Ketamine is increasingly recognized as a mainstream anesthesia agent and, more recently, for its potential role in depression. Despite ongoing concerns over the potential for abuse and increasing street value of ketamine, new guidelines were recently been published for its use in controlling acute pain. The American Society of Regional Anesthesia and Pain Medicine developed the guidelines in collaboration with the American Academy of Pain Medicine, and the guidelines were vetted by the American Society of Anesthesiologists’ Committee on Pain Medicine and Standards and Practice Parameters.

Best known for its ability to induce sedation, amnesia, and analgesia, ketamine is also associated with precipitating psychosis. Ketamine noncompetitively blocks N-methyl-D-aspartate receptors, and this activity is likely responsible for both the beneficial analgesic as well as the psychiatric actions of the medication.

Published in Regional Anesthesia and Pain Medicine in June 2018, the new consensus guidelines offer recommendations on the use of IV ketamine infusions for chronic and acute pain management. Lead author of the new guidelines, Steven P. Cohen, MD, professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, highlights the need to provide guidance on the appropriate use of ketamine for prescribers and insurance payors. “There have been calls from health insurance companies, government regulatory agencies, patient advocacy groups and hospitals to try to standardize patient selection and treatment protocols,” says Dr. Cohen.

With the societal impact of the recent opiate epidemic, the scientific community has strived to develop treatment alternatives following acute opiate exposure, or in cases where there is a need to limit opioids altogether, such as in patients with comorbid sleep apnea. The guidelines focus on using infusions of “subanesthetic doses” of IV ketamine. Although patient-specific factors may require unique dosing strategies, the guidelines recommend that infusions used for acute pain should not exceed 1 mg/kg per hour. The guidelines also advise that bolus doses should not exceed 0.35 mg/kg in settings without available specialized care and intensive monitoring.

The guideline authors also note that although more research is needed to refine selection criteria and ideal dosing, ketamine is a powerful and inexpensive tool for managing acute pain.

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