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Guo H, Zhang X, Wang JG, Kalika P, Ran R, Xie YB. S-ketamine Infusion on Chronic Postoperative Pain Following Breast Cancer Surgery: A Randomized Double-Blind Placebo-Controlled Trial. Clin Breast Cancer 2024:S1526-8209(24)00149-6. [PMID: 38918160 DOI: 10.1016/j.clbc.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Chronic postoperative surgical pain (CPSP) is a frequent complication following breast surgery and poses a challenge in terms of treatment. We hypothesized that the incidence of CPSP would be reduced at 3 months post-breast surgery with the administration of S-ketamine compared to a placebo. PATIENTS AND METHODS Participants were recruited and randomly assigned to either the S-ketamine group (S) or the control group (C). In group S, S-ketamine was administered as a 1.5 mg kg-1 bolus followed by 2 mg kg-1h-1 infusion, while in group C, a placebo of 0.9% saline was administered in the same volume and rate as S-ketamine. The primary outcome was the incidence of CPSP, measured using a 0-10 numeric rating scale (NRS), at 3 months postsurgery. RESULTS A total of 72 patients scheduled for mastectomy were enrolled (group S, n = 33; group C, n = 32). The incidence of CPSP at 3 months postsurgery was significantly lower in group S compared to group C (18.2% vs. 48.3%, P < .05). There was no statistical difference between the 2 groups in terms of the incidence of moderate to severe pain. NRS scores for postoperative pain at rest and during movement were significantly lower at 4 h and 24 h post-surgery (P < .05, respectively). Patients in Group S had lower Patient Health Questionnaire-9 (PHQ-9) scores at one week and 3 months post-surgery compared to Group C (P < .05, respectively). CONCLUSION S-ketamine infusion reduces the incidence of CPSP 3 months after breast surgery.
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Affiliation(s)
- Hao Guo
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xi Zhang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jia-Gao Wang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Prakash Kalika
- Department of Critical Care Medicine, Om Hospital and Research Center, Kathmandu, Nepal
| | - Ran Ran
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, China.
| | - Yu-Bo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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Lou XJ, Qiu D, Ren ZY, Hashimoto K, Zhang GF, Yang JJ. Efficacy and safety of esketamine for perioperative depression in patients undergoing elective surgery: A meta-analysis of randomized controlled trials. Asian J Psychiatr 2024; 95:103997. [PMID: 38492442 DOI: 10.1016/j.ajp.2024.103997] [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: 01/09/2024] [Revised: 02/25/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Depression is a prevalent mood disorder during the perioperative period, with both preoperative concurrent depression and new-onset postoperative depression impacting postoperative recovery. Recent studies have indicated that the dissociative anesthetic esketamine may alleviate perioperative depressive symptoms. OBJECTIVE This meta-analysis aimed to assess the efficacy and safety of esketamine in treating perioperative depression. METHODS We selected randomized controlled trials comparing esketamine to placebo in terms of postoperative depressive symptoms. The primary outcome was postoperative depression scores, with secondary outcomes including the prevalence of postoperative depression, pain scores using the Visual Analogue Scale or Numeric Rating Scale, and incidences of adverse reactions such as nausea/vomiting, dizziness, dreams/nightmares, hallucinations. RESULTS We enrolled a total of 17 studies involving 2462 patients. The esketamine group demonstrated a significant reduction in postoperative depression scores within one week after surgery (SMD -0.47, 95% CI (-0.66, -0.27), P < 0.001) and over the long term (SMD -0.44, 95% CI (-0.79, -0.09), P = 0.01). Furthermore, esketamine significantly decreased the prevalence of postoperative depression both within one week (RR 0.46, 95% CI (0.33, 0.63), P < 0.001) and over the long term (RR 0.50, 95% CI (0.36, 0.70), P < 0.001). Additionally, esketamine effectively relieved pain on the first postoperative day compared to control. However, it also increased the risks of dizziness and hallucinations for a short time. CONCLUSION This meta-analysis suggests that the intraoperative or postoperative application of esketamine could be a potentially effective treatment for perioperative depression, although the increased risk of adverse reactions should be considered.
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Affiliation(s)
- Xue-Jie Lou
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Di Qiu
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Zhuo-Yu Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Kenji Hashimoto
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China; Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Chiba 260-8670, Japan.
| | - Guang-Fen Zhang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China.
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China.
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Baldinger-Melich P, Spies M, Bozic I, Kasper S, Rujescu D, Frey R. Perspectives in treatment-resistant depression: esketamine and electroconvulsive therapy. Wien Klin Wochenschr 2024:10.1007/s00508-024-02358-w. [PMID: 38662240 DOI: 10.1007/s00508-024-02358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 04/26/2024]
Abstract
Modern electroconvulsive therapy (ECT) and the approval of nasal esketamine for clinical use have significantly improved the approach to treatment-resistant depression (TRD), which is defined as non-response to at least two different courses of antidepressants with verified adherence to treatment, adequate dosage, and duration of treatment. The goal of this literature review is to present the newest evidence regarding efficacy and safety. Furthermore, we aim to provide an overview of future perspectives in this field of research, for example, regarding structural and molecular effects. Both treatment methods will be critically evaluated for their individual advantages, disadvantages, and response rates. Firstly, we will discuss the well-established method of ECT and its different treatment modalities. Secondly, we will discuss the properties of ketamine, the discovery of its antidepressive effects and the route to clinical approval of the esketamine nasal spray. We will comment on research settings which have evaluated intravenous ketamine against ECT. The decision-making process between esketamine nasal spray or ECT should include the assessment of contraindications, age, severity of disease, presence of psychotic symptoms, patient preference and treatment accessibility. We conclude that both treatment options are highly effective in TRD. If both are indicated, pragmatically esketamine will be chosen before ECT; however, ECT studies in ketamine non-responders are missing.
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Affiliation(s)
- Pia Baldinger-Melich
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Marie Spies
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Ina Bozic
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Siegfried Kasper
- Department of Molecular Neurosciences, Center for Brain Research, Vienna, Austria
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Richard Frey
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria.
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Abouarab AH, Brülle R, Aboukilila MY, Weibel S, Schnabel A. Efficacy and safety of perioperative ketamine for the prevention of chronic postsurgical pain: A meta-analysis. Pain Pract 2024; 24:553-566. [PMID: 37971167 DOI: 10.1111/papr.13314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 09/23/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
STUDY OBJECTIVE Assessment of the efficacy and safety of perioperative intravenous ketamine in reducing incidence and severity of chronic postsurgical pain. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES The following data sources were systematically searched: MEDLINE, CENTRAL, and EMBASE (till 02/2021). PATIENTS Adult patients undergoing any surgery. INTERVENTIONS Perioperative use of intravenous ketamine as an additive analgesic drug compared to placebo, no active control treatment, and other additive drugs. MEASUREMENTS Primary outcomes were number of patients with chronic postsurgical pain after 6 months and ketamine related adverse effects. Secondary outcomes were chronic postsurgical pain incidence after 3 and 12 months, chronic postsurgical neuropathic pain incidence, chronic postsurgical moderate to severe pain incidence, intensity of chronic postsurgical pain at rest, and during movement, oral morphine consumption after 3, 6, and 12 months and incidence of opioid-related adverse effects. MAIN RESULTS Thirty-six RCTs were included with a total of 3572 patients. Ketamine compared to placebo may result in no difference in the number of patients with chronic postsurgical pain after 6 months (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.71-1.05; I2 = 34%; 16 studies; low-certainty evidence). Ketamine may reduce the incidence of chronic postsurgical neuropathic pain after 3 months in comparison to placebo (RR 0.78, 95% CI 0.62-0.99, I2 = 31%, seven trials, low-certainty evidence). Ketamine compared to placebo may increase the risk for postoperative nystagmus (RR 9.04, 95% CI 1.15-70.90, I2 30%, two trials, low-certainty evidence) and postoperative visual disturbances (RR 2.29, 95% CI 1.05-4.99, I2 10%, seven trials, low-certainty evidence). CONCLUSIONS There is low-certainty evidence that perioperative ketamine has no effect on chronic postsurgical pain in adult patients. Low-certainty evidence suggests that ketamine compared to placebo may reduce incidence of chronic postsurgical neuropathic pain after 3 months. Questions like ideal dosing, treatment duration and more patient-related outcome measures remain unanswered, which warrants further studies. PROTOCOL REGISTRATION Prospero CRD42021223625, 07.01.2021.
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Affiliation(s)
- Ahmed H Abouarab
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Rebecca Brülle
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | | | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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Deng S, Chen L, Song X, Guo L, Zhao F, Liu J, Dong L. Analgesic Effect of Intraoperative Intravenous S(+)-Ketamine During Total Knee Arthroplasty Surgery: Study Protocol for a Randomized Controlled Clinical Trial. JMIR Res Protoc 2023; 12:e53063. [PMID: 38064260 PMCID: PMC10746976 DOI: 10.2196/53063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is currently the main treatment for end-stage knee disease. The number of cases of TKA in China increased from 53,880 in 2011 to 374,833 in 2019, representing a 5.9-fold increase. Moderate to severe pain often occurs after TKA, which seriously affects postoperative rehabilitation, patient satisfaction, and overall outcome. Multimodal analgesia is considered the ideal solution. Adequate postoperative analgesia can not only reduce pain, opioid consumption, and, consequently, opioid-related adverse events, but can also reduce the length of hospital stay and costs and improve rehabilitation and patient satisfaction. OBJECTIVE Effective multimodal pain management in the early postoperative period is essential for anesthesiologists. Additional studies have demonstrated that a low-dose intravenous infusion of ketamine can be administered as an adjuvant drug to alleviate acute postoperative pain. Therefore, we aim to appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients. METHODS This is a protocol for a randomized, placebo-controlled trial. A total of 144 participants aged 65 years and older undergoing TKA will be randomly allocated into the S(+)-ketamine and placebo groups in a 1:1 ratio. S(+)-ketamine or the placebo will be intravenously administered at 0.3 mg/kg/h during the operation by anesthesiologists. Blinded evaluation by trained investigators will be completed at 2 hours, 24 hours, and 48 hours after surgery. The primary outcome measure will be the numeric rating scale score at rest and movement at 24 hours after surgery. The secondary outcomes will include the numeric rating scale scores at rest and movement at 2 hours and 48 hours after surgery, the number of patients who require additional analgesics during the first 48 hours after operation, the total consumption of opioids or nonsteroid anti-inflammatory drugs during the first 48 hours after operation, and adverse events at 2, 24, and 48 hours after operation. RESULTS The protocol was registered at Clinical Trials.gov on February 26, 2022. It was performed in accordance with the approved guidelines and regulations of the participating institutions. Recruitment began in April 2022. Data collection is expected to conclude in September 2024. Study completion is expected in December 2024. CONCLUSIONS A randomized, controlled, clinical study was designed to observe the analgesic effect of intraoperative intravenous administration of a lower dose of S(+)-ketamine (0.3 mg/kg/h) in older patients after TKA surgery. The protocol will appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients who may benefit from the administration of S(+)-ketamine. TRIAL REGISTRATION ClinicalTrials.gov NCT05289050; https://clinicaltrials.gov/ct2/show/NCT05289050. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53063.
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Affiliation(s)
- Shiyuan Deng
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lina Chen
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xiao Song
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Liang Guo
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fei Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jing Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ling Dong
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Tageza Ilala T, Teku Ayano G, Ahmed Kedir Y, Tamiru Mamo S. Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article. Anesthesiol Res Pract 2023; 2023:5668399. [PMID: 37953883 PMCID: PMC10637850 DOI: 10.1155/2023/5668399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/03/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients. Methods An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation. Results A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain. Conclusion The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.
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Affiliation(s)
- Tajera Tageza Ilala
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Gudeta Teku Ayano
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Yesuf Ahmed Kedir
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Selam Tamiru Mamo
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
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Huang Z, Liu N, Hu S, Ju X, Xu S, Wang S. Effect of Dexmedetomidine and Two Different Doses of Esketamine Combined Infusion on the Quality of Recovery in Patients Undergoing Modified Radical Mastectomy for Breast Cancer - A Randomised Controlled Study. Drug Des Devel Ther 2023; 17:2613-2621. [PMID: 37664451 PMCID: PMC10473051 DOI: 10.2147/dddt.s422896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose This study evaluated the effect of a combined infusion of dexmedetomidine and esketamine on the quality of recovery in patients undergoing modified radical mastectomy. Methods A total of 135 patients were randomly divided into three groups: dexmedetomidine group (group D) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion), dexmedetomidine plus low-dose esketamine group (group DE1) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 2 µg/kg/min infusion), dexmedetomidine plus high-dose esketamine group (group DE2) received dexmedetomidine (0.5 µg/kg loading, 0.4 µg/kg/h infusion) and esketamine (0.5 mg/kg loading, 4 µg/kg/min infusion). The primary outcome was the overall quality of recovery-15 (QoR-15) scores at 1 day after surgery. The secondary endpoints were total QoR-15 scores at 3 days after surgery, propofol and remifentanil requirement, awaking and extubation time, postoperative visual analogue scale (VAS) pain scores, rescue analgesic, nausea and vomiting, bradycardia, excessive sedation, nightmares, and agitation. Results The overall QoR-15 scores were much higher in groups DE1 and DE2 than in groups D 1 and D 3 days after surgery (P < 0.05). VAS pain scores at 6, 12, 24 h postoperatively, propofol and remifentanil requirements were significantly lower in groups DE1 and DE2 than in group D (P < 0.05). Compared with group D, awaking time, extubation time, and post-anesthesia care unit (PACU) stay were significantly prolonged in groups DE1 and DE2 (P < 0.05) and were much longer in group DE2 than in group DE1 (P < 0.05). The proportion of postoperative rescue analgesics and bradycardia was higher and the incidence of excessive sedation was lower in group D than in groups DE1 and DE2 (P < 0.05). Conclusion Dexmedetomidine plus esketamine partly improved postoperative recovery quality and decreased the incidence of bradycardia but prolonged awaking time, extubation time, and PACU stay, especially dexmedetomidine plus 4 µg/kg/min esketamine.
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Affiliation(s)
- Zheng Huang
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Ning Liu
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Shenghong Hu
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Xia Ju
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Siqi Xu
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
| | - Shengbin Wang
- Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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9
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Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting. J Am Assoc Nurse Pract 2023; 35:98-103. [PMID: 36346872 DOI: 10.1097/jxx.0000000000000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022]
Abstract
ABSTRACT A subanesthetic intravenous ketamine infusion is a safe and effective acute pain management modality for moderate to severely painful surgical procedures and may be useful in patients who are at increased risk for opioid-related adverse events. Despite its safety profile, intravenous ketamine is often restricted to the intensive care unit, which results in decreased patient access to this effective therapy. For clinicians who wish to implement an intravenous ketamine protocol in the medical-surgical setting, there are few resources available. In this brief report, we present our ketamine infusion protocol for acute pain and the clinical and financial outcomes 1 year after implementation. In our experience, ketamine infusions on the medical-surgical ward are safe and cost-effective when an established acute pain service protocol is followed. Nurse practitioners play an essential role in increasing patient access to intravenous ketamine infusions and leading change by collaborating with stakeholders to develop a protocol, training nurses and interdisciplinary team members, and providing ongoing support to nursing staff.
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Doan LV, Li A, Brake L, Ok D, Jee HJ, Park H, Cuevas R, Calvino S, Guth A, Schnabel F, Hiotis K, Axelrod D, Wang J. Single-Dose of Postoperative Ketamine for Postoperative Pain After Mastectomy: A Pilot Randomized Controlled Trial. J Pain Res 2023; 16:881-892. [PMID: 36942305 PMCID: PMC10024470 DOI: 10.2147/jpr.s389564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/24/2022] [Indexed: 03/17/2023] Open
Abstract
Background and Objectives Perioperative ketamine has been shown to reduce opioid consumption and pain after surgery. Ketamine is most often given as an infusion, but an alternative is single-dose ketamine. Single-dose ketamine at up to 1 mg/kg has been shown to reduce symptoms of depression, and a wide range of dosages has been used for pain in the emergency department. However, limited data exists on the tolerability and efficacy of a single-dose of ketamine at 0.6 mg/kg for pain when administered immediately after surgery. We conducted a pilot study of single-dose ketamine in patients undergoing mastectomy with reconstruction, hypothesizing that a single-dose of ketamine is well tolerated and can relieve postoperative pain and improve mood and recovery. Methods This is a randomized, single-blind, placebo-controlled, two-arm parallel, single-center study. Thirty adult women undergoing mastectomy with reconstruction for oncologic indication received a single-dose of ketamine (0.6mg/kg) or placebo after surgery in the post-anesthesia care unit (PACU). Patients were followed through postoperative day (POD) 7. The primary outcome was postoperative pain measured by the Brief Pain Inventory (BPI) pain subscale on POD 1 and 2. Secondary outcomes include effects on opioid use, PROMIS fatigue and sleep, mood, Quality of Recovery-15, and the Breast Cancer Pain Questionnaire. Results Side effects were minor and not significantly different in frequency between groups. The ketamine group reported lower scores on the BPI pain severity subscale, especially at POD 7; however, the difference was not statistically significant. There were no statistically significant differences between ketamine and placebo groups for the secondary outcomes. Conclusion A single-dose of ketamine at 0.6mg/kg administered postoperatively in the PACU is well tolerated in women undergoing mastectomy and may confer better pain control up to one week after surgery. Future studies with larger sample sizes are necessary to adequately characterize the effect of postoperative single-dose ketamine on pain control in this population.
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Affiliation(s)
- Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Correspondence: Lisa V Doan, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 240 E 38th St, 14th Floor, New York, NY, 10016, USA, Tel +1 212201-1004, Email
| | - Anna Li
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Lee Brake
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Deborah Ok
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Hyun Jung Jee
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Hyung Park
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Randy Cuevas
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Steven Calvino
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Karen Hiotis
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA
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11
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Abdella AMMR, Arida EEAEM, Megahed NA, El-Amrawy WZ, Mohamed WMA. Analgesia and spread of erector spinae plane block in breast cancer surgeries: a randomized controlled trial. BMC Anesthesiol 2022; 22:321. [PMID: 36253729 PMCID: PMC9575234 DOI: 10.1186/s12871-022-01860-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate the analgesic efficacy and spread of variable volumes of local anesthetics (LA) in Erector spinae plane block (ESPB). Methods Sixty patients aged between 18 and 50 years with an ASA I-II and scheduled for breast cancer surgery were randomized to receive either ESPB with 20 ml 0.25% bupivacaine (Standard volume ESPB), or with 40 ml 0.125% bupivacaine (High volume ESPB), or no ESPB (GA only group). The primary outcome was pain intensity evaluated by the visual analogue scale (VAS), 12 hours after surgery. P-values < 0.05 were considered the cutoff point for statistical significance. The secondary outcomes were pain at rest and pain on movement evaluated by the VAS, craniocaudal injectate spread, to paravertebral (PV) and epidural spaces assessed by CT, clinical dermatomal spread, level of sedation or agitation, and patient satisfaction with anesthesia and analgesia. Results VAS at rest 12 h after surgery was less in both intervention groups compared to the control (1.75 ± 0.79 vs. 1.6 ± 0.88 vs. 3.4 ± 1.96, p = 0.001). The LA had extended further in the high volume group than the standard volume group (11.20 ± 3.07 vs. 9.15 ± 2.54 vertebral levels, p = 0.027). No difference of the spread to PV or epidural spaces between the 2 intervention groups. More dermatomes were covered in the high volume group (7.20 ± 2.12 vs. 5.75 ± 1.37 dermatomes, p = 0.014). Agitation was higher in the GA only group than both ESPB groups in the first 8 postoperative hours. Patients were more satisfied in both ESPB groups than the GA only group. Conclusions Preoperative ESPB is an excellent analgesic modality and it can also attenuate both postoperative agitation and sedation. Doubling the injectate volume enhances the craniocaudal spreading and may be useful for surgeries requiring multiple dermatomes. However, larger volume has no effect on analgesic efficacy or patient satisfaction as there is no further spread to the PV, epidural spaces or spinal nerve rami. Trial registration NCT04796363 (12/3/2021).
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Affiliation(s)
- Ahmed Mohamed Mohamed Rabah Abdella
- Department of Anesthesia and Pain Management, Medical Research Institute, University of Alexandria, 165 El-Horeya Rd, Al Ibrahimeyah Qebli WA Al Hadrah Bahri, Qesm Bab Sharqi, Alexandria, Egypt.
| | - Emad Eldin Abd El Monem Arida
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Nagwa Ahmed Megahed
- Department of Anesthesia and Pain Management, Medical Research Institute, University of Alexandria, 165 El-Horeya Rd, Al Ibrahimeyah Qebli WA Al Hadrah Bahri, Qesm Bab Sharqi, Alexandria, Egypt
| | - Wessam Zakaria El-Amrawy
- Department of Anesthesia and Pain Management, Medical Research Institute, University of Alexandria, 165 El-Horeya Rd, Al Ibrahimeyah Qebli WA Al Hadrah Bahri, Qesm Bab Sharqi, Alexandria, Egypt
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12
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Willis DE, Goldstein PA. Targeting Affective Mood Disorders With Ketamine to Prevent Chronic Postsurgical Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:872696. [PMID: 35832728 PMCID: PMC9271565 DOI: 10.3389/fpain.2022.872696] [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: 02/09/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
The phencyclidine-derivative ketamine [2-(2-chlorophenyl)-2-(methylamino)cyclohexan-1-one] was added to the World Health Organization's Model List of Essential Medicines in 1985 and is also on the Model List of Essential Medicines for Children due to its efficacy and safety as an intravenous anesthetic. In sub-anesthetic doses, ketamine is an effective analgesic for the treatment of acute pain (such as may occur in the perioperative setting). Additionally, ketamine may have efficacy in relieving some forms of chronic pain. In 2019, Janssen Pharmaceuticals received regulatory-approval in both the United States and Europe for use of the S-enantiomer of ketamine in adults living with treatment-resistant major depressive disorder. Pre-existing anxiety/depression and the severity of postoperative pain are risk factors for development of chronic postsurgical pain. An important question is whether short-term administration of ketamine can prevent the conversion of acute postsurgical pain to chronic postsurgical pain. Here, we have reviewed ketamine's effects on the biopsychological processes underlying pain perception and affective mood disorders, focusing on non-NMDA receptor-mediated effects, with an emphasis on results from human trials where available.
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Affiliation(s)
- Dianna E. Willis
- Burke Neurological Institute, White Plains, NY, United States
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
| | - Peter A. Goldstein
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Peter A. Goldstein
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13
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McGregor RH, Warner FM, Linde LD, Cragg JJ, Osborn JA, Varshney VP, Schwarz SKW, Kramer JLK. Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review. Reg Anesth Pain Med 2022; 47:263-269. [DOI: 10.1136/rapm-2021-102981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
BackgroundIn an attempt to aggregate observations from clinical trials, several meta-analyses have been published examining the effectiveness of systemic, non-opioid, pharmacological interventions to reduce the incidence of chronic postsurgical pain.ObjectiveTo inform the design and reporting of future studies, the purpose of our study was to examine the quality of these meta-analyses.Evidence reviewWe conducted an electronic literature search in Embase, MEDLINE, and the Cochrane Database of Systematic Reviews. Published meta-analyses, from the years 2010 to 2020, examining the effect of perioperative, systemic, non-opioid pharmacological treatments on the incidence of chronic postsurgical pain in adult patients were identified. Data extraction focused on methodological details. Meta-analysis quality was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) critical appraisal tool.FindingsOur search yielded 17 published studies conducting 58 meta-analyses for gabapentinoids (gabapentin and pregabalin), ketamine, lidocaine, non-steroidal anti-inflammatory drugs, and mexiletine. According to AMSTAR 2, 88.2% of studies (or 15/17) were low or critically low in quality. The most common critical element missing was an analysis of publication bias. Trends indicated an improvement in quality over time and association with journal impact factor.ConclusionsWith few individual trials adequately powered to detect treatment effects, meta-analyses play a crucial role in informing the perioperative management of chronic postsurgical pain. In light of this inherent value and despite a number of attempts, high-quality meta-analyses are still needed.PROSPERO registration numberCRD42021230941.
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14
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Subramanian S, Haroutounian S, Palanca BJA, Lenze EJ. Ketamine as a therapeutic agent for depression and pain: mechanisms and evidence. J Neurol Sci 2022; 434:120152. [PMID: 35092901 DOI: 10.1016/j.jns.2022.120152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 12/14/2022]
Abstract
Ketamine is an anesthetic drug which is now used to treat chronic pain conditions and psychiatric disorders, especially depression. It is an N-methyl-D-aspartate (NMDA) receptor antagonist with additional effects on α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, opioid receptors, and monoaminergic receptors. This article focuses on ketamine's role in treating depression and pain, two commonly comorbid challenging conditions with potentially shared neurobiologic circuitry. Many clinical trials have utilized intravenous or intranasal ketamine for treating depression and pain. Intravenous ketamine is more bioavailable than intranasal ketamine and both are effective for acute depressive episodes. Intravenous ketamine is advantageous for post-operative analgesia and is associated with a reduction in total opioid requirements. Few studies have treated chronic pain or concurrent depression and pain with ketamine. Larger, randomized control trials are needed to examine the safety and efficacy of intravenous vs. intranasal ketamine, ideal target populations, and optimal dosing to treat both depression and pain.
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Affiliation(s)
- Subha Subramanian
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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15
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White PF. Ketamine and depression: An old drug in search of a clinical indication. J Clin Anesth 2021; 75:110500. [PMID: 34517291 DOI: 10.1016/j.jclinane.2021.110500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Paul F White
- Department of Anesthesia, Cedars Sinai Medical Center in Los Angeles, CA, United States of America; White Mountain Institute, The Sea Ranch, CA, United States of America.
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