Had a patient the other day scheduled for a TAH, one sided oophorectomy, bilateral tubal, open cholectomy, small and large bowel resection with placement (actually change of position) of ostomy and hernia repair. The CRNA I was with and I talked about some different options for pain control for the case including an epidural, etc. We decided to use methadone. I have primarily only used methadone in spine cases/TIVAs or if the patient came in on methadone but was up for using it on this case.

Patient was 34, female, BMI approx 35ish, smoker, Crohns, Anxiety, and a very large list of medications and previous surgeries. As we were inducing her in the room she told us that her previous anesthetists had told her she was hard to "put to sleep" b/c she was a recovering addict.

My induction was 2mg Versed and robinul preop, 20 mg Methadone, 100 mg Lidocaine, 70 mg propofol and 50 mg Rocuronium. Tube placed without difficulty, 2nd IV (18ga) placed with some difficulty as she had almost no veins and came to use with a 22 gauge in her wrist. Used low flow Desflurane as this CRNA loves Des.

Surgery began and the surgeon began to curse as he encountered massive amounts of scar tissue and a lot of encapsulated areas of infection. In fact the "pelvic mass" seen on the CT was just that. So they just cleaned them up to the best of their ability and then closed it up with the intention of bringing her back in in a few weeks once the infection was past.

Patient was reversed, and gas blown off. Patient woke up and within a minute of extubation stated she was in pain. Gave her 5 mg morphine and 100 mcg fentanyl. Patient still stating in pain after a couple of minutes as I wait for the circulator to finish her charting. Give 2 mg Versed and 20 mg ketamine. Patient transported to PACU where was still stating intense pain and 150 mcg fentanyl given and patient almost went apneic but was then nodding that they were pain free.

CRNA and I discussed the case afterwards. He was fine with all my choices but stated he would not have given the versed and asked my rationale. I agreed that the combination of the benzo with the opioids probably led to the increased respiratory depression but I wanted to make sure that if she had any reaction from the ketamine that it would be covered with the versed. Patient was comfortable for the rest of their stay in PACU and pain services saw her before she went up to the floor.

Thoughts? Would you have given the versed with the ketamine?