

That sounds... correct. Glad I didn't need to support a family during school. I guess there's NP school. They usually work.

Insert some sort of GIF here about... loans.

Get your bachelors with the necessary prereqs, then apply. The field experience will be useful. Don't plan on being able to work during school.

Thanks Remi.

Blood gas. If significantly hypercarbic, likely intubate. If normal... well honestly I think in most centers they'd still get intubated, but if it's somewhere that's trying to implement this notion of ketamine-assisted NIBBP, then maybe they could have a trial of that.

Fair. For myself, I would be more comfortable using Precedex for this. For us that would mean an ICU admission versus a lower level of care -- but so would ketamine, and either way such a patient probably needs the ICU. I wonder if this differs in the ED/ICU setting versus the anesthesia...

Yeah, or their soul is leaking out from their pores and they're desperately trying to plug them up using telepathy.

:D Fully dissociating someone on BiPap is a little bold. I know Weingart has been talking about that in the context of "DSI" but I don't think it would fly in my world. My concern would be how long you're going to leave them like that; a lot of these COPD exacerbations need to be on the mask...

Right, but if the issue is anxiety, suddenly introducing a herd of cackling were-pandas to the room may not help... In my world, a subdissociative (pain) dose of ketamine is .1-.3 mg/kg (or around 10-25 mg), and I have certainly had people complain of unpleasant dysphoria toward the upper end...

Yes, good choice for this. Best used before they're freaking out too much, as it takes some time to build up. (Loading doses are out of fashion, but you CAN do it if their HR and BP are robust.)

I would be a bit wigged out about a borderline COPD patient wearing a mask having a bad ketamine reaction...

Yeah... but it's easy for you.

I would advise great caution with giving benzos to these patients. They need to breathe.