Article Text

PDF

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
  1. Steven P. Cohen, MD*,,
  2. Anuj Bhatia, MBBS, MD,
  3. Asokumar Buvanendran, MD§,
  4. Eric S. Schwenk, MD,
  5. Ajay D. Wasan, MD, MSc**,
  6. Robert W. Hurley, MD, PhD††,
  7. Eugene R. Viscusi, MD,
  8. Samer Narouze, MD, PhD‡‡,
  9. Fred N. Davis, MD§§∥∥,
  10. Elspeth C. Ritchie, MD, MPH***,†††,
  11. Timothy R. Lubenow, MD§ and
  12. William M. Hooten, MD‡‡‡
  1. *Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine
  2. Uniformed Services University of the Health Sciences, Bethesda, MD
  3. Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
  4. §Department of Anesthesiology, Rush Medical College, Chicago, IL
  5. Department of Anesthesiology, Jefferson Medical College, Philadelphia
  6. **Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
  7. ††Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
  8. ‡‡Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
  9. §§Procare Pain Solutions and
  10. ∥∥Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
  11. ***Department of Psychiatry, Uniformed Services University of the Health Sciences, Georgetown University School of Medicine, Bethesda, MD
  12. †††Howard University College of Medicine, Washington, DC
  13. ‡‡‡Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN
  1. Address correspondence to: Steven P. Cohen, MD, 550 N Broadway, Suite 301 Baltimore, MD 21029 (e-mail: scohen40{at}jhmi.edu).

Abstract

Background Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines.

Methods In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines.

Results Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions.

Conclusions Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.

Statistics from Altmetric.com

Footnotes

  • The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the Department of Defense.

    Because this document has neither been presented to nor approved by either the American Society of Anesthesiologists Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist.

    S.P.C. is funded in part by a Congressional Grant from the Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD (SAP grant 111726), which also paid for Open Access publication.

    The authors declare no conflict of interest.

    Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.rapm.org).

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.