Delayed Sequence Intubation is discussed a lot as procedural sedation to allow for maximized pre oxygenation for the critically ill patient. Be careful. The speed of how you push that aliquot of ketamine and the dose can cause the patient to disassociate too quickly, and the patient will become transiently apneic. ETCO2 quantitative measurements in live time are key. She didnt have one on in the case to be discussed below.
In the case I will describe, I noticed her volumes on the Noninvasive Ventilation mode of bipap has gone down even at pain dose of ketamine at 0.15-0.3mg/kg given. She was only 50 kg this you patient with status asthmaticus. She has only gotten 15 mg ivp. The traditional suggested dose of procedural sedation of ketamine is the same for Rapid Sequence Intubation at 1-2mg/kg ivp. Her dose would have been 50 to 100 mg ivp. I quickly did NO DESAT maneuvers. Kept the bipap machine facemask on her face. Let the machine do its work. This was done instead of bagging with an crappy bvm mask with a sucky seal. She didn't get the bipap facemask with its head straps replaced with a nasal cannula and BVM. I instead performed a bilateral jaw thrust. The sats dropped but then rose. This patient made me realize all patients are different and can get hit hard by even pain dose of ketamine. One can be patient and give aliquots of ketamine ivp for procedural sedation. Consider having up to 3 doses of pain dose ketamine ready or planned to provide adequate sedation to allow for DSI, procedural sedation for oxygenation to work. Likely safer than pushing all of 1mg/kg dose at once for this patient and all future patients.
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6 сен 2024
