Some thoughts on our protocol

[FONT=Arial][COLOR=#000000]Hi guysAs we are awaiting Health Canada approval, I had one thought about our protocol. Currently we have planned to give further doses of med at q 2 min intervals. I think this should be changed to q1-2 min intervals at the discretion of the treating MD. I thought of this as I was sedating a child with multiple head lac’ns with ketamine propofol – I followed our protocol, and she was one of these individuals who required a large amount of propofol to get her sedated nicely. In our protocol, by the time you got around to giving her the third and fourth doses of propofol, the first dose would be wearing off.[/COLOR][/FONT][FONT=Arial][COLOR=#000000]I have been thinking about what the potential pitfalls of our blinding strategy could be, just so we can troubleshoot ahead of time. My experience with the ketamine propofol continues to be excellent – I think if we can replicate the clinical experience with the blinding protocol, we will be in great shape to show advantage. [/COLOR][/FONT][FONT=Arial][COLOR=#000000]Few pitfalls for discussion however:[/COLOR][/FONT][FONT=Arial][COLOR=#000000]1. Propofol dosing is much more variable than ketamine dosing. The dosing works best when small frequent aliquots are given to effect, and our q2 minute protocol will not replicate this at all. I have given this some thought and I do think we need to address this in our protocol now if we want to test the regimen properly. Now one could argue that changing our protocol to a q1-2 min protocol could result in extra doses of ketamine being given. However, IV Ketamine takes effect very quickly also, certainly in most kids within 60 seconds, and has a very high ceiling dose in terms of safety, which we are not approaching even with all of the protocol doses followed in the ketamine only arm. I think it would be a reasonable change, but I would like to hear the group’s comments. [/COLOR][/FONT][FONT=Arial][COLOR=#000000]2. I still think ketamine .75 mg/kg is a more appropriate starting dose for the ketamine propofol arm, I find this works better. This is kind of a moot point in the sense that our protocol in this regard is set I believe, and I don’t think we could change this without some concerns from the overall peds group because of the affinity to low dose ketamine regimens, which I respect. Nonetheless, this has been my clinical experience. If any of you have had occasion to play with the dosing protocols I would like to hear of your experience.[/COLOR][/FONT][FONT=Arial][COLOR=#000000]I just listened to a spring edition of EMRAP (monthly emerg educational series for those unfamiliar). Mel interviewed Steve Green (Ketamine Guru) about a variety of things, and Ketofol was discussed specifically. Steve Green was skeptical of ketofol’s advantage over propofol alone, but said he looked forward future research and RCTs. There is certainly interest in the topic out there, and our up front ketamine protocol actually addresses some of the concerns that Steve raised with how ketofol is titrated in.[/COLOR][/FONT][FONT=Arial][COLOR=#000000]I have discussed ketamine propofol a few times with my St. Thomas group, and how have at least 3 converts – previous diehard propofol fans who find the combo advantageous when they have tried it. [/COLOR][/FONT][FONT=Arial][COLOR=#000000]Just some thoughts, I will post this to the bulletin board also for those who look there.[/COLOR][/FONT][FONT=Arial][COLOR=#000000]Also, just an aside – I will be away from April 23-30, so particularly for Shelley, if you need to get a hold of me I will return for duty May 1. Hope you had a fantastic trip yourself Shelley![/COLOR][/FONT][FONT=Arial][COLOR=#000000]Amit[/COLOR][/FONT]

Hey, I think you’re absolutely right Amit. I remember discussing this in our group meetings and the only reason we went to q2mins was to allow time to record vitals (esp BP) and do sedation scoring. But if the data is recorded and we’re shy of the 2 minute mark, I agree we should be allowed to give the next dose of sedation.I think the Ketamine dosing is going to be difficult to change at this point. I have found it to be very good with both adults and kids so far. I’m happy with the 0.5/kg.As to Dr. Green’s EMRAP interview and his editorial in the Annals (which I read with some skepticism), I am not impressed with his argument against ketofol. He misses the point of the retention of airway reflexes and BP with good depth of sedation that results from the combination. His rant against combination agents is ridiculous, as we use all kinds of combinations and still don’t touch the coctails used by anesthesia.All this has got to be worth at least 3 and a 1/2 cents…Greg