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Lin X, Feng X, Sun L, Wang Y, Wu X, Lu S, Shao L, Wang W, Yang L, Geng W, Lin H. Effects of esketamine on postoperative fatigue syndrome in patients after laparoscopic resection of gastric carcinoma: a randomized controlled trial. BMC Anesthesiol 2024; 24:185. [PMID: 38789968 PMCID: PMC11127346 DOI: 10.1186/s12871-024-02513-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/27/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Despite the implementation of various postoperative management strategies, the prevalence of postoperative fatigue syndrome (POFS) remains considerable among individuals undergoing laparoscopic radical gastrectomy. While the N-methyl-D-aspartic acid receptor antagonist esketamine has demonstrated efficacy in enhancing sleep quality and alleviating postoperative pain, its impact on POFS remains uncertain. Consequently, the objective of this study is to ascertain whether perioperative administration of esketamine can effectively mitigate the occurrence of POFS in patients undergoing laparoscopic radical gastrectomy. METHODS A total of 133 patients diagnosed with gastric cancer were randomly assigned to two groups, namely the control group (Group C) (n = 66) and the esketamine group (Group E) (n = 67), using a double-blind method. The Group C received standardized anesthesia, while the Group E received esketamine in addition to the standardized anesthesia. The primary outcome measure assessed was the Christensen fatigue score at 3 days after the surgical procedure, while the secondary outcomes included the disparities in postoperative fatigue, postoperative pain, sleep quality, and adverse reactions between the two groups. RESULTS In the group receiving esketamine, the fatigue scores of Christensen on the third day after surgery were significantly lower compared to the Group C (estimated difference, -0.70; 95% CI, -1.37 to -0.03; P = 0.040). Additionally, there was a significant decrease in the occurrence of fatigue in the Group E compared to the Group C on the first and third days following surgery (P < 0.05). Also, compared to individuals who had distal gastrectomy, those who had entire gastrectomy demonstrated a higher degree of postoperative tiredness reduction with esketamine. Furthermore, the Group E exhibited reduced postoperative pain and improved sleep in comparison to the Group C. Both groups experienced similar rates of adverse events. CONCLUSIONS The use of esketamine during the perioperative period can improve POFS after laparoscopic radical gastrectomy, without adverse reactions. TRIAL REGISTRATION Registered in the Chinese Clinical Trial Registry (ChiCTR2300072167) on 05/06 /2023.
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Affiliation(s)
- Xinru Lin
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Xiaoxue Feng
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Linxiao Sun
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325000, China
| | - Yijian Wang
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Xudong Wu
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Shufang Lu
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Lulu Shao
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Wenchao Wang
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China
| | - Liqun Yang
- Department of Anesthesiology Renji Hospital, Shanghai Jiaotong University School of Medicine, No.160 Pujian road, Shanghai, 200127, China.
| | - Wujun Geng
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China.
| | - Hai Lin
- Department of Pain, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
- Wenzhou Key Laboratory of Perioperative Medicine (2021HZSY0069), Wenzhou, 325000, China.
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Bell CM, Rech MA, Akuamoah-Boateng KA, Kasotakis G, McMurray JD, Moses BA, Mueller SW, Patel GP, Roberts RJ, Sakhuja A, Salvator A, Setliff EL, Droege CA. Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers. J Pharm Pract 2024; 37:351-363. [PMID: 36282867 DOI: 10.1177/08971900221134551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.
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Affiliation(s)
- Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Megan A Rech
- Department of Pharmacy, Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Kwame A Akuamoah-Boateng
- Department of Surgery: Division of Acute Care Surgical Services, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey D McMurray
- Department of Anesthesia, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin A Moses
- Department of Anesthesia: Division of Critical Care, University of Virginia Health, Charlottesville, VA, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, CO, USA
| | - Gourang P Patel
- Department of Pharmacy, University of Chicago Medical Center, Chicago, IL, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ann Salvator
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Erika L Setliff
- Department of Clinical Education Services, Atrium Health Cabarrus, Concord, NC, USA
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati, OH, USA
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3
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Dai B, Huo Y. A subanesthetic dose of esketamine combined with hip peripheral nerve block has good sedative and analgesic effects in elderly patients undergoing total hip arthroplasty: A randomized-controlled trial. Jt Dis Relat Surg 2023; 34:548-556. [PMID: 37750258 PMCID: PMC10546864 DOI: 10.52312/jdrs.2023.997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/16/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES This study aims to observe the postoperative anesthetic effect of esketamine combined with hip capsule peripheral nerve block (PNB) in elderly patients undergoing total hip arthroplasty (THA). PATIENTS AND METHODS A total of 120 elderly patients (67 males, 53 females; mean age: 72.5±6.1 years; range, 60 to 89 years) who underwent THA between January 2020 and May 2021 were randomly divided into three groups including 40 patients in each group. The observation group (Group A) was treated with a subanesthetic dose of esketamine combined with hip capsule PNB; control group (Group B) was treated with a subanesthetic dose of esketamine combined with lumbar plexus block; and control group (Group C) was treated with a subanesthetic dose of esketamine for general anesthesia. The onset time of anesthesia, duration of block, postoperative recovery time, postoperative extubation time, mean arterial pressure (MAP), heart rate (HR) indexes, Visual Analog Scale (VAS) and Ramsay Sedation Scale (RSS) scores were recorded. RESULTS The onset time of anesthesia, duration of block, postoperative recovery time and postoperative extubation time in Group A were significantly lower than those in Groups B and C (p<0.001). Compared to Groups B and C, the MAP was higher at T1-T3 and the HR was significantly higher at T0-T1 (p<0.05) in Group A. The VAS scores after the operation in Group A were significantly lower than those in Groups B and C (p<0.001), and the RSS scores after the operation were significantly higher in this group than in Groups B and C (p<0.001). CONCLUSION A subanesthetic dose of esketamine combined with hip capsule PNB for elderly patients undergoing THA has better postoperative analgesic effects.
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Affiliation(s)
| | - Yanhua Huo
- Department of Anesthesiology, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou 213000, Jiangsu, China.
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4
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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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Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
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6
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Pouldar TM, Maher DP, Betz AW, Wiegers JJ, Friedman JA, Zaidi SS, Rejali A, Tran HP, Yumul R, Louy C. Adverse Effects Associated with Patient-Controlled Analgesia with Ketamine Combined with Opioids and Ketamine Infusion with PCA Bolus in Postoperative Spine Patients: A Retrospective Review. J Pain Res 2022; 15:3127-3135. [PMID: 36247824 PMCID: PMC9562845 DOI: 10.2147/jpr.s358770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objective There has been increasing use of ketamine at subanesthetic doses as an adjunct to opioids in perioperative pain management. There are several known adverse drug effects (ADEs) associated with ketamine. However, the incidence of ADEs with ketamine infusions with patient-controlled analgesia (PCA) boluses compared with combined opioid and ketamine PCAs is not well described. The objectives of this study were to compare the incidence and type of ADEs in postoperative spine surgery patients on ketamine infusions with as-needed PCA boluses to patients on combined opioid and ketamine PCAs. Methods The medical records of patients who underwent spine surgery between March 2016 and March 2020 who were postoperatively treated with a ketamine infusion and as-needed PCA boluses and parenteral opioids or treated with a combined opioid and ketamine PCA were reviewed. Perioperative information including patient characteristics and preoperative morphine equivalent daily dose (MEDD) were collected. Patient charts were reviewed for ADEs including psychological and neurological side effects, nausea, and new-onset tachycardia. Results A total of 315 patients met the inclusion criteria and were included in the final analysis. Of these patients, 121 experienced at least one ADE (38%). Sixteen of the 68 ketamine infusion with PCA bolus patients (24%), 77 of the 203 hydromorphone and ketamine patients (38%), and 28 of the 44 morphine and ketamine patients (64%) experienced an ADE [p<0.01]. In patients with preoperative MEDD ≤ 90, nausea was the only ADE that differed significantly among the three groups. Conclusion This retrospective analysis suggests that postoperative spine patients treated with a ketamine infusion with as-needed PCA boluses and parenteral opioids were associated with fewer ADEs when compared to an intravenous combined opioid and ketamine PCA. In patients with preoperative MEDD ≤ 90, nausea with and without emesis was the only ADE that showed statistically significant difference amongst the three groups.
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Affiliation(s)
- Tiffany M Pouldar
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Dermot P Maher
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins Hospital, Baltimore, MD, 21205, USA
| | - Alexander W Betz
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Jeffrey J Wiegers
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Jeremy A Friedman
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Sameer S Zaidi
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Ali Rejali
- Department of Pharmacy, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Hai P Tran
- Department of Pharmacy, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Department of Anesthesiology, David Geffen School of Medicine-UCLA, Los Angeles, CA, 90095, USA
| | - Charles Louy
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA,Correspondence: Charles Louy, Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Blvd #8211, Los Angeles, CA, 90048, USA, Tel +1 310-423-5841, Email
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7
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Zhao L, Zhang H, Cheng H. Effect of a single sub-dose of ketamine on postoperative fatigue syndrome in colorectal cancer patients undergoing radical laparoscopic surgery: A double-blind, pilot study. J Affect Disord 2022; 312:146-151. [PMID: 35750094 DOI: 10.1016/j.jad.2022.06.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed at examining the effect of a single sub-anesthetic dose of ketamine on postoperative fatigue syndrome (POFS) in patients undergoing radical laparoscopic surgery for colorectal cancer (CRC). METHODS This prospective, double-blind, pilot study enrolled patients scheduled for radical laparoscopic surgery for CRC under general anesthesia. Eligible patients were randomized into the placebo and ketamine groups. The primary outcome was christensen score change at day 3. The secondary outcomes were the difference of Identity Consequence Fatigue Scale (ICFS) score between the placebo group and ketamine group at day 3 and level of serum tumor necrosis factor (TNF)-α, interleukin (IL)-6, S100β protein, and neuron-specific enolase (NSE). RESULTS 32 participants were assigned to the ketamine group and 31 to the placebo group. Compared with placebo group, the Christensen score was lower in ketamine group at day 3 (absolute difference, -1.13; 95 % confidence interval [CI], -2.02 to -0.24; P = 0.012). Ketamine group was superior to the placebo group with regard to the ICFS scores at day 3 (absolute difference, -6.4; 95 % CI, -11.4 to -1.4; P = 0.013). The plasma TNF-α, IL-6, S100β, and NSE levels were increased after operation compared with baseline in both groups and were significantly higher in placebo group than in ketamine group within 24 h after surgery (all P < 0.05). There was no significant difference of each safety evaluation indicator between the two groups (all P > 0.05). CONCLUSION A single sub-anesthetic dose of ketamine may improve POFS in patients undergoing radical laparoscopic surgery for CRC, without postoperative adverse reactions.
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Affiliation(s)
- Liqin Zhao
- Department of Anesthesiology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hailong Zhang
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.
| | - Hao Cheng
- Department of Anesthesiology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Prabhakar NK, Chadwick AL, Nwaneshiudu C, Aggarwal A, Salmasi V, Lii TR, Hah JM. Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review. Int J Gen Med 2022; 15:4535-4549. [PMID: 35528286 PMCID: PMC9075013 DOI: 10.2147/ijgm.s292698] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.
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Affiliation(s)
- Nitin K Prabhakar
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Chinwe Nwaneshiudu
- Department of Anesthesiology, Perioperative and Pain Management, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | - Anuj Aggarwal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Theresa R Lii
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer M Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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9
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Sachtleben EP, Rooney K, Haddad H, Lassiegne VL, Boudreaux M, Cornett EM, Kaye AD. The Role of Pharmacogenomics in Postoperative Pain Management. Methods Mol Biol 2022; 2547:505-526. [PMID: 36068475 DOI: 10.1007/978-1-0716-2573-6_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pharmacogenomics can improve pain management by considering individual variations in pain perception and susceptibility and sensitivity to medicines related to genetic diversity. Due to the subjective nature of pain and the fact that people respond differently to medicines, it can be challenging to develop a consistent and successful regimen for pain disorders. Numerous factors influence the outcome of pain treatment programs, but two stand out: altered perception of pain and varying responsiveness to analgesic medicines. Numerous polymorphisms in genes such as CYP2D6, OPRM1, and ABCB1 have been identified, culminating in a heterogeneous response to pain medication in people who have these genetic polymorphisms. Improved treatment regimens that factor in pharmacogenetic differences in patients would help reduce the risk of opioid dependency and help effectively treat postoperative pain.
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Affiliation(s)
| | | | - Hannah Haddad
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | | | - Megan Boudreaux
- School of Medicine, Louisiana State University Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, Shreveport, LA, USA
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Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 2021; 38:985-994. [PMID: 34397527 PMCID: PMC8373453 DOI: 10.1097/eja.0000000000001448] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge. OBJECTIVES We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. DESIGN AND DATA SOURCES A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. CONCLUSIONS The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.
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Affiliation(s)
- Piet Waelkens
- From the Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (PW), CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France (EA), the Department of Anaesthesiology and Pain Management, University of Oslo, Oslo, Norway (AS), the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AS), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ), the University Rennes, CHU Rennes, Inserm, INRA, CIC 1414 NuMeCan, Anesthesia and Intensive Care Department, Rennes, France (HB)
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Low-Dose Ketamine Infusion for Perioperative Pain Management in Patients Undergoing Laparoscopic Gastric Bypass: A Prospective Randomized Controlled Trial. Anesthesiol Res Pract 2021; 2021:5520517. [PMID: 34335740 PMCID: PMC8321702 DOI: 10.1155/2021/5520517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/10/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.
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Gil LV, Mazzeffi MA, Cai Y, McLeod WW, Porter SB. Reasons for discontinuation of acute postoperative pain ketamine infusions: A retrospective case-control study. Pain Pract 2021; 21:759-765. [PMID: 33811788 DOI: 10.1111/papr.13012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/23/2021] [Accepted: 03/22/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of the study was to investigate factors associated with early discontinuation of low-dose ketamine infusions due to adverse drug events (ADEs). METHODS A retrospective, matched case-control study of surgical patients who received low-dose ketamine infusions for postoperative pain over 6 years was conducted. Forty-seven study patients, who required early discontinuation of their infusion due to ADEs, were included and matched 1:1 with 47 controls, who did not experience ADEs, for a total of 94 patients. The two groups were compared based on surgery type, American Society of Anesthesiologists (ASA) classification, administration of specific perioperative anxiolytic, anesthetic, and analgesic medications, and use of regional anesthesia. RESULTS Of the study patients, 44.7% underwent spine procedures (vs. 34% of controls), 27.6% underwent abdominal procedures (vs. 8.5% of controls), 19.2% underwent orthopedic procedures (vs. 46.8% of controls), and 8.5% underwent thoracic procedures (vs. 6.4% of controls). There were no statistically significant differences in ASA classification, pre-operative gabapentinoid and antidepressant use, average ketamine infusion dose, or postoperative use of peripheral nerve catheters, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, muscle relaxants, and nonbenzodiazepine sleep aides. Study patients had higher rates of intra-operative volatile anesthetic use (78.7% vs. 57.7%, p = 0.03) and more postoperative opioid patient-controlled analgesia (PCA) use (53.2% vs. 29.8%, p = 0.02) than controls. Control patients had higher rates of preoperative opioid use (76.7% vs. 53.2%, p = 0.02) and premedication with midazolam (89.4% vs. 70.2%, p = 0.02) than study patients. CONCLUSION Patients who required discontinuation of their low-dose ketamine infusion due to ADEs were more likely to be opioid naïve, received less pre-operative benzodiazepines, and had greater postoperative opioid PCA requirements. Control patients, on the other hand, had higher rates of pre-operative opioid use and experienced fewer ADEs despite greater total ketamine doses.
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Affiliation(s)
- Laura V Gil
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yi Cai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Whitney W McLeod
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Culp C, Kim HK, Abdi S. Ketamine Use for Cancer and Chronic Pain Management. Front Pharmacol 2021; 11:599721. [PMID: 33708116 PMCID: PMC7941211 DOI: 10.3389/fphar.2020.599721] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Ketamine, an N-methyl-D-aspartate receptor antagonist, is widely known as a dissociative anesthetic and phencyclidine derivative. Due to an undesirable adverse event profile when used as an anesthetic it had widely fallen out of human use in favor of more modern agents. However, it has recently been explored for several other indications such as treatment resistant depression and chronic pain. Several recent studies and case reports compiled here show that ketamine is an effective analgesic in chronic pain conditions including cancer-related neuropathic pain. Of special interest is ketamine's opioid sparing ability by counteracting the central nervous system sensitization seen in opioid induced hyperalgesia. Furthermore, at the sub-anesthetic concentrations used for analgesia ketamine's safety and adverse event profiles are much improved. In this article, we review both the basic science and clinical evidence regarding ketamine's utility in chronic pain conditions as well as potential adverse events.
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Affiliation(s)
- Clayton Culp
- McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, United States
| | - Hee Kee Kim
- Division of Anesthesiology, Department of Pain Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Salahadin Abdi
- Division of Anesthesiology, Department of Pain Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Herrera-Melendez A, Stippl A, Aust S, Scheidegger M, Seifritz E, Heuser-Collier I, Otte C, Bajbouj M, Grimm S, Gärtner M. Gray matter volume of rostral anterior cingulate cortex predicts rapid antidepressant response to ketamine. Eur Neuropsychopharmacol 2021; 43:63-70. [PMID: 33309459 DOI: 10.1016/j.euroneuro.2020.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 12/28/2022]
Abstract
Ketamine was recently approved for treatment resistant depression. However, despite its therapeutic potential, about 50% of patients do not show improvement under this therapy. In this prospective two-site study, we investigated baseline brain structural predictors for rapid symptom improvement after a single subanesthetic ketamine infusion. Furthermore, given the preclinical evidence and findings from a pilot study in a clinical population that ketamine induces rapid neuroplasticity, we performed an exploratory investigation of macroscopic changes 24 h post-treatment. T1-weighted MRI brain images from 33 depressed patients were acquired before and 24 h after a single ketamine infusion and analyzed using voxel-based morphometry (VBM). Additionally, we performed a region of interest (ROI)-based analysis of structures that have previously been shown to play a role in the antidepressant effects of ketamine: bilateral hippocampus, nucleus accumbens, anterior cingulate cortex, and thalamus. A whole-brain regression analysis showed that greater baseline volume of the bilateral rostral anterior cingulate cortex (rACC) significantly predicts rapid symptom reduction. The right ACC showed the same association in the ROI analysis, while the other regions yielded no significant results. Exploratory follow-up analyses revealed no volumetric changes 24 h after treatment. This is the first study reporting an association between pretreatment gray matter volume of the bilateral rACC and the rapid antidepressant effects of ketamine. Results are in line with previous investigations, which highlighted the potential of the rACC as a biomarker for response prediction to different antidepressant treatments. Ketamine-induced volumetric changes may be seen at later time points.
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Affiliation(s)
- Ana Herrera-Melendez
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Anna Stippl
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sabine Aust
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Milan Scheidegger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, 8032 Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, 8032 Zurich, Switzerland
| | - Isabella Heuser-Collier
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christian Otte
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Malek Bajbouj
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Simone Grimm
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany; MSB -Medical School Berlin, Calandrellistraße 1-9, 12247 Berlin, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, 8032 Zurich, Switzerland
| | - Matti Gärtner
- Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203 Berlin, Germany; MSB -Medical School Berlin, Calandrellistraße 1-9, 12247 Berlin, Germany
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Pang L, Cui M, Dai W, Kong J, Chen H, Wu S. Can Intraoperative Low-Dose R, S-Ketamine Prevent Depressive Symptoms After Surgery? The First Meta-Analysis of Clinical Trials. Front Pharmacol 2020; 11:586104. [PMID: 33192527 PMCID: PMC7604489 DOI: 10.3389/fphar.2020.586104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/18/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Postoperative depression is a common complication after surgery that profoundly affects recovery and prognosis. New research indicates that (R,S)-ketamine is a potent antidepressant that exerts a rapid and sustained antidepressive effect. However, there is no consensus on whether intraoperative low-dose (R,S)-ketamine prevents postoperative depression. Objectives: This study aimed to investigate the safety, feasibility, and short-term complications of intraoperative low-dose (R,S)-ketamine in preventing postoperative depressive symptoms. Methods: The Web of Science, Cochrane, PubMed, and CNKI databases were systematically searched (last search February 28, 2020) to identify studies involving ketamine. Sensitivity and metaregression analyses were performed to identify potential confounders. The meta-analysis was performed using Review Manager 5.3. Results: A total of 13 studies (seven in Chinese and six in English) representing 1,148 cases of patients who were treated with (R,S)-ketamine and 874 cases of patients who received other treatments were included in the meta-analysis. Anesthesia duration and blood loss did not significantly differ between the two groups, demonstrating that (R,S)-ketamine was safe (odds ratio,OR: 0.27; 95% CI: -1.14 to 1.68; P = 0.71) for prophylactic treatment of postoperative depression. Blood loss (OR: -1.83; 95% CI: -8.34 to 4.68; P = 0.58), the number of postoperative depressive patients (95% CI: 0.8-1.07; P = 0.08; (R,S)-ketamine: control = 12.9%:15.8%), and postoperative complications (OR: 0.83, 95% CI: 0.44-1.58; P = 0.57; (R,S)-ketamine: control = 19.3%:19.3%) were all similar across groups. Intra-operative low-dose (R,S)-ketamine reduced extubation time (OR: -2.84; 95% CI: -5.48 to -0.21; P = 0.03). Conclusions: The prophylactic anti-depressant effect of (R,S)-ketamine did not significantly differ between the (R,S)-ketamine and control groups in patients undergoing general or spinal anesthesia. However, (R,S)-ketamine use led to a higher incidence of adverse reactions in patients under 40 years of age who underwent a Cesarean section under spinal anesthesia.
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Affiliation(s)
- Liwei Pang
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meiying Cui
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Wanling Dai
- Innovation Institute of China Medical University, Shenyang, China
| | - Jing Kong
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hongzhi Chen
- Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Shuodong Wu
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
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Liu GL, Cui YF, Lu C, Zhao P. Ketamine a dissociative anesthetic: Neurobiology and biomolecular exploration in depression. Chem Biol Interact 2020; 319:109006. [DOI: 10.1016/j.cbi.2020.109006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
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