At 10:07 AM 3/17/00 -0500, you wrote:
>Steve - you suggest that it is appropriate to add ketamine as an
>analgesic agent at a dose of 0.5 mg/kg to a sedative agent such as
In subdissociative doses ketamine has analgesic properties that are
believed to be roughly equipotent (mg for mg) with meperidine (1). I don't
see any advantage to using ketamine instead of an opioid in this setting,
although there's no apparent problem with it either (assuming an absence of
ketamine contraindications). If you're already using fentanyl for
procedural analgesia, I suggest sticking with it.
>think that it would be safe to use propofol in lower doses (0.5 -
>1.0mg/kg) as part of a propofol + fentanyl (or ketamine) combination? I
>have never tried that combination and I would like to know if it is both
>safe and efficacious.
The safety profile of any dose of propofol in the ED remains to be reliably
delineated, and I look forward to seeing more literature on this in coming
years (go for it, Virgil!). The challenges of propofol use in the ED have
been described (2).
>Nikolaus - you mention that the advantage of adding propofol to ketamine
>is that you can then use less ketamine.
There is no evidence that any ketamine-associated adverse effects
(including emesis) are dose-related within the range of commonly used doses
(1,3,4). My opinion is that there's no point in using ketamine if you're
not going to use dissociative doses! Remember, ketamine is the sole
exception to the sedation continuum. It is more like a
light-switch: +dissociated or -dissociated. I tell me residents to think
of it like they do neuromuscular blockers -- you're either paralyzed or
you're not. We're not skimpy with paralytic doses, and we shouldn't be with
ketamine either. Just give the dose that reliably works!
Steve Green / Loma Linda
1. Green SM, Johnson NE: Ketamine sedation for pediatric procedures: Part
2, Review and implications. Ann Emerg Med 1990; 19:1033-1046.
2. Green SM: Propofol for emergency department procedural sedation Not yet
ready for prime time. [editorial] Acad Emerg Med 1999; 6:975-978.
3. Green SM, Hummel CB, Wittlake WA, Rothrock SG, Hopkins GA, Garrett W:
What is the optimal dose of intramuscular ketamine for pediatric sedation?
Academic Emergency Medicine 1999; 6:21-26.
4. Green SM, Kuppermann N, Rothrock SG, Hummel CB, Ho M: Predictors of
adverse events with ketamine sedation in children. Annals of Emergency
Medicine 2000; 35:35-42.
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