Prolonged Perioperative Low-Dose Ketamine Does Not Improve Short and Long-term Outcomes After Pediatric Idiopathic Scoliosis Surgery

Perelló, Marina; Artés, David; Pascuets, C.; Esteban, Elisabeth; Batlle, Ana M. Ey

doi:10.1097/brs.0000000000001772

Cited by 31 publications

(26 citation statements)

References 40 publications

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“…This finding is consistent with our results from a previous randomized placebo-controlled trial, where ketamine administered in the intraoperative and postoperative periods did not yield an opioid-sparing effect in adolescents with scoliosis undergoing spinal fusion 11. Interestingly, a more recent trial and a new meta-analysis12 also showed lack of beneficial effect of ketamine in postoperative pain 27. It is important to note that one limitation of the most recent study in adolescents undergoing spinal fusion27 as well as ours11 is that neither study examined the effect of ketamine on chronic postsurgery pain.…”

Section: Discussionsupporting

confidence: 92%

“…Interestingly, a more recent trial and a new meta-analysis12 also showed lack of beneficial effect of ketamine in postoperative pain 27. It is important to note that one limitation of the most recent study in adolescents undergoing spinal fusion27 as well as ours11 is that neither study examined the effect of ketamine on chronic postsurgery pain. Nevertheless, our findings from the present study are discrepant to those showing that low-dose ketamine infusion during the perioperative period yields opioid-sparing effects in adults undergoing major surgeries 28.…”

Section: Discussionmentioning

confidence: 99%

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Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study

Sheehy

Lippold

Rice

et al. 2017

JPR

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BackgroundSubanesthetic doses of ketamine, an N-methyl-d-aspartate receptor antagonist used as an adjuvant to opioid for the treatment of pain in adults with acute and chronic pain, have been shown, in some instances, to improve pain intensity and to decrease opioid intake. However, less is known about the role of ketamine in pain management in children, adolescents, and young adults.PurposeWe examined the effects of subanesthetic ketamine on pain intensity and opioid intake in children, adolescents, and young adults with acute and chronic pain syndromes treated in an inpatient setting.MethodsThis is a longitudinal cohort study of patients treated with subanesthetic ketamine infusions in regular patient care units in a tertiary pediatric hospital. Primary outcomes included changes in pain scores and morphine-equivalent intake.ResultsThe study cohort included 230 different patients who during 360 separate hospital admissions received subanesthetic ketamine infusions for pain management. Overall, ketamine infusions were associated with significant reductions in mean pain scores from baseline (mean pain scores 6.64 [95% CI: 6.38–6.90]) to those recorded on the day after discontinuation of ketamine (mean pain scores 4.38 [95% CI: 4.06–4.69]), p<0.001. Importantly, the effect of ketamine on pain scores varied according to clinical diagnosis (p=0.011), infusion duration (p=0.004), and pain location (p=0.004). Interestingly, greater reductions in pain scores were observed in patients with cancer pain and patients with pain associated with pancreatitis and Crohn’s disease. There were no records of psychotomimetic side effects requiring therapy.ConclusionThese data suggest that administration of subanesthetic ketamine for pain management is feasible and safe in regular inpatient care units and may benefit children, adolescents, and young adults with acute and chronic pain. This study is informative and can be helpful in determining sample and effect sizes when planning clinical trials to determine the role of subanesthetic ketamine infusions for pain management in pediatric patients.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study

Sheehy

Lippold

Rice

et al. 2017

JPR

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“…This supported previous data for scoliosis repair, that low-dose ketamine intraoperatively did not prevent remifentanil-induced AOT postoperatively 9. Furthermore, Perelló et al 13 studied a 72-hour course of low-dose ketamine to assess both short-term outcomes of postoperative morphine utilization, adverse side effects, as well as long-term outcomes with incidence of persistent postsurgical pain at 6 months postoperatively. While these three studies did not support ketamine use, Jabbour et al 12 demonstrated that when magnesium was added to ketamine, opioid consumption was reduced.…”

Section: Discussionsupporting

confidence: 84%

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

Kars

Mori

Ahn

et al. 2019

Reg Anesth Pain Med

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IntroductionOpioid-induced hyperalgesia (OIH) and acute opioid tolerance have been demonstrated extensively in patients undergoing adolescent idiopathic scoliosis (AIS) repair. Remifentanil infusion has been strongly linked to both tolerance and OIH in these patients; however, the impact of using an intraoperative fentanyl infusion has not been well studied. This study aims to determine if patients undergoing operative management of AIS have decreased opioid consumption and pain scores when an intraoperative fentanyl infusion is used as compared with a remifentanil infusion.MethodsThis is a retrospective chart review of patients with AIS who underwent posterior spinal fusion. During the period January 2012–June 2013, patients received remifentanil infusion as part of total intravenous anesthesia. From July 2013 to June 2015, remifentanil was replaced by fentanyl as standard protocol. The remifentanil cohort included 37 patients and the fentanyl cohort included 25 patients. The primary outcome was the total opioid consumption (morphine equivalents) in the first 24 hours postsurgery. Secondary outcomes included mean postoperative pain score in the first 24 hours postsurgery, postoperative opioid consumption 24–48 hours after surgery, time to extubation, time to assisted ambulation, length of stay, and incidence of postoperative nausea and vomiting.ResultsCompared with the remifentanil group, the fentanyl group had significantly higher postoperative opioid usage during the first 48 hours and significantly higher postoperative mean pain score during the first 24 hours. There was no difference between the two groups in mean pain score for 24–48 hours, extubation time, time to assisted ambulation, length of stay, or postoperative nausea and vomiting.DiscussionDespite concerns for hyperalgesia and acute tolerance, remifentanil is widely used for intraoperative opioid infusions for surgical correction of AIS. This retrospective study examined a practice change from intraoperative remifentanil to intraoperative fentanyl as a potential approach to avoid OIH. Surprisingly, patients receiving fentanyl intraoperatively showed increased postoperative opioid use and pain scores in the first 24 hours postsurgery compared with the prior cohort receiving remifentanil. Substitution of fentanyl for remifentanil during surgical correction of AIS does not appear to solve the problem of OIH or acute tolerance. Prospective studies are needed to confirm this unexpected result.

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“… 32 However, in a recent small study of 48 pediatric patients undergoing scoliosis spine surgery, a subanesthetic ketamine dose of 0.5 mg/kg followed by an infusion at 0.12 mg/kg per hour for 72 hours yielded no significant differences in opioid consumption or pain scores compared with placebo. 33 In a longitudinal cohort study performed in 230 children, adolescents, and young adults, patients with acute (78%) and chronic (22%) pain were given different doses of ketamine infusions depending on whether they were opioid tolerant. Opioid-naive patients were administered ketamine infusions of 0.05 to 0.4 mg/kg per hour, opioid-tolerant patients received dosages ranging from 0.05 to 1 mg/kg per hour, and those with documented opioid-induced hyperalgesia underwent infusion rates of 1 mg/kg per hour.…”

Section: Discussionmentioning

confidence: 99%

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

Schwenk

Viscusi

Buvanendran

et al. 2018

Regional Anesthesia and Pain Medicine

278

221

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BackgroundKetamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines.MethodsThe development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls.ResultsConsensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions.ConclusionsEvidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.

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Prolonged Perioperative Low-Dose Ketamine Does Not Improve Short and Long-term Outcomes After Pediatric Idiopathic Scoliosis Surgery

Abstract: 2.

Cited by 31 publications

References 40 publications

Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study

Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

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

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