Download Thursday 12th November 2009 - South Thames Acute Pain Group

Parallel session C
Ketamine for complex acute surgical patients
Dr Gillian Chumbley, Consultant Nurse – Pain Service, Imperial College
Healthcare NHS Trust.
Biography
Gillian leads a team of nurses who manage both acute and chronic pain. She
has worked in this field for 15 years and completed her PhD, evaluating the
patient’s experience of patient-controlled analgesia (PCA), at St George’s
Hospital Medical School in 2001. Her recent interest has been the use of lowdose ketamine for uncontrolled post-operative pain.
She has chaired the London RCN and Pain Network Forum and she is a member
of the National Consultant Nurses in Pain Management group. She has been a
member of the South Thames Acute Pain Group for 4 years.
Gillian recently assisted the British Pain Society with updating their guidance on
the use of opioids for persistent non-cancer pain and she was an Editorial
Advisor on the Challenge Pain for Nurses Project.
She has applied for a two year clinical lectureship grant, which if successful, will
enable her to research the role of activated NMDA receptors in the development
of chronic post-surgical pain.
Abstract
Ketamine was introduced into clinical practice as a dissociative anaesthetic agent
and analgesic in 1964 and low-dose infusions were used to treat acute pain as
long ago as 1978 [1]. Despite the evidence to show that ketamine can be
effective in the management of acute pain [2,3], its use in subanaesthetic doses
for pain control is far from routine [4].
Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist. The NMDA
receptor is normally dormant during routine physiological pain transmission, but
becomes activated amid intense synaptic transmission [4]. Activated NMDA
receptors are thought to be responsible for the development of central
sensitization [1,5,6]; thus low-dose ketamine appears to be protective in the
development of hyperalgesia and allodynia [1,4,6]. NMDA receptor antagonists
have been shown to have a preventative analgesic effect [7].
This lecture will discuss the introduction of low-dose ketamine for acute pain
relief at Imperial College Healthcare NHS Trust and present audit data. Patient
selection will be discussed, along with the practical implications of administering
ketamine on busy hospital wards.
1. Schug SA. New Uses for an Old Drug: The Role of Ketamine in postoperative pain treatment. ASEAN Journal of Anaesthesiology 2004; 5: 39-42.
2. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Systematic Review 2006; 1: CD004603.
3. Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as Adjuvant
Analgesic to Opioids: A Quantitative and Qualitative Systematic Review.
Anesthesia and Analgesia 2004; 99: 482-495.
4. Hocking G, Visser EJ, Schug SA, Cousins MJ. Ketamine: Does Life Begin at
40? Pain: Clinical Updates 2007; XV(3): 1-6.
5. Petrenko AB, Yamakura T, Baba H, Shimoji K. The Role of N-Methyl-DAspartate (NMDA) Receptors in Pain: A Review. Anesthesia and Analgesia
2003; 97: 1108-1116.
6. Schmid RL, Sandler AN, Katz J. Use and efficacy of low-dose ketamine in the
management of acute postoperative pain: a review of current techniques and
outcomes. Pain 1999; 82: 111-125.
7. McCartney CJL, Sinha A, Katz J. A Qualitative Systematic Review of the
Role of N-Methyl-D-Aspartate Receptor Antagonists in Preventive Analgesia.
Anesthesia and Analgesia 2004; 98: 1385-1400.