I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.
This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.
Ketamine: (different doses I’ve seen in the literature below)
• Induction: 0.2-0.5 mg/kg
• Infusion: 0.1mg/kg/hr before incision
◦ 2mcg/kg/hr x 24hr (spine)
◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)
◦ 2mcg/kg/min
◦ 2-8mcg/kg/min
Overall, 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 (grade B recommendation, moder-
ate level of certainty).
What I’m using nowadays:
- Oct 2017:
- Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved. Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol. Patients are more comfortable and require less pain medication.
- Dec 2018:
- Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming.
- July 2020:
- Cardiac open hearts: induction infusion 0.3mg/kg/hr + 0.5mg/kg right before incision. 0.2mg/kg/hr when commence CPB. 0.1mg/kg/hr when re-warming. Stop infusion when driving wires.
- Main OR: induction 0.35mg/kg + 0.2mg/kg/hr or 3mcg/kg/min = extubate patient in OR. Stop infusion when closing.
- **Excel spreadsheet for dosing**
- August 2020:
- Cardiac open hearts: induction infusion 0.2mg/kg/hr + 0.35mg/kg right before incision. 0.1mg/kg/hr when re-warming. Stop infusion when driving wires.
- Main OR: induction 0.35mg/kg + 0.1mg/kg/hr = extubate patient in OR. Stop infusion when starting to close. If fast closure, consider stopping infusion 30min to 1 hour prior to end of case.
- March 2021:
- Cardiac: 0.2mg/kg/hr after induction and lines placed + 0.35mg/kg 5-10 minutes before incision. 0.1 mg/kg/hr when re-warming. Stop infusion when placing sternal wires.
- Non-cardiac (2+ hr duration case): 0.3mg/kg at induction.
Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.
Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.
Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.
The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.
Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.
Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.
***UPDATE July 8, 2018 ***
- Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use. - Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events. - Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
Conclusion: There is moderate evidence to support using 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. - Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure. - Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain. - Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.
New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).
The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.
Update Nov, 30, 2018
Updated July 2020
Ketamine: A Versatile Tool in the Perioperative Period and Beyond. ASRA News, Feb 2017.
Update March 2021
- Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.
- Methadone: 0.2 mg/kg of methadone (based on ideal body weight, up to a maximal dose of 20 mg)
- Ketamine: 250 mg of ketamine was added to the dextrose 5% in water bag (total volume 500 ml). 500 ml bags were connected to a pump that was programed to deliver an infusion of ketamine dosed at ideal body weight (or an equal volume of dextrose 5% in water) at a rate of 0.3 mg · kg−1 · h−1 from induction of anesthesia until surgical closure, at which time the infusion was decreased to 0.1 mg · kg−1 · h−1. The infusion was maintained at a rate of 0.1 mg · kg−1 · h−1 in the postanesthesia care unit (PACU) and for the next 48 postoperative hours. Dosing of ketamine was based on recommendations in the literature and from clinical experience at our institution.
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