386 - Ultra-low dose ketamine is safe and effective at reducing pain intensity and total opioid requirement in pediatric patients

Publication Number: 3373.386

Jennifer Busse, New York Presbyterian Hospital, New York, NY, United States; Daniel S. Tsze, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Justin Genziano, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Thomas G. Bachmann, Children's National Hospital, Washington, DC, United States; Jenna Forrester, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Keely M. Craig, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; William S. Schechter, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States

Background:

Background: Ketamine is increasingly used in pediatrics as an adjuvant for pain control to treat nociceptive and neuropathic pain, decrease opioid requirements, reduce opioid-related adverse effects and mitigate development of opioid tolerance. The reported effective dose range of ketamine in children is 0.05-1 milligrams (mg)/kilogram (kg)/hour (h), with a usual starting dose of 0.1 to 0.3 mg/kg/hr1,2. Our institution utilizes ketamine at doses far below these recommendations, from 0.024 to 0.08 mg/kg/h, with good effect.

Objective:

Objective: We seek to examine use of ultra-low dose (ULD) ketamine as an opioid adjuvant including dose, adverse effects, safety, and effectiveness in reducing pain intensity and total opioid requirement.

Design/Methods: Methods: The study was approved by IRB. This was a retrospective study of 77 pediatric patients who had pain treated with opioids and ketamine from May 2020 to December 2022. We examined via medical record review patient characteristics, ketamine doses, adverse effect profiles, as well as 12 and 24 hour pre- and post- ketamine initiation opioid requirements, pain intensity, and sedation scores.

Results:

Results: 77 pediatric patients received ULD ketamine concurrently with opioids during our study period. The ULD ketamine dose range was between 0.024 and 0.08 mg/kg/h with a mean of 0.04 mg/kg/h (SD 0.01). The total opioid dose after 12 and 24 hours of ketamine was significantly less (P=0.04 and 0.001, respectively) than 12 and 24 hours prior to ketamine initiation. Pain intensity was significantly decreased when assessed 24 hours after ketamine initiation (P < 0.001). There was no difference in sedation scores. Ketamine-related side effects were mild and uncommon. There were no major cardiopulmonary adverse events.

Conclusion(s):

Conclusions: The doses of ketamine we describe, when used as an opioid adjuvant, appear to be safe and effective at reducing pain intensity and total opioid requirements. Adverse effects related to ketamine at these doses were rare and very mild. These data show that even doses of less than half those reported in recent pediatric literature are effective at managing pain with very few side effects.

References:
1. Masaracchia MM, Sites BD, Lee J, Thomas J, Fernandez PG. Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: An observational analysis. Acta Anaesthesiol Scand. 2019;63:1225-1230.
2. Bredlau AL, Thakur R, Korones DN, Dworkin RH. Ketamine for pain in adults and children with cancer: A systematic review and synthesis of the literature. Pain Medicine 2013;14:1505-15-17.

Table 1. Demographic and clinical characteristics of patients receiving ULD ketamine infusion



Table 2. ULD ketamine-related outcomes