Substantial Elevation of Liver Enzymes During Ketamine Infusion: A Case Report

A Case of Hepatotoxicity Induced by Therapeutic Ketamine Use for Sedation

Ketamine, initially developed as an anesthetic, has shown versatility in medical applications, including pain management, treatment-resistant depression, and sedation in the intensive care unit (ICU). While generally well-tolerated, long-term use at high doses raises concerns about potential toxicities, particularly in the liver. We present a case of a 27-year-old female with a complex medical history who received ketamine infusion for ICU sedation and experienced a sudden rise in liver function tests (LFTs), indicating possible ketamine-induced liver injury (KILI). The patient's liver function normalized after ketamine discontinuation. KILI is infrequent with short-term ketamine use, but emerging case reports suggest it may be associated with chronic or intermittent exposure. The underlying mechanisms for KILI are not fully understood but may involve the accumulation of ketamine metabolites, causing direct toxic effects on the liver. As ketamine's use expands, especially in critical care settings, clinicians should be vigilant for the potential development of KILI. Further research is needed to better understand its risk factors and mechanisms, as early detection and management of KILI are crucial to ensuring patient safety and optimizing ketamine's therapeutic benefits.

Ketamine for Chronic Pain and Mental Health: Regulations, Legalities, and the Growth of Infusion Clinics

PURPOSE OF REVIEW

In this article, we will review evidence for ketamine's role in chronic pain and mental health conditions, its current legal status and abuse potential, and the regulations related to its administration in stand-alone infusion clinics, as well as future considerations.

RECENT FINDINGS

In the management of chronic pain, ketamine has shown potential to manage neuropathic pain and complex regional pain syndrome and has been used as a treatment for chronic pain management by clinics across the USA. Analogous to the historic rise of lidocaine clinics, ketamine clinics are demonstrating a similar pattern of unregulated growth. Ketamine is an anesthetic and analgesic agent commonly used in the perioperative setting and emergency department for sedation and pain management (Mo et al in West J Emerg Med 21(2):272-281, 2020). It was approved for use by the Federal Drug Administration in the USA in the 1970s as the sole anesthetic agent for short diagnostic and surgical procedures (Coppel et al. in Anaesthesia 28(3):293-296, 1973; Schwenk et al. in Reg Anesth Pain Med 43(5):456-466, 2018). Regarding its rising popularity as a treatment option in mental health, ketamine holds promise as a rapidly acting treatment for suicidal ideation and refractory depression.

Prevention and Management of Common Adverse Effects of Ketamine and Esketamine in Patients with Mood Disorders

The emerging roles of ketamine and esketamine as effective rapid-acting antidepressants hold promise for patients suffering from treatment-resistant depression and/or major depressive disorder with suicidality. Practitioner familiarity with common tolerability/safety concerns along with pragmatic prevention and management strategies are needed to reduce patient burden and improve the acceptability and accessibility of these treatments. The most common treatment-emergent adverse events associated with ketamine/esketamine are dissociation, anxiety, nausea, increased blood pressure, and headache. The majority of side effects are mild, transient, dose dependent, and attenuate with subsequent treatments. Patient selection, baseline physical and psychiatric assessments, and an appropriate setting are critical first steps in the prevention and mitigation of adverse events. Patient education and supportive interventions play central roles in the prevention and management of select adverse events. Severe and/or clinically significant adverse effects may necessitate the judicious use of adjunctive medications. Moreover, practitioners must remain vigilant to the potential for abuse liability and long-term adverse events, for which there are insufficient data. This article succinctly reviews common treatment-emergent adverse events of ketamine and esketamine within the context of mood disorders, and provides practical suggestions for prevention and management at point-of-care.

The Effectiveness of Ketamine in Pediatric Acute Deafferentation Pain after Spinal Cord Injury

Deafferentation pain and allodynia commonly occur after spinal cord trauma, but its treatment is often challenging. The literature on effective therapies for pediatric deafferentation pain, especially in the setting of spinal cord injury, is scarce. We report the case of a 12-year-old patient with acute allodynia after a gunshot injury to the spine. The pain was refractory to multiple analgesics, but resolved with ketamine, which also improved the patient's physical function and quality of life, a trend that continued many months after the injury. We suggest that early initiation of ketamine may be effective for acute pediatric deafferentation pain secondary to spinal cord injury, as well as preventing chronic pain states in that population.