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Pautas de consenso sobre el uso de infusiones intravenosas de
ketamina para el dolor crónico de la Sociedad Estadounidense de
Anestesia Regional y Medicina del Dolor, la Academia Estadounidense de
Medicina del Dolor y la Sociedad Americana de Anestesiólogos.
CONCLUSIONES: La evidencia apoya el uso de la ketamina para el
dolor crónico, pero el nivel de evidencia varía según la condición y el
rango de dosis. La mayoría de los estudios que evaluaron la eficacia de
la ketamina fueron pequeños e incontrolados y no se cegaron o cegaron
ineficazmente. Los efectos adversos fueron pocos y la tasa de efectos
adversos graves fue similar al placebo en la mayoría de los estudios,
con dosis más altas e infusiones más frecuentes asociadas con mayores
riesgos. Se necesitan estudios más amplios que evalúen una variedad más
amplia de afecciones para cuantificar mejor la eficacia, mejorar la
selección de pacientes, refinar el rango de dosis terapéuticas,
determinar la efectividad de las alternativas de ketamina no intravenosa
y desarrollar una mayor comprensión de los riesgos a largo plazo de los
tratamientos repetidos.
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 PainMedicine, and
the American Society of Anesthesiologists.
Cohen SP, Bhatia A1, Buvanendran A2, Schwenk ES3, Wasan AD4, Hurley RW5, Viscusi ER3, Narouze S6, Davis FN, Ritchie EC, Lubenow TR2, Hooten WM7.
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 AmericanSociety 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 infusionsassociated 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.
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Ketamina perioperatoria para dolor por toracotomía
Perioperative Ketamine Administration for Thoracotomy Pain.
Abstract
BACKGROUND: Of all the
postsurgical pain conditions, thoracotomy pain poses a particular
therapeutic challenge in terms of its prevalence, severity, and
ensuing postoperative morbidity. Multiple pain generators contribute to
the severity of post-thoracotomy pain, and therefore a multimodal
analgesic therapy is considered to be a necessary strategy. Along with
opioids, thoracic epidural analgesia, and paravertebral blocks,
N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have
been used as adjuvants to improve analgesia. OBJECTIVE: We reviewed the
evidence for the efficacy of intravenous and epidural administration
of ketamine in acute post-thoracotomy pain management, and its
effectiveness in reducing chronic post-thoracotomy pain. STUDY DESIGN:
Systematic literature review and an analytic study of a data subset were
performed. METHODS: We searched PubMed, Embase, and Cochrane reviews
using the key terms "ketamine," "neuropathic pain," "postoperative," and
"post-thoracotomy pain syndrome." The search was limited to human
trials and included all studies published before January 2015. Data from
animal studies, abstracts, and letters were excluded. All studies not
available in the English language were excluded. The manuscript
bibliographies were reviewed for additional related articles. We
included randomized controlled trials and retrospective studies, while
excluding individual case reports. RESULTS: This systematic literature
search yielded 15 randomized control trials evaluating the efficacy
of ketamine in the treatment of acute post-thoracotomy pain; fewer
studies assessed its effect on attenuating chronic
post-thoracotomy pain. The majority of reviewed studies demonstrated
that ketamine has efficacy in reduction of acute pain, but the evidence
is limited on the long-term benefits of ketamine to prevent
post-thoracotomy pain syndrome, regardless of the route of
administration. A nested analytical study found there is a statistically
significant reduction in acute post-thoracotomy pain with IV or
epidural ketamine. However currently, the evidence for a role
of ketamine as a preventative agent for chronic post-thoracotomy pain is
insufficient due to the heterogeneity of the studies reviewed with
regard to the route of administration, dosage, and outcome measures.
LIMITATIONS: The evidence for a role of ketamine as a preventative agent
for chronic post-thoracotomy pain is insufficient due to the
heterogeneity of the studies reviewed. CONCLUSION:
The majority of randomized controlled trials reviewed show no role
for ketamine in attenuating or preventing post-thoracotomy pain syndrome
at variable follow-up lengths. Therefore, additional research is
warranted with consideration of risk factors and long-term follow-up for
chronic post-thoracotomy pain though the evidence for benefit appears
clear for acute post-thoracotomy pain.Key
words: Ketamine, postoperative, thoracotomy pain, post
thoracotomy pain syndrome, neuropathic pain.
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¿La adición de ketamina a la analgesia controlada por el paciente con morfina mejora de manera segura el dolor post-toracotomía?
Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain?
Abstract
A best evidence topic in thoracic surgery was written according to a
structured protocol. The question addressed was 'is the addition
of ketamine to morphine patient-controlled analgesia (PCA) following
thoracic surgery superior to morphine alone'. Altogether 201 papers were
found using the reported search, of which nine represented the best
evidence to answer the clinical question. The authors, journal, date and
country of publication, patient group studied, study type, relevant
outcomes and results of these papers are tabulated. This consisted of
one systematic review of PCA morphine with ketamine (PCA-MK) trials, one
meta-analysis of PCA-MK trials, four randomized controlled trials of
PCA-MK, one meta-analysis of trials using a variety of
peri-operative ketamine regimes and two cohort studies of PCA-MK. Main
outcomes measured included pain score rated on visual analogue scale,
morphine consumption and incidence of psychotomimetic side
effects/hallucination. Two papers reported the measurements of
respiratory function. This evidence shows that adding ketamine to
morphine PCA is safe, with a reported incidence of hallucination
requiring intervention of 2.9%, and a meta-analysis finding an incidence
of all central nervous system side effects of 18% compared with 15%
with morphine alone, P = 0.31, RR 1.27 with 95% CI (0.8-2.01). All
randomized controlled trials of its use following thoracic surgery found
no hallucination or psychological side effect. All five studies in
thoracic surgery (n = 243) found reduced morphine requirements with
PCA-MK. Pain scores were significantly lower in PCA-MK patients in
thoracic surgery papers, with one paper additionally reporting increased
patient satisfaction. However, no significant improvement was found in a
meta-analysis of five papers studying PCA-MK in a variety of surgical
settings. Both papers reporting respiratory outcomes found improved
oxygen saturations and PaCO(2) levels in PCA-MK patients following
thoracic surgery. We conclude that adding low-dose ketamine to morphine
PCA is safe and post-thoracotomy may provide better pain control than
PCA with morphine alone (PCA-MO), with reduced morphine consumption and
possible improvement in respiratory function. These studies thus support
the routine use of PCA-MK instead of PCA-MO to improve
post-thoracotomy pain control.
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Papel de la ketamina en el tratamiento del dolor crónico por cáncer
The role of ketamine in the treatment of chronic cancer pain.
Clujul Med. 2015;88(4):457-61. doi: 10.15386/cjmed-500. Epub 2015 Nov 15.
Abstract
BACKGROUND AND AIM: Ketamine is a drug used for
the induction and maintenance of general anesthesia, for the treatment
of postoperative and posttraumatic acute pain, and more recently, for
the reduction of postoperative opioid requirements. The main
mechanism of action of ketamine is the antagonization of
N-methyl-D-aspartate (NMDA) receptors that are associated with central
sensitization. In the pathogenesis of chronic pain and particularly in
neuropathic pain, an important role is played by the activation of NMDA
receptors. Although ketamine is indicated and used for the treatment
of chronic cancer pain as an adjuvant to opioids, there are few clinical
studies that clearly demonstrate the effectiveness of ketamine in this
type of pain. The aim of this study is to analyze
evidence-based clinical data on the effectiveness and safety
of ketamine administration in the treatment of chronic neoplastic pain,
and to summarize the evidence-based recommendations for the use
of ketamine in the treatment of chronic cancer pain. METHOD: We reviewed
the literature from the electronic databases of MEDLINE, COCHRANE,
PUBMED, MEDSCAPE (1998-2014), as well as chapters of specialized books
(palliative care, pain management, anesthesia). RESULTS: A number of
studies support the effectiveness of ketamine in the treatment
of chronic cancer pain, one study does not evidence clear clinical
benefits for the use of ketamine, and some studies included too few
patients to be conclusive. CONCLUSIONS: Ketamine represents an option
for neoplasic pain that no longer responds to conventional opioid
treatment, but this drug should be used with caution, and the
development of potential side effects should be carefully monitored.
KEYWORDS: cancer pain; chronic cancer pain treatment; ketamine; neuropathic pain; pain treatment
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