Mostrando entradas con la etiqueta ketamine. Mostrar todas las entradas
Mostrando entradas con la etiqueta ketamine. Mostrar todas las entradas

viernes, 8 de junio de 2018

Ketamina en dolor crónico / Ketamine for chronic pain

Junio 8, 2018. No. 3105

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.
Reg Anesth Pain Med. 2018 Jun 5. doi: 10.1097/AAP.0000000000000808. [Epub ahead of print]
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.
Ketamina perioperatoria para dolor por toracotomía
Perioperative Ketamine Administration for Thoracotomy Pain.
Pain Physician. 2017 Mar;20(3):173-184.
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.
¿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?
Interact Cardiovasc Thorac Surg. 2012 Feb;14(2):194-9. doi: 10.1093/icvts/ivr081. Epub 2011 Nov 28.
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.
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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domingo, 18 de febrero de 2018

Combo sobre ketamina / Combo on ketamine

Febrero 16, 2018. No. 2996
Special K sin licencia para matar: sobredosis accidental de ketamina en la inducción de anestesia general.
Special K with No License to Kill: Accidental Ketamine Overdose on Induction of General Anesthesia.
Am J Case Rep. 2018 Jan 3;19:10-12.
Abstract
BACKGROUND. Ketamine is used as an induction and sedation agent in emergency departments and operating rooms throughout the country. Despite its widespread clinical use, there are few cases of significant morbidity and mortality attributed to ketamine overdose in the clinical setting. CASE REPORT; The anesthesia provider in the room was an oral maxillofacial surgeon who inadvertently took out a more highly concentrated bottle of ketamine that is typically used for pediatric patients. The patient received 950 mg (100 mg/ml concentration) of intravenous ketamine instead of the intended 95 mg (10 mg/ml concentration). After the ketamine was given, there were no signs to any involved provider that a mistake had occurred until the wake-up appeared to be unusually prolonged. CONCLUSIONS; Despite this, the patient did not demonstrate any systemic effects such as hemodynamic or CNS perturbations other than prolonged awakening. This case highlights one (drug overdose) of many causes of delayed emergence from anesthesia and reminds the provider caring for the patient to be mindful of drug concentrations used when preparing to sedate a patient, as relying on effects of the parent drug is not always adequate.
Experiencia en el uso de ketamina para controlar la abstinencia de opiáceos en una mujer adicta: informe de un caso.
Experience of the use of Ketamine to manage opioid withdrawal in an addicted woman: a case report.
BMC Psychiatry. 2016 Nov 10;16(1):395.
Abstract
BACKGROUND: Opioids are good painkillers, but many patients treated with opioids as painkillers developed a secondary addiction. These patients need to stop misusing opioids, but the mild-to-severe clinical symptoms associated with opioid withdrawal risk increasing their existing pain. In such cases, ketamine, which is used by anaesthetists and pain physicians to reduce opioid medication, may be an effective agent for managing opioid withdrawal. CASE PRESENTATION: We describe the case of a woman who developed a severe secondary addiction to opioids in the context of lombo-sciatic pain. She presented a severe opioid addiction, and her physicians refused to prescribe such high doses of opioid treatment (oxycontin® extended-release 120 mg daily, oxycodone 60 mg daily, and acetaminophen/codeine 300 mg/25 mg 6 times per day). To assist her with her opioid withdrawal which risked increasing her existing pain, she received 1 mg/kg ketamine oral solution, and two days after ketamine initiation her opioid treatment was gradually reduced. The patient dramatically reduced the dosage of opioid painkillers and ketamine was withdrawn without any withdrawal symptoms. CONCLUSION: Ketamine displays many interesting qualities for dealing with all symptoms relating to opioid withdrawal. Accordingly, it could be used instead of many psychotropic treatments, which interact with each other, to help with opioid withdrawal. However, the literature describes addiction to ketamine. All in all, although potentially addictive, ketamine could be a good candidate for the pharmacological management of opioid withdrawal.
KEYWORDS: Ketamine; Opioid addiction; Opioid withdrawal; Painkillers
Tratamiento exitoso del prurito asociado al nevo epidérmico con ketamina-amitriptilina-lidocaína tópicas.
Successful Treatment of Epidermal Nevus-associated Pruritus with Topical Ketamine-Amitriptyline-Lidocaine.
Acta Derm Venereol. 2018 Jan 12;98(1):121-122. doi: 10.2340/00015555-2811.
Inflammatory linear verrucous epidermal nevus (ILVEN) is a rare, linear, unilateral, pruritic eruption that usually presents during childhood. It is more commonly seen on an extremity, although cases on the head and neck area have been reported in the past (1). It is considered a variant of keratinocytic epidermal nevus; however, it has a significant histological similarity with psoriasis. Patients who have this condition usually complain of intense pruritus (2). Treatments that are regularly effective in psoriasis have shown low efficacy on the management of these lesions, as well as their related symptoms (3). We present here a case of successful treatment of pruritus associated with an epidermal nevus with the use of topical Ketamine 10% - Amitriptyline 5% - Lidocaine 5% in lipoderm base (TKAL). The preparation is widely used in the US for nociceptive pain and is prepared by a compounding pharmacy. All ingredients are FDA approved
Combinación de ketamina/bupivacaína tópica versus caudal para la analgesia postoperatoria en niños sometidos a herniotomía inguinal.
Topical versus caudal ketamine/bupivacaine combination for postoperative analgesia in children undergoing inguinal herniotomy.
Saudi J Anaesth. 2017 Jan-Mar;11(1):41-48. doi: 10.4103/1658-354X.197338.
Abstract
BACKGROUND: Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy. PATIENTS AND METHODS: This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topicalgroup). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative. RESULTS: Kaplan-Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P = 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6th till 48th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia. CONCLUSION: Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair.
KEYWORDS: Analgesia; caudal; day-case anesthetic techniques; ketamine; pediatrics; postoperative; topical
PDF
Modulación de la Actividad del Receptor NMDA en la Fibromialgia.
Modulation of NMDA Receptor Activity in Fibromyalgia.
Biomedicines. 2017 Apr 11;5(2). pii: E15. doi: 10.3390/biomedicines5020015.
Abstract
Activation of the N-methyl-d-aspartate receptor (NMDAR) results in increased sensitivity of spinal cord and brain pathways that process sensory information, particularly those which relate to pain. The NMDAR shows increased activity in fibromyalgia and hence modulation of the NMDAR is a target for therapeutic intervention. A literature review of interventions impacting on the NMDAR shows a number of drugs to be active on the NMDAR mechanism in fibromyalgia patients, with variable clinical effects. Low-dose intravenous ketamine and oral memantine both show clinically useful benefit in fibromyalgia. However, consideration of side-effects, logistics and cost need to be factored into management decisions regarding use of these drugs in this clinical setting. Overall benefits with current NMDAR antagonists appear modest and there is a need for better strategy trials to clarify optimal dose schedules and to delineate potential longer-term adverse events. Further investigation of the role of the NMDAR in fibromyalgia and the effect of other molecules that modulate this receptor appear important to enhance treatment targets in fibromyalgia.
KEYWORDS: NMDA receptor; drugs; fibromyalgia; ketamine; memantine
La ketamina en el tratamiento del dolor crónico según medicina basada en la evidencia
F. Neira Reina y J. L. Ortega García
Rev Soc Esp Dolor 2016; 23(6): 292-306.
Resumen:
La ketamina es un antagonista no competitivo de los receptores NMDA y tiene un amplio mecanismo de acción que involucra, además, a los receptores AMPA, kainato, ácido gamma-aminobutírico, opioides, monoaminérgicos, muscarínicos y nicotínicos. Actúa sobre los canales de calcio y sodio voltaje-dependientes, interviene en la síntesis y liberación del óxido nítrico e inhibe la recaptación de serotonina. La interacción con todos estos mecanismos de acción hace que tenga una importante participación sobre mecanismos del dolor, inflamación, neuroprotección y tolerancia de opioides ....
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martes, 30 de enero de 2018

Ketamina en dolor por anemia falciforme / Ketamine and sickle cell disease pain

Enero 28, 2018. No. 2977
La evaluación del uso de ketamina para el control del dolor con la crisis de células falciformes en el embarazo: un informe de 2 casos.
Evaluating the Use of Ketamine for Pain Control With Sickle Cell Crisis in Pregnancy: A Report of 2 Cases.
A A Pract. 2018 Jan 1;10(1):20-22. doi: 10.1213/XAA.0000000000000624.
Abstract
Sickle cell crises occur frequently during pregnancy and are difficult to treat, even with high-dose opioids. Analgesia with ketamine has been suggested as an alternative, but its use during pregnancy is underreported. Two pregnant patients with uncontrolled sickle cell pain were treated with ketamine. Patient A reported no decrease in her pain, but her opioid requirements decreased. Patient B's pain resolved during ketamine administration. No serious maternal or neonatal adverse effects occurred. Ketamine may be considered as an adjunct analgesic in pregnant patients with sickle cell pain, although prospective clinical data are needed to fully assess its efficacy.
El papel de un régimen de dosis bajas de ketamina-midazolam en el tratamiento de la crisis dolorosa severa en pacientes con enfermedad de células falciformes.
The role of a low-dose ketamine-midazolam regimen in the management of severe painful crisisin patients with sickle cell disease.
J Pain Symptom Manage. 2014 Feb;47(2):334-40. doi: 10.1016/j.jpainsymman.2013.03.012. Epub 2013 Jul 12
Abstract
CONTEXT: Acute pain is one of the main causes of hospital admission in sickle cell disease, with variable intensity and unpredictable onset and duration. OBJECTIVES: We studied the role of a low-dose intravenous (IV) ketamine-midazolam combination in the management of severe painful sickle cell crisis. METHODS: A retrospective analysis was performed with data from nine adult patients who were admitted to the intensive care unit with severe painful sickle cell crises not responding to high doses of IV morphine and other adjuvant analgesics. A ketamine-midazolam regimen was added to the ongoing opioids as an initial bolus of ketamine 0.25mg/kg, followed by infusion of 0.2-0.25mg/kg/h. A midazolam bolus of 1mg followed by infusion of 0.5-1mg/h was added to reduce ketamine emergence reactions. Reduction in morphine daily requirements and improvement in pain scores were the determinants of ketamine-midazolam effect. The t-tests were used for statistical analysis. RESULTS: Nine patients were assessed, with mean age of 27±11 years. Morphine requirement was significantly lower after adding the IV ketamine-midazolam regimen. The mean±SD IV morphine requirement (milligram/day) in the pre-ketamine day (D0) was 145.6±16.5, and it was 112±12.2 on Day 1 (D1) of ketamine treatment (P=0.007). The Numeric Rating Scale scores on D0 ranged from eight to ten (mean 9.1), but improved to range from five to seven (mean 5.7) on D1. There was a significant improvement in pain scores after adding ketamine-midazolam regimen (P=0.01). CONCLUSION: Low-dose ketamine-midazolam IV infusion might be effective in reducing pain and opioid requirements in patients with sicklecell disease with severe painful crisis. Further controlled studies are required to prove this effect.
Sickle cell disease; ketamine; midazolam; pain management; painful crisis
Crisis drepanocítica y tratamiento del dolor
A. Rojas-Martínez, E. Calderón, M.A. Vidal, F. Arroyo, R. García-Hernández y L.M. Torres
Rev Soc Esp Dolor 2015; 22(4): 165-167
RESUMEN
La drepanocitosis incluye un grupo de desórdenes genéticamente heredados en los que a baja saturación de oxígeno ocurre la agregación de polímeros rígidos de hemoglobina S desoxigenada, otorgando forma de hoz al hematíe y dañando el endotelio vascular por medio de múltiples mecanismos, obstruyendo concomitantemente la microcirculación y produciendo una estimulación de nociceptores. Los pacientes con drepanocitosis pueden presentar múltiples tipos de dolor dependiendo de las estructuras lesionadas, siendo el de tipo músculo-esquelético el más frecuente. La base del manejo del dolor es el reconocimiento y la evaluación de la severidad, ya que de esta dependerá la prescripción del tratamiento analgésico. Las crisis vasooclusivas son la manifestación más característica de esta enfermedad. Una vez instaurado el dolor, el manejo inicial debe enfocarse en proveer control rápido del mismo, garantizándose dosis terapéuticas de los fármacos, y en la detección de complicaciones. Debe evitarse el uso no indicado de las terapias y el tratamiento infraterapéutico, acompañado de un seguimiento cuidadoso, prevención y tratamiento de los efectos adversos. El tratamiento del dolor crónico se hace de forma multidisciplinaria, considerando estrategias no farmacológicas. Palabras clave: Drepanocitosis. Células falciformes. Crisis veno-oclusivas. Opioides. Dolor intenso.
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