First-Ever Ketamine Guidelines for Acute Pain Management Released

Evidence supports the use of intravenous (IV) ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation, according to the first guidelines on the use of ketamine for acute pain management.

Ketamine has captured headlines recently for its potential role in treating severe depression and posttraumatic stress syndrome. Ketamine is also increasingly being used in inpatient and outpatient settings to manage acute pain.

One driving force behind this is the growing effort to reduce the risk for long-term opioid use after acute exposure and its subsequent complications, including addiction. Yet, to date, few recommendations have been available to guide this emerging acute pain therapy.

“The goal of this document is to provide a framework for doctors, for institutions and for payers on use of ketamine for acute pain, who should get it and who should not get it,” guideline author Steven Cohen, MD, from Johns Hopkins School of Medicine in Baltimore, Maryland, told Medscape Medical News.

Reduced Need for Opioids

Development of the guidelines on use of ketamine for acute pain was a joint effort spearheaded by the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, which approved the document, as did the American Society of Anesthesiologists’ Committees on Pain Medicine and Standards and Practice Parameters.

The guidelines state that subanesthetic ketamine infusions should be considered for patients undergoing painful surgery and may be considered for opioid-dependent or opioid-tolerant patients undergoing surgery.

Ketamine may be considered for opioid-dependent or opioid-tolerant patients with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be considered as an adjunct to limit opioids, the guidelines note.

The use of ketamine in subanesthetic doses has “exploded and there definitely seems to be a strong signal that ketamine is effective for acute pain, and a lot of patients don’t have other options,” Cohen commented.

On dosing, the guidelines recommend that ketamine bolus doses do not exceed 0.35 mg/kg and that infusions for acute pain generally do not exceed 1 mg/kg per hour in settings without intensive monitoring. The authors acknowledge that individual pharmacokinetic and pharmacodynamic differences, as well as other factors, such as prior ketamine exposure, may warrant dosing outside this range.

The guidelines also state that moderate evidence supports use of subanesthetic intravenous ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids for perioperative analgesia.

Ketamine should be avoided in people with poorly controlled cardiovascular disease, those with active psychosis, and pregnant women.

For hepatic dysfunction, evidence supports that ketamine infusions should be avoided in individuals with severe disease and used with caution, with monitoring of liver function test results before infusion and during infusions in surveillance of elevations in individuals with moderate disease. Ketamine should be avoided in individuals with elevated intracranial pressure and elevated intraocular pressure.

“Powerful, Inexpensive” Tool

The guidelines state that intranasal ketamine is beneficial for acute pain management; it provides not only effective analgesia but also amnesia and procedural sedation.

Scenarios in which this should be considered include individuals for whom IV access is difficult and children undergoing procedures.

For oral ketamine, the evidence is “less robust, but small studies and anecdotal reports suggest it may provide short-term benefit in some individuals with acute pain,” the authors say.

They found only “limited” evidence to support patient-controlled IV ketamine analgesia as the sole analgesic for acute or periprocedural pain. However, there is moderate evidence of benefit of the addition of ketamine to opioid-based IV patient-controlled analgesia for acute and perioperative pain management, the authors note.

They conclude that “despite its drawbacks, ketamine remains a powerful and inexpensive tool for practitioners who manage acute pain. We believe its use will continue to expand as more institutions treat increasingly challenging patients in the perioperative period as well as those with painful disease exacerbations while trying to combat the opioid epidemic.”

They say more research is needed to “refine selection criteria for the treatment of acute pain and possible prevention of chronic pain, to determine the ideal dosing and treatment regimen to include coadministration of ketamine with opioids and adjuvants, and to better understand the long-term risks of ketamine in patients who receive serial treatments for frequent acute pain exacerbations.”

This research had no commercial funding. The authors have disclosed no relevant financial relationships.

Reg Anesth Pain Med. Published online June 7, 2018. Abstract


7 Responses

  1. This drug caused me dissociative disorder for 3 days after a procedure, even after 3 days it took longer to feel normal again.

  2. find out who the senators re for your state’then make their lives a living hell thru phone calls and ‘letters’of grief.Squeak and moan as loudly as you do wgggggggggggggggggg !!!!!!!!!!!!!!!!!!!!!!!!!In Fla.senators are Mark Rubio and Bill Nelson.GIVE EM HELL!!!!Udoo every day!If we dont unite soon,they will walk all over us!!!

  3. Apparently someones research was not well thought out on this because research also shows that ketamine is not the great drug some scientists and doctors say it is. Case in point:

    On February 28, 2015 I was admitted to a hospital in Seattle that morning for a scheduled 3 level acdf (anterior cervical disc fusion of c4 thru c5, c5-c6, c6-c7. I’ve had had 2 lumbar spine surgeries at this hospital the prior February 3 wks apart so I felt confident it would go just as great as the 2 previously spine surgeries. Little did I know that with this last surgery I would be anesthetized with ketamine. I woke up 3 times hallucinating screaming in pain. The third I clearly heard a voice say dc the ketamine. Since I have a medical background I knew that they were discontinuing the drug. I woke up some time later in post OP still in pain and was given my post OP pain pump button to push every six minutes, but it was doing nothing for the pain! Every 3 hours I was given 3 5mg of oxycodone which really did nothing either because the pain was that far out of control. For 2 days I continued to complain of terrible pain then that Friday the day nurse sent a message to the doctor. Later that evening when the nurse came in to dispense the nighttime meds I asked if she would please check the computer that she was on next to my bed to see if there was a response. That nurse laughed in my face and said she didn’t have time her shift was about to end she was clocking out and going home. At that point I got out of my bed grabbed my Walker and took the elevator tp the first floor emergency room and checked in to see if maybe they could have a lil mercy. The floor nurse was called she came and spoke to me convinced me to return to my room and she medicated me. That was the night I started sleep walking. The next day a pain assessment team came in and they added gabapentin. I continued to wakeup from sleep walking which included me banging my head into things which was how I would wakeup. When my pain pump was discontinued I asked to be shown what it was administering per pump. 000.01 was what it was set to. So it was literally dispensing nothing. Therapeutic range is between 3 and 5. Even after coming home I continued sleep walking and head banging. Then the neuropathic pain in my hands returned to what it was prior to my surgery. Pain still very much uncontrolled. Gabapentin was increased to max dose 3600mg a day. It got worse. I finally had to quit gabapentin cold Turkey because of the pain it was causing me and the lack of sleep. I began havng homicidal and suicidal thoughts. Once I quit the gabapentin my hand pain diminished as did that thinking. I found out at the end of May at my 3 months post OP appointment my x rays revealed my donor bone wasn’t grafting and some was missing and have to have this last surgery redone! I have done nothing but spin on how horribly this last surgical experiece was and believe that because I was not properly anesthetized like I was with the first 2, …and being subjected to such awful pain that I am still in, my surgery failed. I called patient advocate at the hospital in mid May to report the experiece and was profusely apologized to. The advocate was in shock to say the least. Then I told my surgeon what I told the advocate. He was outraged because I woke up after he was done and the residents were closing. So he has no idea until he heard from the advocate. He was also very apologetic and promised me that ketamine would not be used on me ever again. So if you are gonna have surgery be aware that they may use ketamine. I was never told prior and wished I had been. I have PTSD I told them prior to this last surgery why I had it because i had concerns waking up post OP freaking out because I had survived being choked many years ago and cannot tolerate any thing coming towards my neck. The fact that they used ketamine knowing that was really a very bad decision in my book. This is used on very large animals and also used as one of a handful of date eape drugs. Using it on humans is despicable especially without prior consent.

    • That’s a horrific account of a surgery gone wrong. Since she had already had good luck with the first two surgeries using opioids, why in the hell did they change it?

      In no way am I opposed to using alternatives (or at least, researching them), but – good grief – I refuse to be a human guinea pig once again. If opioids have worked with a human in the past, why in the hell change it???

      Also, ketamine is a drug of abuse. Special K, anyone? Now in no way do I agree with doing away with a medication simply because some have abused it (opioids, anyone?), but they need to quit acting like K is God’s gift to man and is not abused by some humans.

      • Yes I wish I knew why they decided to use ketamine on me. Its been almost 4 months since my surgery and i’m from not ok about that happening to me. It’s no different than having some one roophie my drink. I talked about my experiece oon Facebook and I literally had people saying I needed to get over it how when they took ketamine they had such a great time I said but you knew what you were taking I was not informed big difference

    • I put the wrong year it was just this past February 2018.

  4. GOODNEWS for operative procedure and acute pain. Just don’t “rely” on ketamone soley. Long way tp gp before “chronic: pain management patients stop suffering and killing ourselves though. Just a note, why was an alternative (if their is one) to opioid medications not established, tested, and approved as effective BEFORE the CDC
    guideline” was enforced by DEA causing so much suffering and even death by suicide??????

Leave a Reply

%d bloggers like this: