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Clinical Case 024: Livin’ the ketamine dream

If you are new to Broome Docs, then you might have missed my mild obsession with Acute Psychiatric Sedation.  (GO back and read the posts from earlier 2011 to get the background and some tricky cases to ponder.)

Last night I had my first opportunity to put Dr Minh Le Cong’s secret weapon (ketamine) into action.  I had a large, schizophrenic patient who was very agitated and due to fly in an hour on the RFDS.  The patient had good going sleep-apnoea, a thick neck, big belly and a history of aspiration pneumonia during a previous sedation-gone-wrong.  This is one of those scenarios where you can make a bad situation worse without trying too hard.  So how did I manage this?

  1. Communication.  Get on the phone and make a plan with the flight crew.  We decided to try and avoid intubation if possible, this patient had a lot of co-morbidities and would not do well with a day or two on the blower.
  2. Team huddle.  Organise your own team, make it clear what the plan is and what plans B, C etc are.
  3. Move to the light => we moved the patient into the Resus area, fully monitoring (including ETCO2) and had the airway gear all ready to go
  4. Sedation.  Titrated sedation is the only way to go.  Give a dose and watch for a bit – chronic Psych patients have a wide range of tolerance to various drugs – so don’t just use a pre-formatted recipe – you have to give a bit and observe response, then repeat. As previously stated – I do not see why a Psych sedation should be done in a low-acuity area, where we would never do procedural sedation for a surgical problem.
  5. Change the plan if plan A is not great.  This patient got quite deep with 4 mg of midazolam and required a nasalpharygeal airway.  So I changed the plan – ketamine.  This worked well – RR went up a bit, patient  was tranquil and allowed us to site another IVC and an IDC with minimal fuss.
  6. Bedside vigil.   You need to be nearby to monitor this patient – you cannot give drugs and wander off to other areas.  I stayed around and actually went with the patient to the airstrip to ensure the plan was working.  Maybe once we are all more familiar with these agents in practice we can relax a bit, but for now I plan to keep my eye on them.

At the end of the night all was well. The patient was sedated, but rousable, moving herself on the stretcher.  Nobody got punched or spat upon.  The RFDS crew seemed happy and her numbers remained perfect throughout.

Comments

  1. Minh Le Cong says:

    Awesome stuff! How much ketamine did you use and how did you monitor etco2 non invasively??
    Did police escort accompany her?
    I will be presenting my ketamine retrieval sedation paper in Perth Burswood complex at the ASA meeting in 4 days time . I will give a shout out to Broome Docs for being the first WA practitioner I know of to use ketamine in an acutely agitated patient with schizophrenia !

    • Casey Parker says:

      HI mInh
      I monitor CO2 using our nasal prong sampling set – we use it a lot for colonoscopies etc, you can place it under a Hudson etc.
      I gave an initial dose of ~ 0,5mg/kg, which was OK. Then a bolus of ~ 0.25mg/kg to allow us to site the IDC and 2nd IVC.

      About an hour later I gave another 0.5mg/kg to keep the patient sedate during lifting into ambo trolley etc / transport to plane.
      We had a Police man, he was bored, and did not need to do a thing except carry her bag of clothes.
      Enjoy Perth
      Casey

  2. But Casey, thsi si not described in the “Sedation for Mental Health Patients Awaiting Transfer from etc etc” guidelines….

    – closes the door and runs away quickly-

    • Casey Parker says:

      Hey Roy
      Guidelines? Hmmmm… should probably read those sometime

      As I said in the post – blind adherence to guideline-based sedation recipes is a recipe for disaster.
      None of the guidelines even have a minimum monitoring requirement or airway assessment as part of the planning.

      Not sure what evidence the guidelines were based upon, other than retrospectoscopy and tradition – both level 17B I think!

      Oh, did you catch my pharmacist bashing in the OTC cough mix post? LOve to hear your POV as a public (hence honest) Pharmacy type

      Casey

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