Lower dose of Ketamine for certain patients
Question# 893
In regards to the removal of patch in the combative pt MD, do the same guidelines (treating pt with lesser dosing when unable to rule out other reversible causes) apply to Ketamine as it does to Midazolam?
It seems like since the removal of mandatory patch BH has been explicit about the approach to Midazolam administration, however I'm not sure if we can administer Ketamine without the patch. If so, do we proceed with +/- half the dose or would the lesser dosing be ineffective for violent psychosis/excited delirium?
It seems like since the removal of mandatory patch BH has been explicit about the approach to Midazolam administration, however I'm not sure if we can administer Ketamine without the patch. If so, do we proceed with +/- half the dose or would the lesser dosing be ineffective for violent psychosis/excited delirium?
Answer:
Firstly, there is no mandatory patch point in the Combative Patient Medical Directive, therefore you can proceed, based on clinical findings and patient assessment with either Midazolam or Ketamine for sedation. However, as always, if you would like further support and a consultation with a BH physician, the option is always available to you.
Secondly, you mention one of the Clinical Considerations listed at the bottom that states a lower weight-based dose of Midazolam can be considered based on clinical judgment. The dosing for Ketamine in the ALS PCS of 5mg/kg for patients ≥18 years < 65 and 3mg/kg for patients ≥65 years was set for a few reasons. First, the lower dosing for older patients is due to the potential for them to be more sensitive to the effects of ketamine due to changes in metabolism and other age-related factors. Second, the dose was set for those patients where rapid sedation is required, the combative, hyperactive delirium with severe agitation patients. These patients have the potential to harm themselves or others and it is imperative that they be sedated quickly for their safety, and that of others.
Thirdly, Ketamine is a dissociative anesthetic that has specific properties at different dosing levels. At doses below a certain threshold, Ketamine produces analgesia and sedation. However, once the critical threshold of roughly 1 to 1.5 mg/kg intravenously (IV) or 3 to 4 mg/kg intramuscularly (IM) is reached, the characteristic dissociative state abruptly appears [4]. And as previously mentioned, rapid treatment to those in severe crisis is imperative.
In conclusion, it is recommended to remain with the dosing that is outlined in the ALS PCS to ensure that proper and effective dissociative sedation is produced in the hyperactive delirium with severe agitation (excited delirium) patient. However, if you have some clinical concerns and/or think a lower dose would be more appropriate for your patient, a patch to a BH physician would be best.
Secondly, you mention one of the Clinical Considerations listed at the bottom that states a lower weight-based dose of Midazolam can be considered based on clinical judgment. The dosing for Ketamine in the ALS PCS of 5mg/kg for patients ≥18 years < 65 and 3mg/kg for patients ≥65 years was set for a few reasons. First, the lower dosing for older patients is due to the potential for them to be more sensitive to the effects of ketamine due to changes in metabolism and other age-related factors. Second, the dose was set for those patients where rapid sedation is required, the combative, hyperactive delirium with severe agitation patients. These patients have the potential to harm themselves or others and it is imperative that they be sedated quickly for their safety, and that of others.
Thirdly, Ketamine is a dissociative anesthetic that has specific properties at different dosing levels. At doses below a certain threshold, Ketamine produces analgesia and sedation. However, once the critical threshold of roughly 1 to 1.5 mg/kg intravenously (IV) or 3 to 4 mg/kg intramuscularly (IM) is reached, the characteristic dissociative state abruptly appears [4]. And as previously mentioned, rapid treatment to those in severe crisis is imperative.
In conclusion, it is recommended to remain with the dosing that is outlined in the ALS PCS to ensure that proper and effective dissociative sedation is produced in the hyperactive delirium with severe agitation (excited delirium) patient. However, if you have some clinical concerns and/or think a lower dose would be more appropriate for your patient, a patch to a BH physician would be best.