Three Pain Medicine Societies Issue Consensus Panel Guidelines on IV Ketamine for Acute Pain

Although ketamine infusions have been used for decades to treat acute pain, the drug has in recent years become a mainstay of treatment in emergency and perioperative settings for patients who have refractory pain and in opioid-tolerant patients.

Members of 3 large pain medicine societies have written consensus guidelines1 for the use of IV ketamine in acute pain, an outgrowth of earlier guidelines for ketamine IV use in chronic pain.

The authors wrote that the need for a consensus guideline became apparent because the current practice across the country involved widespread variability in patient selection, treatment parameters, and monitoring of patients.

The guideline authors write that evidence supports the use of ketamine for acute pain in a variety of contexts, including as a standalone 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.

The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The joint effort was launched in November 2016 by leaders of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine.

In December 2017, the preliminary draft document was sent to the American Society of Anesthesiologists committees on pain medicine, and on standards and practice parameters, which approved the document with minor revisions.

To write the guidelines, the consensus panel members formed groups of 3 to 5 members each, who, along with the committee chair, drafted guidelines based on consensus. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls.

Consensus guidelines are organized along the following areas: indications and contraindications for acute pain treatment with IV ketamine, whether these uses 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.

The authors also called for larger studies evaluating different acute pain conditions, with the hope that such studies will 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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