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Ketamine

Ketamine. Facilitator: Barbara Bischoff, BSN, RN. Case Study. A 51 year old woman presents to ED with right shoulder pain 11/25/14 Stage 4 Breast Cancer Carcinoma of breast/Cellulitis History of left side Mastectomy Port to left side of chest wall Pt weight 70 kilograms.

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Ketamine

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  1. Ketamine • Facilitator: Barbara Bischoff, BSN, RN

  2. Case Study • A 51 year old woman presents to ED with right shoulder pain 11/25/14 • Stage 4 Breast Cancer • Carcinoma of breast/Cellulitis • History of left side Mastectomy • Port to left side of chest wall • Pt weight 70 kilograms

  3. Case Study (continued) Initial Medications • Duragesic Patch 100 mcg/hr (Fentynal) 1 patch Q72 hr • Hydrocodone (APAP) 5 mg/325 mg (Norco) 1 tab PO Q6 hr PRN • Morphine Sulfate (MS Contin) 60 mg tab PO Q12 hr • Miralax 17 gm 1 time daily PO • Ondansetron (Zophran) 8 mg tab PO Q6 hr

  4. Case Study (continued) Lab Results on Admission • WBC 7.7 ( 3.9–10.7 x 103 cells/μL) • RBC 3.99 (4.2–5.9 x 106 cells/μL) • H & H 12.2/36.6 (12–16 g/dL/36–47%) • INR 2.6 (2.0–3.0) • Na 139 (136–145 mEq/L) • K 3.9 (3.5–5 mEq/L) • Cl 104 (98–106 mEq/L) • BUN 7 (10-20 mg/dl) • Creatinine 0.5 (0.7–1.3 mg/dL)

  5. Case Study (continued) • Patient on Maria Hall 11/25/15-12/2/15 • Patient placed in Palliative Care • Patient transferred from Maria Hall to ICU @1300 12/2/15 • Continuous monitoring • Pain management with ketamine drip • Ketamine bolus 10 mg with doctor at bedside • Ketamine drip initiated Ketamine 12 mg/Dilaudid 10 mg/hr

  6. Ketamine Pain Management Mechanism of Action Clinical Effects Therapeutic Administration Use as an analgesic in palliative care (FDA, 2014; Micromedex, 2015)

  7. Ketamine • NMDA glutamate receptor antagonist • Binds to opioid mu and sigma receptors • Acts on cerebral cortex and limbic system • Release of endogenous catecholamine • Reduces polysynaptic spinal reflexes • Anesthetic agent used as analgesic to manage complex pain GOPIXPIC. (n.d.). (Micromedex, 2014, NHS, 2013)

  8. NMDA Receptor • N-methyl-D-aspartate receptor • Located in the dorsal horn of the spinal cord • Usually inactive • Activated by development of persistent pain • NMDA receptor antagonists used to block this receptor

  9. Problem Description • Increasing number of opioid tolerant patients. • High Tolerance • Usual multimodal regimen: • Opioids • Non-opioids • NSAIDs • Gabapentanoids • Muscle Relaxers • May not manage pain. (Colfer, Wolo & Viscusi, 2013).

  10. Goals of Acute Pain Management in Opioid Tolerant Patients • Identify at-risk population • Prevent withdrawal symptoms/complications • Effective analgesic treatment in acute pain • Treatment of psychological disorders • Rehabilitation to maintenance therapy (Bourne, 2010)

  11. Opioid-tolerant patients in practice • Three main groups of opioid-tolerant patients : • Patients with cancer pain • Patients with chronic non-cancer pain • Patients with current addiction to opioid drugs • Patients on a maintenance drug program (ANZCA, 2010)

  12. Opioids Alone • Compromise patient safety • Cause side effects • Nausea • Vomiting • Dependence • Respiratory Depression (Colfer, Wolo & Viscusi, 2013)

  13. Chronic Wounds/Chronic Pain • A wound that fails to heal within 3 months. • Social, psychological, physical and economic cost • Consequences: • Severe impairment of quality of life • Restriction of daily activity • Emotional distress • Lengthy treatment • High treatment expense (Frykberg, 2011; Werdin et al., 2009; Ruttermann et al.,2013)

  14. Position Statement Pain Management • American Society for Pain Management Nursing • Nurses must advocate for optimal • Pain management • Symptom relief • A meta-analysis • 52 studies • Spanning 40 years • Found 64% of advanced cancer patients have pain (Reynolds, Drew & Dunwoody, 2013, Colfer, Wolo & Viscusi, 2013)

  15. Policy Statement • Oral or IV Ketamine will be initiated upon order from a physician via CPOE. • First 24 hours or TBD by MD • Administered by nurses in critical care • Follow standing order set (NHS, 2013; Zittel, 2011)

  16. Signs and Symptoms of OpioidWithdrawal (Adapted from Collett, 1998; Bourne, 2010)

  17. Process • Patient specific order • Infusions prepared by pharmacy • Infuse through dedicated line via most proximal port • Use portless IV tubing • No bolus without anesthesia provider (Zittel, 2011; DRE, 2015)

  18. Low-dose Ketamine Defined • Bolus < 2 mg/kg intramuscular administration • Bolus < 1 mg/kg intravenous administration • Continuous IV is < or = 20 microg/kg per min (Schmidt, Sandler & Katz, 1999)

  19. Administration • Initial ketamine concurrent with opioid. • Monitor for sedation or confusion • If drowsy notify MD • Ketamine side effects (patient not drowsy): • Hallucinations or dysphoria • Administer as ordered by MD: • Haloperidol • Midazolam (NHS, 2013)

  20. Administration Process Dosing By Pharmacy • Prepare new syringe every 24 hours. • Dilute ketamine with sodium chloride 0.9%. • Check: Syringe is not cloudy • Protect it from light. • Check: Stability and compatibility. • Rotate SC infusion site daily. (NHS., 2013)

  21. Monitor • Vital signs • Alertness • Orientation • Evidence of: • Nystagmus • Bad dreams • Unpleasant hallucinations. (Zittel, 2011)

  22. Report • Heart rate >100 beats per minute • Systolic B/P <90 mmHg • Respiratory < 10 breaths per minute • Oxygen saturation of <93% • Emergence reaction symptoms: • Bad dream • Hallucinations • Nystagmus (Zittel, 2011)

  23. Onset and Duration • Rapid Onset: • IV within 30 seconds • Half-life: • 10-15 min (Alpha phase) • > 2.5 h (Beta phase) • IM within 3-4 minutes. • Duration: • IV 2 mg/kg lasts 5-10 minutes • IM 9 to 13 mg/kg lasts 12-25 minutes (SEMAC, Micromedex, 2015)

  24. Common Side Effects • Dizziness • Tachycardia • Altered mental status • Anxiety • Palpitations • Slurred speech • Hallucinations • Nystagmus • Mydriasis • Muscular hypertonus • Trismus • Psychomotor reactions • Psychomimetic reactions • Emergence delirium • Hypertension • Chest Pain

  25. Converting from IV to Oral Ketamine • Oral ketamine is more potent than IV ketamine • Dose reduction with change • Prescribed in divided doses - four times daily • Titrated in 5-10 mg incrementsper order • IV infusion may be stopped with the first dose • Or gradually reduced with increase of oral infusion. (NHS., 2013)

  26. Contraindications • Drug allergy • Use of droxidopa • Pregnancy • Breast-feeding • Head trauma or injury • Bleeding in the brain • Stroke • Increased spinal fluid pressure • Increased ocular pressure • Bladder or urinary problems • Congestive heart failure • High blood pressure • Mental or mood problems • Thyroid problems.

  27. Pain Management Resource Sites • American Society of Regional Anesthesia and Pain Management •• http://www.asra.com/ • American Society for Pain Management •• http://www.aspmn.org/ • American Society of Anesthesiologists •• http://www.asahq.org/ • Food and Drug Administration ••http://www.fda.gov/Drugs/ • Anesthesia Patient Safety Foundation •• http://www.apsf.org/ • Institute for Safe Medication Practices•• http://www.ismp.org/ (Colfer, Wolo & Viscusi, 2013).

  28. Thank you for your Time Questions? Comments?

  29. References • ANZCA (Australian and New Zealand College of Anesthetists, Faculty of Pain Medicine). (2010). Acute Pain Management: Scientific Evidence(3rd ed.). Melbourne, Victoria, Australia.ANZCA. • Bourne, N. (2010). Acute pain management in the opioid-tolerant patient. Nursing Standard. 25, 12, 35-39. • Chin, M.L. (2014). Multimodal analgesia: Role of non opioid analgesics. American Society of Regional Anesthesia and Pain. Retrieved from https://www.asra.com/pain-resource/article/35/multimodal-analgesia-role-of-non-opioid-analgesics • Colfer, K., Wolo, E. & Viscusi, E.R. (2013). Acute pain management: Current trends,technologies, and new agents. Journal of Legal Nurse Consulting, 24(1), 11-19. • Collett, B.J. (1998). Opioid tolerance: the clinical perspective. British Journal of Anaesthesia,81(1), 58-68. • Dickenson, A. H. (1997). NMDA receptor antagonists: Interactions with opioids. ActaAnaethesiologicaScandinavica, 41(1), 112-115.

  30. References (Cont) • Drugs.com. (2015). Droxidopa. Retrieved from http://www.drugs.com/mtm/droxidopa.html • FDA (U. S Food and Drug Administration). (2014). "Off-Label" and investigational use Of marketed drugs, biologics, and medical devices - information sheet guidance for institutional review boards and clinical investigators. Retrieved from http://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm • Frykberg, R.G. (2011). The science of advanced wound care: What should you be using in your office? Podiatry Today Supplement: Emerging evidence on advanced wound care for diabetic foot ulcerations. HMP Communications, LLC (HMP), 1-3, 8-15. • GOPIXPIC. (n.d.). Cerebral cortex. Limbic system. Image retrieved from http://www.gopixpic.com/limbic-system-not/ • Loftus, R.W., Yeager, M.P., Clark, J.A., Brown, J.R., Abdu, W.A., Sengupta, D.K. & Beach, M.L. (2010). Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology, 113(3), 639-646. doi: 10.1097/ALN.0b013e3181e90914.

  31. References (Cont) • Medtronic. (2014). Common Types of chronic pain. Retrieved from http://www.medtronicneuro.com.au/chronic_pain_commontypes.html • Micromedex. (2014). Ketamine Hydrochloride. DrugPoint Summery. Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/PFDefaultActionId/evidence • NHS. (2013). Ketamine in palliative care. Lothian. • Reynolds, J., Drew, D. & Dunwoody, C. 2013. American Society for Pain Management Nursing Position Statement: Pain Management at the End of Life. • RuttermannM., Maier-Hasselmann, A., Nink-Grebe, B. & Burckhardt, M. (2013). Clinical practice guideline: Local treatment of chronic wounds in patients with peripheral vascular disease, chronic venous insufficiency, and diabetes. DtschArzteblInt; 110(3): 25–31. DOI: 10.3238/arztebl.2013.0025

  32. References (Cont) • Schmid, R.L., Sandler, A.N. & Katz, J. (1999).Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes. Pain, 82(2), 111-125. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10467917 • SEMAC (State Emergency Medical Advisory Committee). (n.d.). Ketamine. Drug Formulary. Retrieved from https://www.health.ny.gov/professionals/ems/pdf/ketamine_formulary • Sigma-Aldrich. (2015). S-(+)-Ketamine hydrochloride. Picture retrieved from http://www.sigmaaldrich.com/catalog/product/sigma/k1884?lang=en&region=US • Werdin, F., Tennenhaus, M.,  Schaller, H.E. &  Rennekampff, H.O. (2009). Evidence-based Management Strategies for Treatment of Chronic Wounds. Open Access Journal of Plastic Surgery, 9(19), 169-179.

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