Improving Acute Pain Care with Ketamine

The benefit of Ketamine for acute pain care is decreased opioid consumption immediately in the postoperative period, and over the longer postoperative period as well. A lot has been published about ketamine use for depression or outpatient IV ketamine infusion for chronic pain, but I think this may be a Forgotten Gem—that its use in the operating room is worth it. I know this because I used to anesthetize patients , and I also think people will be convinced that it’s worth incorporating IV ketamine infusion in the ERAS protocols as we are doing now at Cedars-Sinai.

One of the conclusions that I drew from a comparative analysis between the studies is that giving a single loading dose in the operating room is not sufficient; you have to chase it with an infusion either during the entire surgery or even for 24 hours. That I think is one of the clinical pearls that I’m trying to impart. Also, if IV ketamine is not possible for one reason or another, gabapentin is a good substitute or adjunct. Using ketamine doesn’t mean that we’re not going to use other adjuncts such as acetaminophen and non-steroidal anti-inflammatory drugs and another dose of opioids, which is I think a well-accepted philosophy these days. Paying attention to numbers is important in this arena, and also we have to individualize the dosages for each patient. Another insight, which is probably not well known, is that rather than putting patients on pure opioid PCAs such as hydromorphone or morphine, you can mix the ketamine with an opioid. That’s something we’ve been doing for more than 10 years at Cedars-Sinai and has been shown in the literature to have an opioid-sparing effect. It’s a very safe technique, and we haven’t had any major problems.