Things you might see when ketroperidol is NOT administered
In the latest July-September 2012 edition of Prehospital Emergency Care Journal, there are two case studies published on the same issue of managing combative agitated patients in the prehospital setting. Here are the article abstract links
Ketamine and Droperidol in these case studies, what a coincidence! Both used separately but I thought a good opportunity to highlight a practice that I am using lately in retrieval sedation/analgesia
Ketamine is a great analgesic and sedative. BUT it has issues. It makes you dysphoric and hallucinatory state. It causes release of catecholamines, raising heart rate and BP. It makes you vomit. It can cause laryngospasm ( illustrated by case study above)
HOW TO COUNTERACT THOSE PROBLEMS OF KETAMINE?
Midazolam has been well studied and does reduce delirium/dysphoria/hallucinations when coadministered with ketamine. It does not prevent or treat nausea though and has a nasty habit of unpredictably making patients stop breathing.
Propofol and ketamine = ketofol. Nice combination, addressing nausea issues and counteracting delirium and hallucinations. Still issues with potential apnoea. Recent research indicating not superior to propofol alone.
Droperidol works well with ketamine. It is an antiemetic and sedative yet does not affect respiration/ventilation at doses of 0.1mg/kg
It also helps ameliorate the haemodynamic effects of ketamine on BP and HR
The DORM study supported the safety of droperidol over midazolam for acute ED sedation of agitated patients.
LARYNGOSPASM IS RARE BUT YOU NEED TO KNOW WHAT TO DO! READ THIS BY MASTER CLIFF REID
CLINICAL SITUATIONS WHERE KETROPERIDOL MIGHT BE HELPFUL
1. Agitated patient of uncertain cause
2.Extrication/movement of patient with limited monitoring or access for airway/ventilatory support.
3. Procedural sedation in limited resource setting ( Ketamine alone would suffice but improved sedation profile with droperidol)
DOSING ( What I do in retrieval practice)
Droperidol 1-2mg IV followed 5 minutes later by Ketamine 0.5-1mg/kg IV
Like any sedation, there is individual patient variability so you need to adjust things for each case. The safest technique I have found that establishes a reliable and steady level of sedation with minimal respiratory problems or haemodynamic perturbations is to initiate the sedation with the boluses above, then start a ketamine infusion of 1mg/kg/hr initial rate, supplementing with boluses of droperidol rather than increasing the infusion rate. You need to run the infusion rate for around 40 minutes to reach steady state plasma levels with ketamine so little point in increasing the rate too quickly.
This technique provides a safe and effective prehospital balanced sedation for a broad range of scenarios, from trauma to acute mental health related agitation.
Ketroperidol. You come up with a better name.