Ketamine Infusions for Outpatient Pain Management
A Policy Development Project
Cheryl A. Allen, BSN, RN-BC | Ruth Conner, PhD, APRN, FNP-BC Julius R. Ivester, Jr, MD
Current literature supports using ketamine for both acute and chronic pain management. It is imperative that the development of evidence-based protocols and policies keep pace with health care delivery to ensure patient safety. This project’s objective was to formulate an outpatient ketamine infusion policy that promotes consistent and evidence-based care within a specified hospital system. This policy addresses potential side effects and minimization of adverse events by addressing patient selection, level of nursing care required, appropriate monitoring, and staff education.
Key words: chronic pain, evidence-based practice, ketamine infusion, pain, quality improvement.
Allowing pain to go untreated or undertreated has negative consequences for both the patient and the health care system, including extended hospital stays and increased hospital admissions that can lead to increased health care costs and decreased patient satisfaction.1-3 Almost 2 decades ago, Cousins et al4 recognized that health care could save between $100,000 and $1 million over the lifetime of 1 patient by preventing acute pain from becoming chronic pain. In a retrospective chart review, Coley et al1 determined that their per patient charge for unanticipated admission or readmission for postsurgical pain management was $1869. In addition, persistent or chronic pain has been estimated to cost the United States between $560 billion and $635 billion a year in treatment and lost productivity.5 Thus, health care research has long established the financial implications of undertreating or improperly treating chronic and acute pain. Recent findings suggest that ketamine hydrochloride (Ketalar; Par Pharmaceutical, Spring Valley, NY) may help prevent acute postsurgical pain from developing into difficult-to-manage chronic pain.6 Because the N-methyl-D- aspartate receptor antagonist ketamine has shown promise in conditions with difficult-to-manage pain, this older medication is now also gaining application for acute postsurgical pain.7,8 Ketamine’s use for analgesia is still considered off-label, although its utility as an analgesic is gaining acceptance. The project site had no outpatient policy on ketamine infusions for its patient population. Patients receiving ketamine infusions in an outpatient pain facility were at risk for receiving non–evidence-based care during those infusions.
Author Affiliations: Medical University of South Carolina, Charleston, South Carolina (Ms Allen, Dr Conner); Roper Hospital Ambulatory Surgery and Pain Management–James Island, Charleston, South Carolina (Ms Allen); Anesthesia Associates of Charleston PA, Charleston, South Carolina (Dr Ivester).
Medication options for chronic pain management differ from those used in acute pain management. Chronic pain conditions typically do not respond well to opioids, giving rise to nontraditional pain medications, such as ketamine, that may prevent and/or reverse central sensitization 6 and are gaining interest. 7 The project site had no policy or guiding documents for addressing patient care with ketamine infusions in the outpatient environment.
Ketamine, a realistic option for pain management, is an attractive alternative to other pain medications, such as opioids. Its attraction stems from its ability to support hemodynamic function while not suppressing respirations. In addition, ketamine has shown promise in subanesthetic intravenous doses for difficult-to-treat pain conditions, is
“safe and effective in reducing acute postoperative pain, and may help reduce opioid consumption.”
Ketamine is a surgical anesthetic that may cause a dissociative state, with an altered perception of the environment and/or hallucinations. Traditionally, because of these potential psychomimetic risks, ketamine infusions were relegated to the intensive care unit. However, Schwartzman et al12 and Patil and Anitescu13 demonstrated the safe use of ketamine infusions in the outpatient environment. Because additional medications, such as propofol, benzodiazepines, and antihypertensives, may be used during subanesthetic infusions for chronic pain management, nursing care during infusion is similar to the care in a level 1 post anesthesia care unit. Because ketamine infusions have been demonstrated to be safe in the outpatient environment, health care facilities need to have a policy in place that guides patient care for this procedure.
Much of the literature on ketamine infusions for pain management does not distinguish inpatient from out- patient use. Common themes in the literature on the use of ketamine have included its potential to cause a dissociative state, including hallucinations and emergent reactions, as well as the potential to minimize these events by using low/subanesthetic dosing and pretreating with a benzodiazepine. Although the use of ketamine infusions for pain management raises concerns for its potential side effects, it is important to remember that most pain medications have side effects that must be taken into consideration. Ketamine’s side effects quickly resolve after the completion or discontinuation of the infusion. Potential side effects that have been reported include headache, sedation, psychomimetic issues, nausea, vomiting, and hypertension.
Schwartzman et al12 used a double-blind, placebo- controlled trial to evaluate outpatient low-dose ketamine infusions for the treatment of complex regional pain syndrome, a chronic pain condition that manifests as pain disproportionate in intensity and lasting longer than expected in consideration to the original injury. Nineteen subjects completed the study—10 in the placebo group and 9 in the ketamine group. The researchers reported that among the 19 participants, 6 complained of headache; of those, 4 were members of the group that received ketamine. The authors further reported that there were no psychomimetic events during the infusions. All participants in the study were pretreated with a benzodiazepine.
Patil and Anitescu’s13 retrospective chart review of 369 outpatient ketamine infusions in 49 patients over a 5-year period was undertaken to discern the efficacy of outpatient ketamine infusions in patients with difficult-to-manage chronic pain. Patients were pretreated with a benzodiazepine and antiemetic before the infusion. The authors noted that 23 (46.9%) patients experienced 35 adverse effects, the most common being hypertension and sedation. A literature review on acute postsurgical pain by Jouguelet- Lacoste et al8 indicated that out of 25 studies reviewed, only 1 study reported significant adverse events, which included excessive postoperative bleeding and an anaphylactic reaction to ketamine itself.
It is possible that the lack of reported significant adverse events in other studies is related to small study sizes, adequate pretreatment for anticipated side effects, proper monitoring, and patient selection.7,12-16 Although standard dosing for ketamine infusions has yet to be established— the literature indicates wide dosing ranges, which are beyond the scope of this paper to address—the likely starting dose will be conservative, then adjusted to the patient’s response. Furthermore, to mitigate ketamine’s more problematic side effects, such as nausea, psychomimetic sensations, and/or hypertension, it is feasible that other medications may be used during ketamine infusions. Side effects can be anticipated and minimized by developing patient selection criteria, providing an appropriate level of nursing care during the infusion, monitoring patients properly, developing infusion treatment protocols, and creating policies for inpatient and outpatient environments. With these elements in place, a standardized level of care in the hospital system could be offered for patients who receive ketamine infusions for pain management.
Rogers’ diffusion of innovation theory, which recognizes the complex nature of change and the importance of commitment for change to be successful, was the framework of the project.17,18 Rogers’ theory is applicable because ketamine historically had negative connotations because of its psychomimetic side effects related to the large doses that typically had been used for anesthesia management. However, the side effects may be minimized in the low doses used for pain management. Because of the previously negative association with ketamine, the project leader decided that an interdisciplinary approach would help ensure that most, if not all, clinical concerns would be addressed, increasing the likelihood that the project would move forward based on clinical team consensus and commitment. Before the project start, knowledge-building interactions were used as a change tool for overcoming possible preconceived attitudes concerning ketamine’s use for analgesic purposes.
The preproject phase for knowledge building and task force development took place from April to August 2016. During the fall of 2016, the official policy task force was created. Four formal meetings of 1 hour each were held. The initial meeting was held during the first week of September 2016. Subsequent meetings were held and sometimes repeated until the final meeting, which occurred in the first week of November 2016. The agenda for the initial meeting included:
The second meeting focused on development of the initial draft document, the third focused on a review of revisions, and the fourth finalized the draft policy. The final version was submitted to the CNO for review and approval. The CNO then submitted it to the Practice Policy Committee (PPC) for consideration. It took approximately 10 weeks for a final draft to be developed, revised, and ready for submission.
Setting, Ethical Considerations, and Budget
The initial reaction of the various health care disciplines that use ketamine in the outpatient environment was one of caution. This hesitation was based on the negative history of the medication as an anesthetic agent. However, by thoughtful application of Rogers’ diffusion of innovation theory and by bringing evidence-based literature to the task force, all parties were soon able to become familiar and comfortable with how the use of this treatment modality in the outpatient environment might benefit a specific patient population. An interdisciplinary approach to clinical policy development allowed each discipline’s concerns to be addressed rapidly, with the primary interest being the safety of patients. The policy was developed based on evidence-based literature, and it addressed the concerns of all task force members regarding patient safety, patient selection, appropriate monitoring during infusion therapy, staff education, and appropriate staffing. The interdisciplinary task force was able to reach consensus quickly on a clinical policy and gain the approval of both the CNO and the PPC.
In today’s world of fast-paced health care change, using an interdisciplinary group for clinical needs allows for most, if not all, clinical concerns to be addressed in a timely manner. When considering patients with chronic pain conditions, treatment in the outpatient environment offers many benefits, including lower treatment costs. In addition, the patient usually sees the same clinical staff. Under these circumstances, a therapeutic relationship may develop that allows a holistic approach to pain care. This project was specific to the health care system in which it took place, and it is recognized that it may not be applicable to other institutions. However, it is hoped that other facilities treating patients with chronic pain conditions will consider researching if and how outpatient ketamine infusions might be provided in their own system.
The authors would like to thank members of the project task force: Carin Hosler, BSN, RN, Roper Hospital pharmacy nurse liaison; John Fowler, PharmD, BCPS, Roper Hospital pharmacy manager; Stacey Daffin, BSN, RN, staff nurse at the project site; Robyn Getsinger, BSN, RN, clinical manager at the project site; Debbie Liafsha, BSN, RN, and Barbara Evans, RT, staff at the project site; and Carolyn Donohue, MSN, RN, NE-BC, chief nursing officer for Roper Hospital and project mentor. They also thank Tom Smith, PhD, and John Dinolfo, PhD, at the Center for Academic Excellence of the Medical University of South Carolina, and Margaret E. Allen, freelance copy editor, for their help in the preparation of this manuscript.