Sample1_PPT.pptx

APSEP

Oluwatobi Hunter, DNP, PMGT-BC, AGACNP-BC January 23, 2024 Inpatient Infusions for Acute Pain

Navigation and coruses requirements Information provided by ILEAD How to Navigate the Course Course Completion and Bookmarking

Estimated Duration: 20 to 30 minutes

Completion Requirements Review each page of the module Pass the posttest with a score of 80% or better

By the end of the module, you will be able to:

Describe the mechanism of action for intravenous ketamine and intravenous lidocaine for acute pain.

Identify appropriate patient selection for intravenous infusions for acute pain.

Discuss the safety and monitoring of patients receiving intravenous infusions for acute pain.

Review opportunities and obstacles to implementing acute pain infusions.

We will review:

Topic One: Ketamine infusions for acute pain.

Topic Two: Lidocaine infusions for acute pain.

Topic Three: Implementing infusions for acute pain at your facility.

TOPIC ONE:

Intravenous Ketamine Infusions for Acute Pain

What is ketamine?

Introduced clinically in 1970 as a dissociative anesthetic

Subanesthetic (low-dose) intravenous ketamine is used for pain relief Mion, G. (2017). Eur. J. Anaesthesiol, 34(9), 571-575.

Gorlin, A. (2016). J. Anaesthesiol. Clin. Pharmacol, 32(2), 160–167.

Vadivelu, N. (2016). J. Anaesthesiol. Clin. Pharmacol, 32(3), 298-306.

Low-dose Ketamine Provides analgesia

Reduces hyperalgesia

Potentiates the analgesic effects of opioids

Opioid-spearing effects

Preserves respiratory function and airway reflexes

Ketamine Mechanism of Action Primary drug effect:

N-methyl-D-aspartate (NMDA) receptor inhibition

Secondary drug effects:

Opioid receptor agonist Anti-inflammatory effects Niesters. (2014). Br J Clin Pharmacol, 77(2), 357-367.

Vadivelu, N. (2016). J Anaesthesiol Clin Pharmacol, 32(3), 298-306.

NMDA Receptor Antagonism Ketamine binds non-competitively to the NMDP receptor

Reduces glutamate release

Blocks calcium influx to inhibit neurotransmission

Adapted from Lisek M. (2020). Int J Mol Sci, 21(21):8410.

Ketamine Pharmacology Niesters. (2014). Br J Clin Pharmacol, 77(2), 357-367.

Vadivelu, N. (2016). J Anaesthesiol Clin Pharmacol, 32(3), 298-306.

Dose-dependent analgesic, amnesic, and anesthetic effects

Highly lipophilic and rapidly crosses the blood-brain barrier

Half-life: 2-3 hours

Hepatically metabolized to active and inactive metabolites

Excreted in urine and stool

Schwenk, E. (2018). Reg Anesth Pain Med, 43(5), 456-466.

Laskowski, K. (2011) Can J Anesth, 58(10), 911-923.

Ketamine Indications

Acute pain associated with moderately to severely painful surgery (e.g., thoracic, major abdominal, or major orthopedic)

Opioid-experienced patients

Patients at risk for opioid-related adverse events (e.g., asthma, sleep apnea, home oxygen, substance misuse)

Non-operative patients with severe acute pain or palliative care refractory to multimodal analgesics

Ketamine Patient Selection Contraindications:

Ketamine hypersensitivity Uncontrolled hypertension Severe hepatic dysfunction Pregnancy Active psychosis Poorly controlled psychiatric disorder

Relative Contraindications:

Catecholamine depletion (e.g., sepsis) Psychiatric disorder with hallucinations or nightmares Elevated intracranial pressure Elevated intraocular pressure Cardiovascular disease for which elevated blood pressure may be dangerous Current or prior ketamine misuse

CRE_Ketamine_Infusion_for_the_Treatment_of_Intractable_Neuropathic_Pain.pdf (va.gov) Gorlin, A. (2016). J. Anaesthesiol. Clin. Pharmacol, 32(2), 160–167.

Niesters, N. (2014). Br. J. Clin. Pharmacol, 77(2), 357-367.

Adverse effects

n=35

Chumbley GM. (2019). Eur J Pain, 23(5):985-993.

Other Adverse Effects Cohen, S. (2018). Reg Anesth Pain Med, 43(5), 521-546.

Niesters, N. (2014). Br. J. Clin. Pharmacol, 77(2), 357-367.

CRE_Ketamine_Infusion_for_the_Treatment_of_Intractable_Neuropathic_Pain.pdf (va.gov)

Psychomimetic effects are dose-dependent Less common with doses under 30mg/hr Treat with alpha-2 agonists or benzodiazepines Excessive salivation Stop ketamine if patient is unable to protect airway Central sympathetic stimulation Hypertension and tachycardia Direct myocardial depression More common at anesthetic doses or catecholamine depletion Cystitis Associated with illicit use or chronic use

Avoid standing titration orders outside of critical care settings

Loading bolus at the start of the infusion must be administered by an anesthesia provider, or someone credentialed with the routine use of ketamine, followed by direct observation for at least 30 minutes

Follow your facility’s controlled substance policy and medication policy Hunter OO. (2023). J Am Assoc Nurse Pract, 35(2):98-103.

VHA Directive 1073 (1) Appendix E “Parameters for the Safe Administration of Ketamine for Non-Sedation Purposes” January 13, 2023

Ketamine Prescribing

Ketamine Dosing Recommendations Must use ideal body weight

Optional loading bolus: 0.2-0.5 mg/kg Not necessary if continuing intraoperative infusion

Initiate at 0.1-0.2 mg/kg/hr IBW

Titrate by 0.1 mg/kg/hr IBW based on analgesia and side effects Hunter OO. (2023). J Am Assoc Nurse Pract, 35(2):98-103.

VHA Directive 1073 (1) Appendix E “Parameters for the Safe Administration of Ketamine for Non-Sedation Purposes” January 13, 2023

Ketamine Dosing Recommendations cont.

Consider intraoperative dosing recommendations for enhanced recovery after surgery (ERAS) protocols

Consider setting a maximum infusion dose on medical-surgical units

Hunter OO. (2023). J Am Assoc Nurse Pract, 35(2):98-103.

VHA Directive 1073 (1) Appendix E “Parameters for the Safe Administration of Ketamine for Non-Sedation Purposes” January 13, 2023

IV Ketamine Sample Order Set Part 1

VA Palo Alto HCS

IV Ketamine Sample Order Set Part 2

VA Palo Alto HCS

Monitoring & Documentation Vital signs, pain score, and sedation scale:

At the start of the infusion At 15 minutes Every 1 hr for the first 4hrs Then if stable every 4hrs until discontinued Telemetry optional if dose < 0.5mg/kg/hr IBW

Frequency of monitoring should be facility-specific Hunter OO. (2023). J Am Assoc Nurse Pract, 35(2):98-103.

VHA Directive 1073 (1) Appendix E “Parameters for the Safe Administration of Ketamine for Non-Sedation Purposes” January 13, 2023

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