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  Table of Contents  
LETTERS TO THE EDITOR
Year : 2019  |  Volume : 56  |  Issue : 2  |  Page : 186
 

Ketamine-an essential component of postoperative pain management following oncosurgeries: TMH experience


Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication2-May-2019

Correspondence Address:
Pritish P Kumbhare
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_320_18

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How to cite this article:
Kumbhare PP, Bakshi SG, Purohit R. Ketamine-an essential component of postoperative pain management following oncosurgeries: TMH experience. Indian J Cancer 2019;56:186

How to cite this URL:
Kumbhare PP, Bakshi SG, Purohit R. Ketamine-an essential component of postoperative pain management following oncosurgeries: TMH experience. Indian J Cancer [serial online] 2019 [cited 2019 Aug 18];56:186. Available from: http://www.indianjcancer.com/text.asp?2019/56/2/186/257550




Postoperative pain management (PPPM) following thoracic oncosurgeries is challenging.[1] There has been a new interest in use of ketamine in the perioperative period. We discuss PPPM of three patients with pain issues following thoracic oncosurgeries.

Case 1: A 45- year-old 52 kg woman, American Society of Anaesthesiologists (ASA) grade I physical status, post Cisplatin, underwent transthoracic esophagectomy (TTE). PPPM included epidural analgesia (EA), with intravenous (IV) fentanyl boluses through a patient controlled analgesia (PCA) pump and 8 hourly injectable diclofenac and paracetamol. EA catheter removed on postoperative day (POD) 6, but patient continued to have moderate–severe pain and needed high doses of IV fentanyl. Injection midazolam 0.5 mg IV followed by ketamine 10 mg in 100 mL normal saline was given over 1 h. Pain scores (PS) substantially reduced to 2/10 (rest) and 4/10 (movement). Ketamine infusion was repeated after 2 days, patient was discharged with oral pregabalin 75 mg and amitriptyline (10 mg) with no pain issues.

Case 2

: PPPM in a 25-year-old man, ASA I, weighing 59 kg following open TTE was initiated using EA and 8 hourly injectable paracetamol and diclofenac. On POD 1, following accidental EA catheter dislodgement, patient was started on fentanyl PCA (IV). Patient complained of moderate pain despite high fentanyl usage (1500 mcg/24 hours). Patient refused EA catheter reinsertion. After consent, ketamine 12 mg was administered IV as slow infusion. PS reduced to mild at movement and the fentanyl usage reduced by 50% (840 mcg/24 hours).

Case 3: A 58-year-old woman weighing 75 kg underwent video-assisted TTE and PPPM included IV fentanyl PCA pump with 8 hourly paracetamol and diclofenac. She had moderate PS at movement with high opioid requirement. Injection ketamine 15 mg slow IV infusion was administered with a 30% reduction in opioid requirement and reduction in PS.

Opioid sparing PPPM lead to reduction in side effects like nausea, vomiting, and enhances early recovery.[2] With evidence suggestive of opioid role in immunosuppression and cancer recurrence, it is essential to adapt opioid sparing PPPM in oncology.[3] Ketamine, a phencyclidine derivative, acts on a variety of receptors, including nicotinic, muscarinic receptors, sodium channels in peripheral and central nervous system, mu, delta, and kappa opioid receptors and voltage sensitive calcium channels. It also acts as a noncompetitive antagonist at the phencyclidine receptor site in the NMDA stands for (N-Methyl-D-aspartate) receptor complex channel thus blocks NMDA receptors and prevents hyperexcitability of dorsal horn neurons, thus pain reduction, when used in subanesthetic doses.[4] Established role of the NMDA receptor in the processing of nociceptive inputs has led to renewed clinical interest in NMDA receptor antagonists such as ketamine. Though ketamine has been reported to be a safe and well-tolerated drug in subanesthetic doses, possible side effects includes diplopia, nystagmus, dizziness and confusion, cardiac arrhythmias, nausea, vomiting and psychomimetic reactions.[5] Several studies have shown the effectiveness of using ketamine in pain management through various routes like IV, IM, local infilteration, in a dose of 0.2–0.5 mg/kg.[5] In our experience, patients with persistent pain postsurgery (case 1), with high opioid requirement (case 2, 3) benefitted following ketamine infusion. In our practice, a dose of 0.2–0.3 mg/kg of ketamine was found to be beneficial when given slow intravenously over an hour. Though the current evidence is lacking in determining the dose and frequency of ketamine administration for its optimal benefit, one must consider the use of ketamine in PPPM especially in patients postthoracic oncosurgeries.

Financial support and sponsorship

Departmental funding only.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery. Anesthesiology 2006;104:594-600.  Back to cited text no. 1
    
2.
Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. JAMA Surg 2017;152:691-7.  Back to cited text no. 2
    
3.
Cata JP, Bugada D, Marchesini M, Gregori MD, Allegri M. Opioids and cancer recurrence: A brief review of the literature. Can Cell Microenviron 2016;3:e1159.  Back to cited text no. 3
    
4.
Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology 2005;102:211-20.  Back to cited text no. 4
    
5.
Radvansky BM, Shah K, Parikh A, Sifonios AN, Le V, Eloy JD. Review Article, role of ketamine in acute postoperative pain management: A narrative review. BioMed Res Int 2015;2015:10. doi: 10.1155/2015/749837.  Back to cited text no. 5
    




 

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