A review on the recent application of ketamine in management of anesthesia, pain, and health care

Exploring the impact of music on response to ketamine/esketamine: A scoping review

Music and ketamine are both known to affect therapeutic outcomes, but few studies have investigated their co-administration. This scoping review describes the existing literature on the joint use of music and ketamine-or esketamine (the S(+) enantiomer of ketamine)-in humans. The review considers that extant studies have explored the intersection of ketamine/esketamine and music in healthy volunteers and in patients of various age groups, at different dosages, through different treatment processes, and have varied the sequence of playing music relative to ketamine/esketamine administration. Studies investigating the use of music during ketamine anesthesia are also included in the review because anesthesia and sedation were the early drivers of ketamine use. Studies pertaining to recreational ketamine use were omitted. The review was limited to articles published in the English language but not restricted by publication year. To the best of our knowledge, this scoping review is the first comprehensive exploration of the interplay between music and ketamine/esketamine and offers valuable insights to researchers interested in designing future studies.

Herb-drug interactions: A short review on central and peripheral nervous system drugs

Herbal medicines are widely perceived as natural and safe remedies. However, their concomitant use with prescribed drugs is a common practice, often undertaken without full awareness of the potential risks and frequently without medical supervision. This practice introduces a tangible risk of herb-drug interactions, which can manifest as a spectrum of consequences, ranging from acute, self-limited reactions to unpredictable and potentially lethal scenarios. This review offers a comprehensive overview of herb-drug interactions, with a specific focus on medications targeting the Central and Peripheral Nervous Systems. Our work draws upon a broad range of evidence, encompassing preclinical data, animal studies, and clinical case reports. We delve into the intricate pharmacodynamics and pharmacokinetics underpinning each interaction, elucidating the mechanisms through which these interactions occur. One pressing issue that emerges from this analysis is the need for updated guidelines and sustained pharmacovigilance efforts. The topic of herb-drug interactions often escapes the attention of both consumers and healthcare professionals. To ensure patient safety and informed decision-making, it is imperative that we address this knowledge gap and establish a framework for continued monitoring and education. In conclusion, the use of herbal remedies alongside conventional medications is a practice replete with potential hazards. This review not only underscores the real and significant risks associated with herb-drug interactions but also underscores the necessity for greater awareness, research, and vigilant oversight in this often-overlooked domain of healthcare.

The Efficacy and Safety of Remimazolam Besylate Combined with Esketamine for Outpatient Colonoscopy: A Prospective, Randomized, Controlled Clinical Trial

Purpose

Evaluate the efficacy and safety of remimazolam besylate combined with esketamine for outpatient colonoscopy.

Patients and methods

A total of 150 outpatients undergoing colonoscopy were randomized into two groups. A MOAA/S score ≤3 was maintained. The primary outcome was the rate of successful colonoscopy completion. Time indicators, hemodynamic parameters, the consumption of lidocaine, esketamine, propofol and remimazolam besylate, MOAA/S scores and bispectral index (BIS) values, the lowest SpO2, body movement, the use of rescue medication, endoscopist and patient satisfaction, recall of the procedure, mini-mental state examination (MMSE), fatigue level and adverse events were recorded.

Results

Procedure completion was equivalent between groups (P > 0.05). Both induction and awakening times were significantly shorter in the P group (P < 0.05). There were no significant differences in colonoscopy time and discharge time (P > 0.05). The lowest SpO2 was significantly lower in the P group, while the level of fatigue was higher (P < 0.05). Patient satisfaction was significantly higher in the R group (P < 0.05). Endoscopist satisfaction was significantly higher in the P group (P < 0.05). There were no significant differences in both systolic and diastolic blood pressure between groups except at T5 and T6 (P > 0.05). Both HR and RR were significantly lower in the P group from T3 to T5 (P < 0.05). BIS values were significantly lower in the P group from T3 to T5, while MOAA/S was significantly lower in the P group at T3 and T4 (P < 0.05). Pain on injection was significantly higher in the P group (P < 0.05).

Conclusion

Remimazolam besylate has a similar efficacy to propofol when combined with subanesthetic doses of esketamine during outpatient colonoscopy. Remimazolam besylate combined with esketamine resulted in less injection pain and more stable hemodynamics, although it prolonged induction and awakening time.

The Missing Piece? A Case for Microglia's Prominent Role in the Therapeutic Action of Anesthetics, Ketamine, and Psychedelics

There is much excitement surrounding recent research of promising, mechanistically novel psychotherapeutics - psychedelic, anesthetic, and dissociative agents - as they have demonstrated surprising efficacy in treating central nervous system (CNS) disorders, such as mood disorders and addiction. However, the mechanisms by which these drugs provide such profound psychological benefits are still to be fully elucidated. Microglia, the CNS's resident innate immune cells, are emerging as a cellular target for psychiatric disorders because of their critical role in regulating neuroplasticity and the inflammatory environment of the brain. The following paper is a review of recent literature surrounding these neuropharmacological therapies and their demonstrated or hypothesized interactions with microglia. Through investigating the mechanism of action of psychedelics, such as psilocybin and lysergic acid diethylamide, ketamine, and propofol, we demonstrate a largely under-investigated role for microglia in much of the emerging research surrounding these pharmacological agents. Among others, we detail sigma-1 receptors, serotonergic and γ-aminobutyric acid signalling, and tryptophan metabolism as pathways through which these agents modulate microglial phagocytic activity and inflammatory mediator release, inducing their therapeutic effects. The current review includes a discussion on future directions in the field of microglial pharmacology and covers bidirectional implications of microglia and these novel pharmacological agents in aging and age-related disease, glial cell heterogeneity, and state-of-the-art methodologies in microglial research.

Acute Traumatic Pain in the Emergency Department

Trauma is a major cause of mortality throughout the world. Traumatic pain—acute, sudden, or chronic—is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Patients’ perceptions of pain assessment and management have become an important criterion and relevant outcome measure for healthcare institutions. Several studies show that 60–70% of ER patients experience pain, and more than half of them express a feeling of sorrow, which can be moderate or severe, at triage. The few studies that have analyzed how pain is assessed and managed in these departments agree that approximately 70% of patients receive no analgesia or receive it with remarkable delay. Specifically, less than half of the patients receive treatment for pain during admission and 60% of discharged patients have higher intensity pain than at admission. Trauma patients are also the ones who most commonly report low satisfaction with pain management. Associated with this lack of satisfaction, we can describe the poor use of tools for measuring and recording pain, poor communication among caregivers, inadequate training in pain assessment and management, and widespread misconceptions among nurses about the reliability of patients’ estimation of pain. The aim of this article is to review the scientific literature to explore the methodologies of pain management in trauma patients attending the emergency room and analyzing their weaknesses as a starting point to improve the approach to this, unfortunately too often, underestimated issue. A literature search was performed using the major databases to identify relevant studies in indexed scientific journals. The literature showed that the multimodal approach in trauma patients is the best approach to pain management. It is becoming increasingly crucial to manage the patient on multiple fronts. Drugs acting on different pathways can be administered together at lower doses, minimizing risks. Every emergency department must have staff trained in the assessment and immediate management of pain symptoms as this allows the reduction of mortality and morbidity and shortens hospital stays, contributing to early mobilization, reduced hospital costs, and enhanced patient satisfaction and quality of life.

Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting

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.

Recent advances in drug delivery to the central nervous system by inhalation

INTRODUCTION

Drugs need to enter the systemic circulation efficiently before they can cross the blood-brain barrier and reach the central nervous system. Although the respiratory tract is not a common route of administration for delivering drugs to the central nervous system, it has attracted increasing interest in recent years for this purpose.

AREAS COVERED

In this article, we compare pulmonary delivery to three other common routes (parenteral, oral, and intranasal) for delivering drugs to the central nervous system, followed by summarising the devices used to aerosolise neurological drugs. Recent studies delivering drugs for different neurological disorders via inhalation are then discussed to illustrate the strengths of pulmonary delivery.

EXPERT OPINION

Recent studies provide strong evidence and rationale to support inhaling neurological drugs. Since inhalation can achieve improved pharmacokinetics and rapid onset of action for multiple drugs, it is a non-invasive and efficient method to deliver drugs to the central nervous system. Future research should focus on delivering other small and macro-molecules via the lungs for different neurological conditions.

Electrocorticographic effects of acute ketamine on non-human primate brains

OBJECTIVE

Acute blockade of glutamate N-methyl-D-aspartate (NMDA) receptors by ketamine induces symptoms and electrophysiological changes similar to schizophrenia. Previous studies have shown that ketamine elicits aberrant gamma oscillations in several cortical areas and impairs coupling strength between the low-frequency phase and fast frequency amplitude (PAC), which plays an important role in integrating functional information.

APPROACH

This study utilized a customized wireless electrocorticography (ECoG) recording device to collect subdural signals from the somatosensory and primary auditory cortices in two monkeys. Ketamine was administered at a dose of 3 mg/kg (intramuscular) or 0.56 mg/kg (intravenous) to elicit brain oscillation reactions. We analyzed the raw data using methods such as power spectral density, time-frequency spectra, and PAC.

MAIN RESULTS

Acute ketamine triggered broadband gamma and high gamma oscillation power and decreased lower frequencies. The effect was stronger in the primary auditory cortex than in the somatosensory area. The coupling strength between the low phase of theta and the faster amplitude of gamma/high gamma bands was increased by a lower dose (0.56 mg/kg iv) and decreased with a higher dose (3 mg/kg im) ketamine.

SIGNIFICANCE

Our results showed that lower and higher doses of ketamine elicited differential effects on theta-gamma PAC. These findings support the utility of ECoG models as a translational platform for pharmacodynamic research in future research.

Effect of Anesthetics on Functional Connectivity of Developing Brain

The potential anesthetic neurotoxicity on the neonate is an important focus of research investigation in the field of pediatric anesthesiology. It is essential to understand how these anesthetics may affect the development and growth of neonatal immature and vulnerable brains. Functional magnetic resonance imaging (fMRI) has suggested that using anesthetics result in reduced functional connectivity may consider as core sequence for the neurotoxicity and neurodegenerative changes in the developed brain. Anesthetics either directly impact the primary structures and functions of the brain or indirectly alter the hemodynamic parameters that contribute to cerebral blood flow (CBF) in neonatal patients. We hypothesis that anesthetic agents may either decrease the brain functional connectivity in neonatal patients or animals, which was observed by fMRI. This review will summarize the effect and mechanism of anesthesia on the rapid growth and development infant and neonate brain with fMRI through functional connectivity. It is possible to provide the new mechanism of neuronal injury induced by anesthetics and objective imaging evidence in animal developing brain.

Should Ketamine Not Be Banned? A Scoping Review

OBJECTIVES

Although the importance of ketamine in clinical practice and in resource-poor settings and disaster zones, several attempts were made to reschedule it because of the issues around its misuse. Resisting future moves to reschedule ketamine is important for its continuous availability where needed. This scoping review addresses the question of whether ketamine should or should not be banned and the state of preparedness of low resource settings if ketamine petitions become successful in the future.

METHODS

A search was performed using PubMed and Google Scholar to identify articles published in the English language from March 2015 to August 2020. The articles were searched with a wide range of priori search terms related to the research questions. The selection of articles was based on relevance and eligibility.

RESULTS

Seventy-five articles were selected and grouped into 4 ethical themes. The search revealed that several articles addressed the importance of ketamine, pharmacology, misuse, supply, and consequences of a ketamine ban; however, none addressed how resource-poor countries should prepare for a future without the overreliance of ketamine.

CONCLUSION

Four ketamine petitions in about 10 years are an indication that another may resurface soon; therefore, it is important to continue to study the clinical importance of ketamine while discouraging its overreliance for clinical practice.

Perioperative pain, analgesics and cancer-related outcomes: where do we stand?

Cancer-related pain is one of the most common and debilitating symptoms among cancer patients. Undertreated cancer-related pain interferes with daily activities and increases morbidity and mortality. While opioids continue to play an essential role in treating moderate to severe cancer-related pain, they are associated with many adverse effects including misuse. While preclinical and retrospective studies have shown a negative association between opioid use and cancer outcomes, randomized control trials demonstrate that opioid use does not influence cancer recurrence. Additionally, analgesics and adjuvants used for perioperatively or chronic pain control are unlikely to improve oncological outcomes. This article focuses on the pharmacological management of cancer-related pain and offers an overview regarding the use of these medications perioperatively and the cancer outcomes.

Ketamine-polymer based drug delivery system for prolonged analgesia: recent advances, challenges and future prospects

Introduction: With a sharp increase in NSAIDs and opioid use for chronic pain conditions associated with traumatic injuries and diseases, there has been an escalated risk of life-threatening side effects (cardiac and respiratory malfunction), inadvertent overdose, and even death. Their short duration of action and toxicity induces the need to develop extended-release analgesic drug formulations based on safe drugs like ketamine.Areas covered: This review presents progressive breakthroughs in pain control strategies for augmenting patient's comfort and minimizing unnecessary adverse effects associated with NSAIDs and opioids. Advantages of using ketamine, a dissociative anesthetic and potent analgesic over opioids have been elaborated here for the development of advanced sustained-release analgesic drug formulations based on ketamine and polymers (hydrogels, microparticles, and nanoparticles) as mainstream systems. These systems can be very promising in the resource-constrained healthcare set-up where frequent drug dosing at short time intervals is extremely challenging. PubMed, Embase, Google Scholar electronic databases, and clinical websites were used for conducting extensive research.Expert opinion: Controlled drug release analgesic systems can significantly reduce the burden of repeated drug dosing and opioid drug dependency, maximizing the function of analgesic drugs for clinical translation, and improving the quality of life of those living with pain.

Comeback of ketamine: resurfacing facts and dispelling myths

Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.

Pharmacodynamic elucidation of glutamate & dopamine in ketamine-induced anaesthesia

General anaesthetics are some of the most widely used and essential therapeutic agents. However, despite over a century of research, the molecular mechanisms of general anaesthesia in the central nervous system remain elusive. Ketamine (ketamine hydrochloride) has been approved for use in general anaesthesia either alone or in combination with other medications. It is a superb drug for use in short-term medical procedures that do not require skeletal muscle relaxation, and it has approval for the induction of general anaesthesia as a pre-anaesthetic to other general anaesthetic agents. However, Several questions remain unsolved, including the exact identification of the neural substrate of consciousness and its components, the pharmacodynamic interactions between anaesthetic agents, the mechanisms of cognitive alterations that follow an anaesthetic procedure, the identification of an eventual unitary mechanism of anaesthesia-induced alteration of consciousness, the relationship between network effects and the biochemical targets of anaesthetic agents, leading to difficulties in between-studies comparisons. Thus, the glutamate and dopamine systems play distinct roles in terms of neuronal signalling, yet both have proposed to contribute significantly to the pathophysiology of neuropsychiatric diseases. Imaging of the glutamate system and other aspects of research on the dopamine system have produced less consistent findings, potentially due to methodological limitations and the heterogeneity of the disorder. In this review, we discuss the neural circuits through which the two systems interact and how their disruption may cause psychotic symptoms. We also summarize from a molecular perspective of mechanisms of action of ketamine as general anaesthetics on ligand-gated ion channels mediated modulation of dopamine in the brain region.