Use of Intravenous Ketamine Infusions for Chronic Pain
Publication Date: July 1, 2018
Recommendations
Indications
(1) For spinal cord injury pain, there is weak evidence to support short-term improvement. (C, Low)
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(2) In CRPS, there is moderate evidence to support improvement for up to 12 wk. (B, )
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(3) For other pain conditions such as mixed neuropathic pain, fibromyalgia, cancer pain, ischemic pain, headache, and spinal pain, there is weak or no evidence for immediate improvement. (D, Low)
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Dosing range and dose response
(1) Bolus: up to 0.35 mg/kg. (C, Low)
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(2) Infusion: 0.5 to 2 mg/kg per hour, although dosages up to 7 mg/kg per hour have been successfully used in refractory cases in ICU settings. (C, Low)
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(3) There is evidence for a dose-response relationship, with higher dosages providing more benefit. Total dosages be at least 80 mg infused over a period of >2 h. (C, Low)
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Relative contraindications
(1) Poorly controlled cardiovascular disease, pregnancy, active psychosis. (B, Low)
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(2) Severe hepatic disease (avoid), moderate hepatic disease (caution). (C, Low)
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(3) Elevated intracranial pressure, elevated intraocular pressure. (C, Low)
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(4) Active substance abuse. (C, Low)
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Role of oral NMDA receptor antagonist as follow-on treatment
(1) Oral ketamine or dextromethorphan, and intransal ketamine can be tried in lieu of serial infusions in responders.
Preinfusion tests
(1) No testing is necessary for healthy individuals. (C, Low)
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(2) In individuals with suspected or at high risk of cardiovascular disease, baseline ECG testing should be used to rule out poorly controlled ischemic heart disease. (C, Low)
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(3) In individuals with baseline liver dysfunction or at risk of liver toxicity (eg, alcohol abusers, people with chronic hepatitis), and those who are expected to receive high doses of ketamine at frequent intervals, baseline and postinfusion liver function tests should be considered on a case-by-case basis. (C, Low)
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Positive response
(1) A positive response should include objective measures of benefit in addition to satisfaction such as ≥30% decrease in pain score or comparable validated measures for different conditions (eg, Oswestry Disability Index for back pain). (C, )
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Personnel and monitoring
(1) Supervising clinician: a physician experienced with ketamine (anesthesiologist, critical care physician, pain physician) who is ACLS certified and trained in administering moderate sedation. (A, Low)
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(2) Administering clinician: registered nurse or physician assistant who has completed formal training in safe administration of moderate sedation. (A, Low)
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(3) Setting: at dosages exceeding 1 mg/kg per hour, a monitored setting containing resuscitative equipment and immediate access to rescue medications and personnel who can treat emergencies should be used, although this dose may vary based on individual characteristics. (A, Low)
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Title
Use of Intravenous Ketamine Infusions for Chronic Pain
Authoring Organization
American Society of Regional Anesthesia and Pain Medicine
Publication Month/Year
July 1, 2018
External Publication Status
Published
Country of Publication
US
Document Objectives
Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines.
Target Patient Population
Patient with chronic pain
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospice, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D000072716 - Cancer Pain, D059350 - Chronic Pain, D059408 - Pain Management, D001416 - Back Pain
Keywords
chronic pain, Pain Management
Source Citation
Reg Anesth Pain Med 2018;43: 521–546