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Anesthesiology/Ketamine - terrifying

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QUESTION: Dr. Levy,
Thank you for taking my question.

Background information:
I have a paradoxical reaction to Versed (high anxiety)
I am highly allergic to Fentanyl (throat swelling, hives, and difficulty urinating)
I have had 2 very negative experiences from Ketamine (disassociative, hallucinations, etc)

Unfortunately I have had several health problems requiring multiple major surgeries and other medical/dental procedurtes requiring sedation (general and twilight) over the past 3 years. Because of my previously mentioned problems with the "standard" medications given for sedation purposes I have become  fearful of being sedated. It seems that regardless of my making very sure that I highlight this information on all medical history forms, and notify every medical person involved, that I must still try and keep my wits about me while laying on the table, to tell the actual operating room personel about these issues at which time everything is stopped while they hastily make last second decisions about how to handle sedating me. I have been at top notch medical centers when this has happened, ass well as oral surgeons offices.

Questions:
How would you recommend I handle this dilemma with medical providers in the future?
When Ketamine is administered (to obtain the disassociative result of consciousness) is it standard practice to also administer a sedative - the terriifying experience of what has been described as the "K hole" occurs at the beginning of the procedure, as well as when I'm coming out of anethesia.

Thank you

ANSWER: There are other medications they can give you that don't involve Versed or Ketamine. The most likely option is Propofol which has anesthetic, sedative, antiemetic and amnestic effects. Another option is Precedex (Dexmedetomidine) which is similar to Ketamine but without the hallucinations and nightmares. There are also other pain meds they can give you. Whenever you have these procedures, you should probably have an anesthesiologist perform your anesthetic (as opposed to the GI doc or dentist) since we have a wider array of medications we can give you.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your reply.

I have a couple of follow up question primarily in regard to Propofol. This medication was mentioned to me by a anethesiiologist who was discussing my care with me prior to a recent surgery I had. The doctor said this medication was the option they wanted to use were going to decide not to because of a concern that I would be at more of a risk of encountering respiration difficulties because my left lung doesn't function properly (it doesn't functiion much at all due to phrenic nerve damage from thoracic outlet surgery).

This procedure ended up being my first bad experience with Ketammine. In your opinion, without of course knowing anything about my medical history, should Propofol be a medication I put on my "allergy information list" that anethesiiologists  review prior to surgery?

Also with regard to Propofol, when the oral surgeon saw I was having a terrible reaction to Ketamine, he said that he immediately switched to Propofol even though he had also previously mentioned a concern with giving it to me because my lung problem.

I understand (and agree) that I should have a anethesiiologist provide my anesthetic but how should I handle things when there isn't one on staff (oral surgeons offices, etc)? Should I possibly mention Precedex to them?

Sorry, one last thing I've always wanted to ask. Is having a paradoxil reaction to Versed as unusual as some doctors have related to me?

Thank you for your time

Answer
I disagree that Propofol is a bad option and it is not an allergy. If administered by an anesthesiologist, it is an excellent choice. Having a bad lung does not increase the risk of respiratory difficulties. The Propofol needs to be titrated correctly or you may need general anesthesia for your procedures. If the dental office is unable to provide an anesthesiologist, you may need to go to a hospital that provides oral surgeons and anesthesiologists. As for Precedex, if your dentist is not familiar with the medication, I would not want him to use it. Where did your dentist get his anesthesia training. Oral surgeons should have 2 years experience in an anesthesia program to be qualified to provide the kind of anesthesia you need. As for the paradoxical reaction, it is rare but not as rare as they claim.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

Anesthesiology

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Ronald Levy, M.D.

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Associate Professor of Anesthesiology, University of Texas Medical Branch at Galveston. I am a board certified anesthesiologist who can answer all questions related to any type of Anesthesia with the exception of Pain Management.

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