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.
Precedex would probably work great for this. Personally, I'd need a really good reason to try to avoid intubation before I'd be starting several sedating infusions on someone just to facilitate NIPPV, though.
I wonder if this differs in the ED/ICU setting versus the anesthesia population, though. One supposes the latter is better primed with a calm, controlled environment to accept unusual sensations or experiences with equanimity. I haven't seen many critically ill patients for whom perturbations in their sensory experience would be welcome, particularly if they're already anxious.
I doubt the setting matters at all. There's also a lot of data supportive of ketamine use in the ED setting.
The anxiety that you keep referring to is really a non-issue. In my practice I see a very high proportion of morbidly obese patients with OSA, so I use a LOT of ketamine for procedural sedation for brief procedures and sometimes as the primary anesthetic for bigger procedures. I have only occasionally seen it induce or worsen anxiety and adding more ketamine or 1-2mg of versed has never failed to fix it.
Not that long ago I gave a 230kg guy with severe Pickwikian syndrome 500mg of ketamine for an "awake" intubation and then nothing else but local for a painful I&D that took about a half hour. He breathed well on PSV the whole time, and after the case I gave him a couple mg of versed and extubated him to CPAP sitting straight up and when he finally woke up (which admittedly took a long time) he was fine and had no complaints.
I certainly throw in a benzo if/when they're having a hard time. Do you do it prophylactically when using ketamine?
I used to never give ketamine without a benzo or propofol, but more and more, I use it alone.
For preoperative nerve blocks, I used to mix 2cc (50mg) of ketamine in a syringe with 2cc (2mg) of versed and push 1-2cc as needed. This worked awesome, but then patients would occasionally be too sleepy after the block to interact with the surgeon or their family before their operation, plus I don't like using versed in older patients anyway. So I started using propofol plus ketamine. This worked better, but in an effort to keep things simpler and cleaner, I started using just ketamine. Now I usually give just a 25mg dose of ketamine and get a still, calm patient for the 10 minutes or so that I need them that way. Often they'll talk to me, sometimes not but usually about 20 minutes after I give it, they are pretty lucid. Sometimes I end up giving 50mg. Never had an issue with increased anxiety or a bad trip.
