Effects of Low-Dose IV Ketamine on Peripheral and Central Pain from Major Limb Injuries Sustained in Combat

Authors

  • Rosemary C. Polomano PhD, RN, FAAN,

    Corresponding author
    1. Department of Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
    • Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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  • Chester C. Buckenmaier III MD,

    1. Defense and Veterans Center for Integrative Pain Management, Rockville, Maryland
    2. Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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  • Kyung H. Kwon MSN, CRNP,

    1. Defense and Veterans Center for Integrative Pain Management, Rockville, Maryland
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  • Alexandra L. Hanlon PhD,

    1. University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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  • Christine Rupprecht MSN, RN,

    1. Inova Mount Vernon Hospital Pain Service, Alexandria, Virginia, USA
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  • Cynthia Goldberg MSN, RN-BC,

    1. Orthopedic Trauma & Physical Medicine and Rehab, Walter Reed National Military Medical Center, Bethesda, Maryland
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  • Rollin M. Gallagher MD, MPH

    1. Department of Psychiatry and Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
    2. Pain Management, Veterans Health System, Philadelphia, Pennsylvania
    3. Pain Policy Research and Primary Care, Penn Pain Medicine, Philadelphia, Pennsylvania
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  • Conflict of Interest/Disclosure: There are no perceived conflicts of interests by any authors related to the conduct of this research.
  • Funding: This work was supported by institutional funding and the Defense and Veterans Center for Integrative Pain Management.
  • Copyright Protection: Our team is comprised partly of military service members and employees of the US Government. This work was prepared as part of our official duties. Title 17 United States Code (USC) 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 USC 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person's official duties.
  • Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy of the Department of the Army, the Department of Defense, or the United States Government.

Reprint requests to: Rosemary C. Polomano, PhD, RN, FAAN, University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences, 418 Curie Blvd. RM 324, Philadelphia, PA 1904, USA. Tel: 215-898-0934; Fax: 215-573-7507; E-mail: polomanr@nursing.upenn.edu.

Abstract

Objective.

Examine response patterns to low-dose intravenous (IV) ketamine continuous infusions on multiple pain outcomes, and demonstrate effectiveness, safety, and tolerability of ketamine administration on general wards.

Design.

Retrospective case series of consecutive patients given low-dose IV ketamine continuous infusions.

Setting.

Walter Reed Army Medical Center, Washington, DC.

Patients.

Nineteen eligible inpatients with neuropathic pain from major limb injuries sustained in combat with inadequate pain control from multimodal analgesia.

Interventions.

A 3-day IV infusion of ketamine at doses ≤120 μg/kg/h.

Outcome Measures.

Daily present (PPI), average (API), and worst (WPI) pain intensity (0–10), global pain relief (GPR) (1 “no relief” to 5 “complete relief”), daily assessments of adverse events, and daily opioid requirements measured during therapy.

Results.

A significant reduction in PPI (P < 0.001) and improvement in GPR (P = 0.031) was noted over time. Higher baseline WPI (≥7; N = 14) was associated with a significant decrease in WPI (P = 0.0388), but lower baseline WPI (N = 5) was not. Significant mean percent decreases in PPI with higher baseline PPI (N = 8; P = 0.0078) and WPI with no phantom limb pain (PLP) (N = 10; P = 0.0436) were observed. Mean percent increase in overall GPR was better for those reporting GPR scores ≤3 (N = 13) in the first 24 hours of therapy (P = 0.0153). While not significant, mean opioid requirement (IV morphine equivalents) decreased from 129.9 mgs ± 137.3 on day 1 to 112.14 ± 86.3 24 hours after therapy.

Conclusions.

Low-dose ketamine infusions for complex combat injury pain were safe and effective, and demonstrated response patterns over time and by baseline pain score stratification and presence or absence of PLP.

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