Low dose ketamine in the age of opioids

The Use of Ketamine as an Adjunct to Treating Opioid Refractory Cancer-Related Pain in the Emergency Department

The Research to Practice column is designed to provide advanced practice registered nurses (APRNs) with an analysis of a current research topic with implications for practice change within the emergency care settings. This review examines a recent study conducted by entitled "Ketamine as an adjunct to opioids for acute pain in the emergency department: A randomized controlled trial." The authors conducted a randomized, double-blinded, placebo-controlled trial at a single academic emergency department (ED) to compare standard opioid pain control in the ED population to the use of ketamine in conjunction with opioids in the same population. Participants were randomized into either the ketamine group, receiving 0.1 mg/kg of ketamine in conjunction with an intravenous opioid, or to the control group, receiving an equivalent volume of normal saline in addition to an intravenous opioid. Participants were evaluated for adequacy of pain control, side effects, and level of sedation every 30 min up to the 120-min time point. Data revealed that patients receiving ketamine had a statistically significant lower mean pain score, 0.6512 (p = 0.0083), compared with patients in the control group. The data also showed that patient satisfaction with pain control was similar for the ketamine group and the control group. These and other associated findings have implications for APRN practice, including managing acute pain in the ED setting and preventing hospital admission of acute-on-chronic pain exacerbations in the ED.

Cost-Effectiveness of Postoperative Ketamine in Chiari Decompression

INTRODUCTION

In Chiari I patients, postoperative pain and discomfort frequently slow the transition back to the home setting.

OBJECTIVE

We sought to determine the effect of standardized ketamine infusion protocols on hospital length of stay (LOS).

METHODS

This retrospective cohort study reviewed 100 consecutive adult patients undergoing Chiari I decompression. Fifty-nine patients were placed on a 2-3 mg/hr ketamine drip until postoperative day 1. This group was compared with a group who received 2-3 mg/hr of ketamine until postoperative day 2 (19 patients) and patients who did not receive ketamine at all (22 patients). Clinical characteristics, opioid use, LOS, and relative hospitalization costs were assessed. All narcotic amounts were converted into milligram equivalents of morphine.

RESULTS

LOS of the short-ketamine group was 46.5 hours when compared with the long-ketamine group (66.8 hours) and no-ketamine group (56.9 hours). There was a statistically significant difference when comparing the short-ketamine group with the long-ketamine group and no-ketamine group together (P < 0.001), as well as when compared individually (P = 0.001 and 0.004). The mean cost of hospitalization was 20% less when a short-ketamine protocol was used (P < 0.001). Mean morphine milligram equivalents used postoperatively were 148 mg in the short-ketamine group, 196 mg in the long-ketamine group, and 187 mg in the no-ketamine group (P = 0.65). No adverse events from ketamine were noted.

CONCLUSIONS

Ketamine at subanesthetic levels may be an effective tool to facilitate early return home postoperatively and may significantly reduce medical costs.