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PED-EM-L  March 2000

PED-EM-L March 2000

Subject:

Re: Ketamine & propofol

From:

"Richard O. Gray MD." <[log in to unmask]>

Reply-To:

Richard O. Gray MD.

Date:

Tue, 21 Mar 2000 00:18:19 -0600

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (77 lines)

I would think a possible advantage would be a lack of respiratory depression with Ketamine as
opposed to fentanyl.

R

Steve Green wrote:

> 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
> >propofol (1mg/kg).
>
> 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.
>
> >Do you
> >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.
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>   http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

--

Richard O. Gray MD. FAAEM
Assistant Professor Emergency Medicine
Hennepin County Medical Center
701 Park Avenue South
Minneapolis Minnesota 55405
[log in to unmask]
[log in to unmask]
"I can't complain but sometimes I still do."

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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