CPAP vs BiPAP

truetiger

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Having used ketamine a lot...and for this purpose, I'm sold. Do you really need a study to back up common sense in this instance? If you have a respiratory patient who is toeing the line of respiratory arrest, do you really want to risk making them worse? Disassociate them. They'll either get better on BiPAP or they won't. It won't be the fault of the ketamine if they don't. If they don't, drop your tube and move on.
 

Brandon O

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It isn’t really even a risk, because if you give someone a small dose of ketamine and they start to get a little crazy, there’s an easy fix.....more ketamine.
: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 for hours, and I'm not sure what the endgame is -- leave them dissociated all day?
 

PotatoMedic

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Brandon O

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Least they are having a good time trying to breath!
Yeah, or their soul is leaking out from their pores and they're desperately trying to plug them up using telepathy.
 

Remi

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: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.
I'm not going to argue in defense of the idea because as I wrote before, I don't advocate for routinely sedating folks in severe respiratory distress.

All I said was if the decision was made that the best course of management involved using some mild sedation to facilitate NIPPV, then ketamine was probably the best choice, and if the initial dose of ketamine caused agitation, a little more would fix that.

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 for hours, and I'm not sure what the endgame is -- leave them dissociated all day?
Generically, my plan would be to use a low-dose ketamine infusion or small periodic boluses along with very small doses of a benzo or a-agonist, until respiratory status started to improve, at which point I would gradually decrease the dose of first the ketamine, and then the benzo. Hopefully, as they start to wake up their anxiety would have improved. If it did not, then you'd have to choose whether to toss them back in the hole, or intubate. That decision would be heavily influenced, of course, on the progression of their exacerbation.

Yeah, or their soul is leaking out from their pores and they're desperately trying to plug them up using telepathy.
You seem really concerned about the hallucinogenic effects of ketamine. To be blunt, it isn't that big of a deal. Most folks have no explicit recall of it at all, especially if they were very physiologically stressed at the time. Some who do have recall actually enjoy it. Others remember a very strange, but not at all distressing experience. Relatively few people have the classic "bad trip" that they find very distressing. And all it takes to substantially reduce the chance of an unpleasant experience is a little GABA enhancement or Alpha agonism. There's a lot of research in the anesthesia literature on the topic.
 

TXmed

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How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.

Do you ride with that or do you take their airway ?
 

VFlutter

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How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.

Do you ride with that or do you take their airway ?
Very situation dependent. I've sat on sedated or severely obtunded BiPAP patients in the ICU and it can be sketchy at times. Usually frequent flyers who were known to be difficult to wean from the vent or terminal patients that should not be full code. It can be done but tends to be resource intensive and probably better off intubating most of them.
 

E tank

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How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.

Do you ride with that or do you take their airway ?
I get a blood gas for starters.
 

PotatoMedic

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Brandon O

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Generically, my plan would be to use a low-dose ketamine infusion or small periodic boluses along with very small doses of a benzo or a-agonist, until respiratory status started to improve, at which point I would gradually decrease the dose of first the ketamine, and then the benzo. Hopefully, as they start to wake up their anxiety would have improved.
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.

... Relatively few people have the classic "bad trip" that they find very distressing.
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.

And all it takes to substantially reduce the chance of an unpleasant experience is a little GABA enhancement or Alpha agonism.
I certainly throw in a benzo if/when they're having a hard time. Do you do it prophylactically when using ketamine?
 

Brandon O

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How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.

Do you ride with that or do you take their airway ?
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.
 

RocketMedic

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I'd edge more towards intubation than not.
 

Remi

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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.
 
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Brandon O

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Thanks Remi.
 
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