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, )
(low to moderate certainty)
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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.
  • oral preparations
(B, Low)
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  • intranasal ketamine.
(B, Moderate)
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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, )
(low-to-moderate certainty)
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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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Recommendation Grading

Disclaimer

Overview

Title

Use of Intravenous Ketamine Infusions for Chronic Pain

Authoring Organization

Publication Month/Year

July 1, 2018

Document Type

Guideline

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

Scope

Management

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