Ketamine For Acute and Chronic Pain
Cardinal Presentations / Presenting Problems
- Ketamine is a phencyclidine (PCP) derivative, and its therapeutic effects rely on N-methyl-D-aspartate receptor inhibition.
- It can be used as an analgesic, for procedural sedation and anesthesia induction.
- It is also increasingly used in prehospital settings.
- BCEHS guidelines recommend bolus dosing as follows:
- Analgesia dose range – 0.1 to 0.3 mg/kg IV, 0.75 mg/kg Intranasal, 0.5 mg/kg IM.
- Procedural sedation dose range – 0.1 to 0.5 mg/kg
- Anesthesia induction dose range – 1.0 to 2.0 mg/kg
- Also attractive option for patients presenting to the ED with acute pain, especially when contra-indications to opioids or opioid tolerance.
- Studied more in the context of post-operative pain, but also shown to be effective in treating acute pain in the ED.
- Still much more research needed to establish contra-indications and the significance of adverse event rates at subanesthetic doses.
- Relative contraindications include severe cardiovascular disease, Elevated intracranial pressure or intraocular pressure, cirrhosis, psychosis, pregnancy – extrapolated from higher dose ketamine contraindications.
- Nausea, vomiting, and psychomimetic effects (eg. vivid dreams, hallucinations, dissociation) are possible side effects – less significant at low doses.
- Adverse effects of ketamine generally treated with benzodiazepines/clonidine.
For management of acute pain these are some guideline dose ranges, however starting at the lower end and titrating as needed is recommended based on analgesia & side effects:
- Intermittent bolus doses: 0.1 – 0.35mg/kg (eg. q4hrs or followed by infusion).
- Continuous infusion: 0.1-0.5 mg/kg/hour (max 1mg/kg/hour infusion).
There is limited evidence for use in chronic pain, and ideally a pain specialist should be consulted before initiating treatment.
- Low quality evidence to support short term improvement in pain for spinal cord injury (eg. 0.4 mg/kg/hour for 5 hours daily for 7 consecutive days), and complex regional pain syndrome (eg. 0.35 mg/kg/hour for 4 hours daily for 10 days).
- Lack of evidence for longer term pain relief, and limited evidence for use in other causes of chronic pain.
Criteria For Hospital Admission
Ketamine treatment for analgesia is recommended to be done under medical supervision, often in a hospital setting.
Criteria For Close Observation And/or Consult
If larger doses required consider cardiac monitoring and frequent vital signs.
Respiratory depression uncommon side-effect, but possible with larger doses administered quickly. Have resuscitative equipment available.
Criteria For Safe Discharge Home
Advise patients to avoid driving and heavy equipment use for 24 hours if otherwise well enough to discharge.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
There is moderate quality of evidence for the use of subanesthetic doses for the management of pain – Recent consensus guidelines reviewed number of studies showing significant reduction of pain, but many studies limited to pain in the perioperative period.
Low quality of evidence that ketamine is as effective as morphine for management of acute pain in the ED – Recent systemic review and metanalysis found limited number of trials with some inconsistency in results, also imprecise results eg. Confidence intervals overlapping increase and decrease of pain in some studies.
Limited evidence to guide use for long term chronic pain management.
OTHER RELEVANT INFORMATION
BC EHS handbook:
Balzer N, McLeod SL, Walsh C, et al. Low-dose ketamine for acute pain control in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2021;28:444-54.
Cohen SP, Bhatia A, Buvanendran A, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):521-546.
Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43:456-66.
Silverstein W, Juurlink D, Zipursky J. Ketamine for the treatment of acute pain. CMAJ. 2021 November 1;193:E1663.
Tran K, McCormack S. Ketamine for Chronic Non-Cancer Pain: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. 2020 May 28.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 04, 2022
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