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Evidence supports the use of intravenous (IV) 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, according to the first guidelines on the use of ketamine for acute pain management.

Ketamine has captured headlines recently for its potential role in treating severe depression and posttraumatic stress syndrome. Ketamine is also increasingly being used in inpatient and outpatient settings to manage acute pain.

One driving force behind this is the growing effort to reduce the risk for long-term opioid use after acute exposure and its subsequent complications, including addiction. Yet, to date, few recommendations have been available to guide this emerging acute pain therapy.

"The goal of this document is to provide a framework for doctors, for institutions and for payers on use of ketamine for acute pain, who should get it and who should not get it," guideline author Steven Cohen, MD, from Johns Hopkins School of Medicine in Baltimore, Maryland, told Medscape Medical News.

Dr Steven Cohen

The guidelines were published online June 7 in Regional Anesthesia and Pain Medicine.  

Reduced Need for Opioids

Development of the guidelines on use of ketamine for acute pain was a joint effort spearheaded by the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, which approved the document, as did the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters.

The guidelines state that subanesthetic ketamine infusions should be considered for patients undergoing painful surgery and may be considered for opioid-dependent or opioid-tolerant patients undergoing surgery.

Ketamine may be considered for opioid-dependent or opioid-tolerant patients with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be considered as an adjunct to limit opioids, the guidelines note.

The use of ketamine in subanesthetic doses has "exploded and there definitely seems to be a strong signal that ketamine is effective for acute pain, and a lot of patients don't have other options," Cohen commented.

On dosing, the guidelines recommend that ketamine bolus doses do not exceed 0.35 mg/kg and that infusions for acute pain generally do not exceed 1 mg/kg per hour in settings without intensive monitoring. The authors acknowledge that individual pharmacokinetic and pharmacodynamic differences, as well as other factors, such as prior ketamine exposure, may warrant dosing outside this range.

The guidelines also state that moderate evidence supports use of subanesthetic intravenous ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids for perioperative analgesia.