Use of Intravenous Ketamine Infusions for Acute Pain Management

Publication Date: July 1, 2018
Last Updated: March 14, 2022

Recommendations

1: Which Patients and Acute Pain Conditions Should Be Considered for Ketamine Treatment?

Overall, we conclude that subanesthetic ketamine infusions should be considered for patients undergoing painful surgery. (B, Moderate)
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Ketamine may be considered for opioid-dependent or opioidtolerant patients undergoing surgery. (B, Low)
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Because evidence is limited to case reports and series as well as the clinical experience of the committee, ketamine may be considered for opioiddependent or opioid-tolerant patients with acute or chronic sickle cell pain. (C, Low)
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For patients with sleep apnea, ketamine may be considered as an adjunct to limit opioids. (C, Low)
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2: What Dose Range Is Considered Subanesthetic, and Does the Evidence Support Dosing in This Range for Acute Pain?

Therefore, we recommend that ketamine bolus doses do not exceed 0.35 mg/kg, and infusions for acute pain generally do not exceed 1 mg/kg per hour in settings without intensive monitoring, but we also acknowledge that individual pharmacokinetic and pharmacodynamic differences, as well as other factors (eg, prior ketamine exposure), may warrant dosing outside this range. Ketamine's adverse effects will prevent some patients from tolerating higher doses in acute pain settings, and unlike for chronic pain therapy, lower doses (ie, 0.1–0.5 mg/kg per hour) may be needed to achieve an adequate balance of analgesia and adverse effects. (C, Moderate)
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3: What Is the Evidence to Support Ketamine Infusions as an Adjunct to Opioids and Other Analgesic Therapies for Perioperative Analgesia?

Overall, we conclude that moderate evidence supports use of subanesthetic IV ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids for perioperative analgesia. (B, Moderate)
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What Are the Contraindications to Ketamine Infusions in the Setting of Acute Pain Management, and Do They Differ From Chronic Pain Settings?

Evidence indicates that ketamine should be avoided in individuals with poorly controlled cardiovascular disease (C, Moderate)
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  • and pregnancy or active psychosis.
(B, Moderate)
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For hepatic dysfunction, evidence supports that ketamine infusions should be avoided in individuals with severe disease (eg, cirrhosis) and used with caution (ie, with monitoring of liver function tests before infusion and during infusions in surveillance of elevations) in individuals with moderate disease. (C, Low)
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Evidence indicates that ketamine should be avoided in individuals with elevated intracranial pressure and elevated intraocular pressure. (C, Low)
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5: What Is the Evidence to Support Nonparenteral Ketamine for Acute Pain Management?

Based on a review of these studies, we conclude that the use of IN ketamine is beneficial for acute pain management, providing not only effective analgesia but also amnesia and procedural sedation. Particular scenarios in which this should be considered include individuals for whom IV access is difficult and children undergoing procedures. (C, )
(low-to-moderate level of certainty)
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For oral ketamine, the evidence is less robust, but small studies and anecdotal reports suggest it may provide short-term benefit in some individuals with acute pain. (C, Low)
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6: Does Any Evidence Support Patient-Controlled IV Ketamine Analgesia for Acute Pain?

Overall, we conclude that evidence is limited for the benefit of IV-PCA–delivered ketamine as the sole analgesic for acute or periprocedural pain. (C, Low)
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We conclude that moderate evidence supports the benefit of the addition of ketamine to an opioidbased IV-PCA for acute and perioperative pain management. (B, Moderate)
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Recommendation Grading

Disclaimer

Overview

Title

Use of Intravenous Ketamine Infusions for Acute Pain Management

Authoring Organization

Publication Month/Year

July 1, 2018

Last Updated Month/Year

July 7, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines.

Target Patient Population

Patient with acute pain

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospice, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D059408 - Pain Management, D000079645 - Perioperative Medicine, D059787 - Acute Pain

Keywords

post-surgery, anesthesia and analgesia, Pain Management, acute pain

Source Citation

Reg Anesth Pain Med 2018;43: 456–466