Jump to comment:
- Page navigation anchor for RE: Ketamine for the treatment of acute pain.RE: Ketamine for the treatment of acute pain.
With great interest, we read the five things to know about “Ketamine for the treatment of acute pain” by Silverstein et al. (1). The “second thing” the authors wish us to know is that low-dose ketamine is an effective analgesic in several clinical settings including anaesthesia, critical care, pain management and emergency medicine. (2)
We wish to bring attention to an emerging literature that effective and safe administration of low-dose ketamine can be provided to adult and pediatric patients by paramedics in the prehospital setting. (3) Importantly, a joint position statement supporting the pre-hospital use of ketamine as an analgesic in acute trauma patients has recently been published by several American organizations including the American College of Surgeons Committee on Trauma, American College of Emergency Physicians and the National Association of EMS Physicians. (4)
Given typical limitations of opioids, there is a clear need for a non-opioid analgesia in the prehospital environment. Examples include high acuity trauma patients at risk for (or exhibiting) hemorrhagic shock or respiratory compromise, patients in severe pain with known allergies to morphine and fentanyl, and patients with a history of narcotic use disorder who do not wish to be administered opioids or who are being treated with buprenorphine/naloxone.
Ketamine analgesia medical directives are already in place for paramedic use in several Canadian provinces and Ontario is in...
Show MoreCompeting Interests: None declared.References
- William K. Silverstein, David N. Juurlink, Jonathan S. Zipursky. Ketamine for the treatment of acute pain. CMAJ 2021;193:E1663-E1663.
- 2. Schwenk ES, et al. Guidelines on the use of ketamine infusions for acute pain from the American Society of Regional Anesthesia, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018;43:456-466.
- 3. Sobieraj DM, Martinez BK, Miao B, et al. Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting. Prehospital Emergency Care 2020;24:163-174.
- 4. Morgan MM, Perina DG, Acquisto NM, et al. Ketamine use in prehospital and hospital treatment of the acute trauma patient: A joint position statement. Prehospital Emergency Care 2021;25:588-592.
- Page navigation anchor for Re: KetamineRe: Ketamine
I believe that ketamine is poorly understood despite it's use for >50 years. Furthermore, like many drugs we use, I think the analysis of effects is significantly biased by modern "statistical methods".
Show More
As a clinical anesthesiologist I have interviewed many patients who have reported significant dysphoric effects, including more than a few who state 'I never want that drug again', and a fellow consultant anesthesiologist who was prescribed ketamine for postop analgesia who reported to me "I went completely bonkers, ripped out my lines, and wandered all over the hospital warning everybody that the soldiers were coming and other incomprehensible scenarios. Even though the ketamine drip was discontinued a few days postop, my nightly recurring hallucinations lasted for another 2 -3 weeks or so." This type of report - which may represent an outlier, but perhaps not - likely doesn't show up in statistical analysis but in my view reports a significant danger which is difficult to detect in routine clinical research.
Our own research with ketamine, albeit with reported pain a secondary variable, and not sufficiently powered to provide definitive evidence, found no difference in pain scores with or without ketamine. My clinical observations (weak as that is) of colleagues who routinely use ketamine, is that this is a frequent outcome, and indeed many nurses in the postop care unit are not impressed by the use of ketamine. Th...Competing Interests: I have been involved with research utilizing ketamine.References
- William K. Silverstein, David N. Juurlink, Jonathan S. Zipursky. Ketamine for the treatment of acute pain. CMAJ 2021;193:E1663-E1663.
- Napoleone G, doi:10.1213/ANE.0000000000005372van Heusden K, Cooke E, et al. The Effect of Low-Dose Intraoperative Ketamine on Closed-Loop-Controlled General Anesthesia: A Randomized Controlled Equivalence Trial [published online ahead of print, 2021 Feb 8
- White PF. Ketamine and Perioperative Analgesia: A Predictable Outcome? Anesth Analg. 2021 Jun 1;132(6):e113-e114. doi: 10.1213/ANE.0000000000005506. PMID: 34032678.