Ketamine-- how to prepare patients?

[u/rainbowsforeverrr]

Hi folks, ER nurse here. I'm curious how you talk to patients about ketamine admin for procedures or for intractable pain relief. I give it fairly often but I still haven't found the right way to prepare patients (or parents of littles) for the psychotropic effects. I've never used ketamine personally, but it seems to be a very intense experience that ought to be part of the informed consent conversation. What is our ethical obligation?

[u/jubbyboi]

Sedated a 7 year old for fracture reduction 2 days ago and the nurse said “you’re gonna love this! A lot of people pay money to do this and you get it for free”… so I guess that’s an option.

[u/MrPBH → u/jubbyboi]

Oh man, as an addiction doc and father that makes alarm bells go off in my head.

I think these kind of lines are a great way to relieve the tension and anxiety of an adult patient, but a bad message to kids. It's sending the message that this medicine can be used recreationally and that lots of people do it.

These statements might be true, but it's the wrong message for a seven year old.

I'd prefer a message that emphasizes A) this medicine is going to make it so it doesn't hurt when we fix your arm and you don't remember it, and B) it might be scary, but I promise if it is scary, it won't last forever.

[u/caffeinated_humanoid → u/MrPBH]

I agree with you about glorifying the drug in that way. However, I avoid telling patients that they will not remember it. Ketamine doesn't reliably cause amnesia in my experience (but I also don't like to use it alone).

[u/MrPBH → u/caffeinated_humanoid]

If dosed properly, it pretty reliably obliterates consciousness. Most of my ketamine sedation patients cannot recall the events during dissociation, aside from a vague sense of existing in the same room. Even those who are yelling and screaming don't recall doing so when they come to.

Contrast that with benzos, which will produce amnesia even at anxiolytic doses. Ketamine is a very dose dependent drug and low doses work qualitatively different from high doses.

Sub dissociative doses of ketamine are not amnestic and can cause a lot of trauma. That's why I don't like "pain dose" ketamine. It's enough to cause an unpleasant experience, but not enough to cause dissociation, so you remember that unpleasant experience.

[u/Equivalent-Lie5822 → u/MrPBH]

I got midazolam for a procedure once- I always thought versed was weak sauce until I got it myself. Man, oh man. Apparently I was aggressively hitting on the anesthesiologist (telling him I don’t have a gag reflex). I have zero recollection of that. Thank god, because I would have died of embarrassment if I had to face him again.

[u/uranium236 → u/Equivalent-Lie5822]

I’m picturing cartoon eyebrow waggles

[u/caffeinated_humanoid → u/MrPBH]

Yes, if you are the one dosing it and speaking with the patient, that makes sense. But to tell nurses to say that to patients without explaining the nuance could be more of an issue.

[u/Purple_Opposite5464 → u/MrPBH]

Anecdotally a guy who we RSIed with ketamine and gave 100mg x2 pushes for post sedation (HEMS scene) did not remember a thing. He said he recalled bright lights, people talking, and then waking up in the ER

[u/Negative_Way8350 → u/caffeinated_humanoid]

Patient's don't appear to have amnesia, but when asked about the procedure when back to baseline many express astonishment. Most ask if we've started yet and we're already done.

[u/caffeinated_humanoid → u/Negative_Way8350]

Yes, most shouldn't if they get an appropriate dose. "However, I had a patient who had previously received only ketamine and fentanyl for a colonoscopy. They remembered the whole procedure, but told me that they felt so disocciated that they were unable to move/speak, and was traumatized by the experience. Setting appropriate expectations is one of the most important things for a patient's experience. If they aren't going to be "out" or you can't assure that they won't remember anything, then I don't tell them that.