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Abdelfattah M, Abdelbaser I, Awad KA, Atallah AM, Sanad M, Sayedalahl M. Effect of Low-dose Ketamine Infusion on Opioid Consumption in Children Undergoing Open Cardiac Surgery: A Randomized Controlled Double-Blind Study. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00293-3. [PMID: 38908932 DOI: 10.1053/j.jvca.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery. DESIGN A randomized, controlled, double-blinded single-center study was conducted. SETTING The study took place in a tertiary care children's hospital. PARTICIPANTS Patients of both sexes aged 2-12 years who underwent cardiac surgery were included. INTERVENTIONS Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group. MEASUREMENTS AND MAIN RESULTS The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations. CONCLUSIONS Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations.
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Affiliation(s)
- Mahmoud Abdelfattah
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Ibrahim Abdelbaser
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Karim Ali Awad
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Mohamed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Sayedalahl
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Johnston JN, Kadriu B, Kraus C, Henter ID, Zarate CA. Ketamine in neuropsychiatric disorders: an update. Neuropsychopharmacology 2024; 49:23-40. [PMID: 37340091 PMCID: PMC10700638 DOI: 10.1038/s41386-023-01632-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
The discovery of ketamine as a rapid-acting antidepressant led to a new era in the development of neuropsychiatric therapeutics, one characterized by an antidepressant response that occurred within hours or days rather than weeks or months. Considerable clinical research supports the use of-or further research with-subanesthetic-dose ketamine and its (S)-enantiomer esketamine in multiple neuropsychiatric disorders including depression, bipolar disorder, anxiety spectrum disorders, substance use disorders, and eating disorders, as well as for the management of chronic pain. In addition, ketamine often effectively targets symptom domains associated with multiple disorders, such as anxiety, anhedonia, and suicidal ideation. This manuscript: 1) reviews the literature on the pharmacology and hypothesized mechanisms of subanesthetic-dose ketamine in clinical research; 2) describes similarities and differences in the mechanism of action and antidepressant efficacy between racemic ketamine, its (S) and (R) enantiomers, and its hydroxynorketamine (HNK) metabolite; 3) discusses the day-to-day use of ketamine in the clinical setting; 4) provides an overview of ketamine use in other psychiatric disorders and depression-related comorbidities (e.g., suicidal ideation); and 5) provides insights into the mechanisms of ketamine and therapeutic response gleaned from the study of other novel therapeutics and neuroimaging modalities.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Translational and Experimental Medicine, Neuroscience at Jazz Pharmaceuticals, San Diego, CA, USA
| | - Christoph Kraus
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Bodnar RJ. Endogenous opiates and behavior: 2022. Peptides 2023; 169:171095. [PMID: 37704079 DOI: 10.1016/j.peptides.2023.171095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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Cuviello A, Pasli M, Hurley C, Bhatia S, Anghelescu DL, Baker JN. Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration. Front Oncol 2022; 12:1017272. [PMID: 36313632 PMCID: PMC9606590 DOI: 10.3389/fonc.2022.1017272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/30/2022] [Indexed: 12/04/2022] Open
Abstract
Context Approximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs. Methods A retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied. Results Charts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines. Conclusions Pediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.
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Affiliation(s)
- Andrea Cuviello
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Andrea Cuviello,
| | - Melisa Pasli
- Pediatric Oncology Education Program, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Caitlin Hurley
- Division of Critical Care Medicine, Departments of Pediatric Medicine and Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Shalini Bhatia
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Doralina L. Anghelescu
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Zavala NA, Knoebel RW, Anitescu M. Lidocaine and Ketamine Infusions as Adjunctive Pain Management Therapy: A Retrospective Analysis of Clinical Outcomes in Hospitalized Patients Admitted for Pain Related to Sickle Cell Disease. FRONTIERS IN PAIN RESEARCH 2022; 3:878985. [PMID: 35992021 PMCID: PMC9386131 DOI: 10.3389/fpain.2022.878985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objective In this study, we aim to evaluate the efficacy of adjunctive lidocaine and ketamine infusions for opioid reduction in the treatment of sickle cell disease in patients with vaso-occlusive crisis (VOC). Design We retrospectively reviewed a cohort of 330 adult sickle-cell crisis hospital encounters with 68 patients admitted to our institution from July 2017 to August 2018. Methods Upon institutional IRB approval, we obtained initial data from billing records and performed chart reviews to obtain pain scores and confirm total opioid consumption. If provided by the acute pain consultation service, the patients received either a lidocaine or a ketamine infusion of 0.5–2 mg/min or 2–3 mcg/kg, respectively, for a maximum of 24–48 h. We compared the change in opioid consumption before and after infusion therapy to patients that did not receive ketamine or lidocaine. Results Compared to patients that did not receive infusion therapy, ketamine and lidocaine accounted for respective relative decreases of 28 and 23% in average daily morphine consumption (p = 0.02). Patients that received either infusion were 3 to 4 times more likely to decrease their opioid consumption independent of treatment length or baseline opioid doses (p < 0.01). Ketamine and lidocaine therapies were not associated with change in pain scores. When a patient had multiple admissions, opioid reduction was strongly correlated with initiation of infusions in the later visits. Conclusion Both ketamine and lidocaine infusion therapies are effective in reducing opioid consumption for patients with vaso-occlusive crisis. Lidocaine infusion is emerging as an agent for stabilizing opioid doses in VOC for patients with high daily MME.
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Affiliation(s)
- Nicolas A. Zavala
- Department of Anesthesiology, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Randall W. Knoebel
- Department of Pharmacy, The University of Chicago Medicine, Chicago, IL, United States
- Department of Medicine, The University of Chicago Medicine, Chicago, IL, United States
| | - Magdalena Anitescu
- Department of Anesthesia and Critical Care, The University of Chicago Medicine, Chicago, IL, United States
- *Correspondence: Magdalena Anitescu
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