tag:blogger.com,1999:blog-21605329.post7577370559521047835..comments2024-03-19T02:52:27.788-07:00Comments on The Neurocritic: Update on Ketamine in Palliative Care SettingsThe Neurocritichttp://www.blogger.com/profile/08010555869208208621noreply@blogger.comBlogger8125tag:blogger.com,1999:blog-21605329.post-2143994213957376762016-09-08T13:58:00.202-07:002016-09-08T13:58:00.202-07:00How long does ketamine last<a href="http://www.dissociativeszone.com/" rel="nofollow">How long does ketamine last</a>Anonymoushttps://www.blogger.com/profile/14750119858189476009noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-10653868452471127852013-10-20T12:24:37.841-07:002013-10-20T12:24:37.841-07:00I'm very sorry about your father and your trea...I'm very sorry about your father and your treatment-resistant status. But I'm not sure I understand your point, or why Dr. Carl Hart is relevant here.The Neurocritichttps://www.blogger.com/profile/08010555869208208621noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-3194943538622538412013-10-20T12:15:02.123-07:002013-10-20T12:15:02.123-07:00If only 8 patients completed the Ketamine trial, i...If only 8 patients completed the Ketamine trial, it is insufficient to claim "but all showed at least 30% improvement in symptoms." How much is 30% in "hard data"? <br /><br />For example, let's hypothetically place 8 patients in a depression trial, where the initial BDS (Beck Depression Scale) ranged from 1 (completely disabled by the illness) to 10 (in full remission and even describing oneself as "happy"), with 5 indicating partial remission (improvement in mood but without approaching "normalcy" and with no apparent improvement in functioning). All 8 patients began at 0 on the scale. A 30% improvement from 0 to 3 may be a slight improvement on paper but the patient as an individual has not improved substantially. Or let's say the only patients who reached a "7 to 8" level on the BDI were patients who had started at 4 to 5 at the beginning of the study. They were mildly depressed, and their depression improved to nearly a full remission. Terrific, right? But the same sample bias you attack Dr. Carl Hart for is exactly what you're doing here. Is it a good beginning for a pilot study? Can Ketamine and MDMA therapy ever be tested in a lab where "set and setting" were utterly discarded? I don't know. I do know that I take a MAOI+an amphetamine (for only the most extreme treatment-resistant patients), have endured ECT and found it kept me chained to being a "professional patient" even before it stopped helping, and I believe that it's time for innovative thinking. But let's ALL keep our biases in check.<br /><br />[I watched my father die of metastatic liver cancer. It was so traumatic I went into complicated grief/post-traumatic shock for 2 and 1/2 years and am only now improving, more than 3 years later. I would have injected him with a mixture of diacetylmorphine (heroin) and diazepam (Valium) myself or strapped fentanyl patches all over his body because I know that despite the Dilaudid, fentanyl, morphine, oxycodone, lorazepam, etc. they gave him at the hospice to "keep him comfortable," even they said "he medically should be dead but he's refusing to let go." I gave him my permission at the very end, told him to fly away and be free. Maybe that's what he was so desperately waiting for. I will never know. I do know that even if Ketamine would have provided some placebo peace-of-mind (because it's very hard to experience a true blinded placebo response in a Ketamine clinical trial, I'd imagine) ... I'd tell them to do it. But it's not the media's fault for taking pilot studies and making them into definitive conclusions about medicine ... We do it, too. (Hey, have you heard Oreos are as addictive as cocaine?)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-21605329.post-17114570036252798492013-09-13T02:21:46.712-07:002013-09-13T02:21:46.712-07:00Thanks for relaying your clinical experiences with...Thanks for relaying your clinical experiences with different uses for ketamine (and for the kind words).The Neurocritichttps://www.blogger.com/profile/08010555869208208621noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-84659723707893910482013-09-12T13:36:53.788-07:002013-09-12T13:36:53.788-07:00There is some evidence for use of ketamine in comp...There is some evidence for use of ketamine in complex regional pain syndrome. http://www.ncbi.nlm.nih.gov/pubmed/19604642 I had an opportunity to use it in about 10 patients in a previous job. Pretty good results. My results in the couple of cancer pain patients was disappointing. <br /><br />There is some (mostly anecdotal) evidence for use in sickle cell pain crisis as well. I haven't yet convinced my hospital to allow me to use it for this purpose in our particularly difficult cases. <br /><br />Some docs are using it orally (compounded from the IV solution). My compounding costs were surprisingly high when I checked, so this wasn't an option the couple times I wanted to prescribe it.<br /><br />My interest in use of ketamine for depression would mostly center on use in elderly patients (who didn't improve with more traditional antidepressants + cognitive therapy if available), yet couldn't get ECT because of lack of availability in my area. I've had a couple of candidates in mind, but once again my hospital will not permit it. (Despite the fact that ketamine is so -relatively- safe that it is on the WHO list of essential medications in 3rd world countries...for surgeries without a full operating theater. And despite the fact that I'm fellowship-trained and boarded, and experienced in use.) I've not yet been convinced that the evidence for maintenance oral use is strong enough to try to fight the battle at nursing home. I'd love to see more data.Bruce Scotthttps://www.blogger.com/profile/04422105650141812623noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-24150815288595877052013-09-12T10:29:01.673-07:002013-09-12T10:29:01.673-07:00Thanks so much for linking to Pallimed. We apprec...Thanks so much for linking to Pallimed. We appreciate the link love. Excellent post. I found it actually via Research Blogging's Twitter Feed. Will be looking here more often for palliative care content.<br /><br />For many doctors, there is little experience in working with ketamine outside of ERs and ORs and maybe ICUs. The medication has been often given a special status where you may only prescribe it on certain floors or only if you have had hospital specific training in its use. Even in palliative care settings many HPM fellows do not get consistent exposure to situations where prescribing ketamine may be an option. It will be interesting to see if more research brings down some of these self-imposed cultural barriers to appropriate use of ketamine. <br /><br />My condolences on your father. It is great that you can combine your advocacy and concern for him with the education of more people. One of the great special powers of blogs.Christian Sinclairhttps://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-75040568679243691252013-09-09T11:12:49.351-07:002013-09-09T11:12:49.351-07:00Thanks.
I did find a paper on use of the Kosish C...Thanks.<br /><br />I did find a paper on use of the <a href="http://www.ncbi.nlm.nih.gov/pubmed/20859467" rel="nofollow"><i>Kosish Cocktail</i></a> in India. It's "a mixture of ketamine, midazolam, pentazocine lactate, and other adjuvants for use in the domiciliary set-up as intermittent subcutaneous injections in a morphine-naïve community."The Neurocritichttps://www.blogger.com/profile/08010555869208208621noreply@blogger.comtag:blogger.com,1999:blog-21605329.post-32191579036975938282013-09-09T10:34:24.640-07:002013-09-09T10:34:24.640-07:00Good post.
Perhaps ketamine could be added to a n...Good post.<br /><br />Perhaps ketamine could be added to a next-generation <a href="http://en.wikipedia.org/wiki/Brompton_cocktail" rel="nofollow">Brompton Cocktail.</a>Neuroskeptichttps://www.blogger.com/profile/06647064768789308157noreply@blogger.com