Most nurses quickly learn how to monitor patients after administration of opioids or various sedatives. “Maybe they should change Mr. Smith’s sleeping pill because he just ate our entire stash of saltines in his sleep.” I’ve previously mentioned the lovely shade of periwinkle some patients display when they don’t breathe, so we don’t need to spend much time on the topic of narcotics and anesthetics. Do you know what’s really sexy right now in anesthesia, besides that one rep with the shiny teeth who laughs at everything you say as if you were actually funny? Opioid-free anesthesia. No fentanyl or morphine or “that one drug that begins with a ‘D’, that’s the only one I’m not allergic to,” just analgesia provided by nerve blocks and lidocaine and esmolol and magnesium and Precedex and Neurontin. Oh, and ketamine. Let’s talk about Monitoring Patients after Ketamine, including the context in which I administer it in my new clinic.
Monitoring Patients after Ketamine
How Ketamine Works
Used safely for decades in the ER and OR, ketamine induces a dissociative state that preserves respiratory and cardiac function while providing the necessary components for anesthesia. Depending on the dose, amnesia, analgesia, and sedation result from noncompetitive antagonism of the N-methyl D-aspartic acid (NMDA) receptor so the patient doesn’t remember, doesn’t hurt, and isn’t awake for procedures. Ketamine also interacts with opioid, cholinergic, and other receptors to potentiate other drugs while providing anti-inflammatory effects and preventing hyperalgesia. Opioids can cause non-painful stimuli to be interpreted as pain, and hyperalgesia is also common in fibromyalgia, chronic regional pain syndrome (CRPS), and similar disorders.
Latest Research
This is the part that relates to my work with Alleviant Health Centers of Akron. We use ketamine as a slow infusion in a medical spa environment—much more of a tranquil experience than slamming in 75mg to set a bone in the emergency department. Ketamine regulates the effects of glutamate, a brain-nourishing neurotransmitter also associated with inflammation and even some autoimmune responses. Along with mood disorders including depression; suicidal ideation; migraines and various pain syndromes, Ketamine can drastically improve outcomes where other treatments have failed. Through neuroplasticity and synaptogenesis, ketamine grows new connections to heal from physical and emotional trauma. Ketamine works best in consort with seeing a therapist to strengthen new perspectives and thought patterns as cyclical patterns of pain or destructive thoughts lose their power. Although researchers study intravenous ketamine as the gold standard for these off-label uses, the FDA recently approved a nasal spray administered to monitored patients for treatment-resistant depression. It can reduce or replace multiple medicines used for anxiety, PTSD, OCD, or pain disorders, but some patients will need maintenance therapy after the usual course of sessions. Despite its reputation as a street drug, ketamine successfully treats select patients struggling with various addictions or substance abuse issues, especially during the current opioid epidemic.
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Monitoring and Precautions
Well, this all sounds spectacular, can we ride a magical unicorn off into the rainbow-hued sunset now? Not quite. I mentioned nurse education in troubleshooting problems and solutions for patients on narcotics functions well, but not so much for novel medications, other than referencing “guided imagery” in care plans whenever possible. Like other drugs common in anesthesia, ketamine effects are synergistic rather than just additive—think of how peanut butter tastes so much better with chocolate.
Continual monitoring is a must, even if ketamine seems to wear off within 30 minutes of administration. But how should you assess ketamine’s effects? When I was a fresh RN, our ICU was one of the first to try Precedex. I didn’t think it did anything until I quit expecting it to work like fentanyl. It still took me a while to stop counting respirations to interpret pain like I did when patients were receiving opioids. Like Reglan and Haldol, patients receiving ketamine may appear calmer than they actually feel. Rather than expecting thoughtful, introspective information about their mental state while receiving the drug (although that does happen), patient education beforehand helps set expectations. Don’t underestimate the power of your words. I tell all my patients to give me a thumbs up or thumbs down signal. I explain that altered perception is common as ketamine rewires the brain. Turn the lights down and avoid overstimulation. The larger doses required for sedation can result in hallucinations, so in those instances give with a benzodiazepine if possible. Are they restless or agitated? Patients may even appear catatonic or unresponsive after a bolus dose. Is the air warm next to their nose and mouth? Oh good, they’re still breathing. Make sure there are prn orders for whatever you may need. The increased heart rate, blood pressure, and bronchodilation from ketamine’s sympathomimetic effects can be useful in trauma, but many patients you’ll encounter receive ketamine because they can’t tolerate more typical anesthetics.
What questions do you have about taking care of patients who have received ketamine? Maybe next time we’ll delve into the related topics of Brain-Derived Neurotrophic Factor and Transcranial Magnetic Stimulation.
Nick Angelis is a CRNA and the CEO of Alleviant Health Centers in Akron, Ohio, dedicated to healing pain, restore hope, and regain purpose. He is the author of multiple articles, courses such as FreshRN’s Critical Doing, and books, most notably How to Succeed in Anesthesia School (And RN, PA, or Med School). Besides mediocre attempts to become a snowbird, play sports with any measure of competence, and perform comedy poorly, Nick is a member of First City Improv and a writer and actor for Improbable Cause Mystery Theatre in Pensacola, Florida.
More resources for Monitoring Patients after Ketamine
How to Succeed in Anesthesia School (And Nursing, PA, or Med School)
Ketamine: Use and AbuseEvaluating of Ketamine, Tramadol, Paracetamol, and Xylazine Combination in Sheep AnesthesiaModerate Sedation/Analgesia Practice Guidelines: Fourth EditionI think I saw a Leprechaun Ketamine Anesthesia T Shirt
I just came from a FLASPAN meeting where pain management and the Opioid crisis was the topic. By me was a group largely consisting of other perianesthesia nurses. Loved learning more of the great benefits of Ketamine’s synergistic attributes , i.e learning that in small doses during surgery, it helps promote a PACU recovery with less opioids and well managed pain.
Your post added even more insight.
Thanks, I always try to plan in the OR so the patient won’t start having pain when it’s time to leave PACU.
Let’s resurrect cyclopropane. When Ketamine was first used in the early 1970’s some anesthesia folks thought it was very similar in terms of emergence. I have a recent blogpost about the magic of Cyclo. oldfoolrn.blogspot.com
I am from South Africa, working with a psychiatrist. He wants to start a Ketamine clinic for patients with Depression. What do we need to prepare for such a clinic and how to monitor the patient receiving IM Ketamine