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Song B, Zhu JC. Mechanisms of the Rapid Effects of Ketamine on Depression and Sleep Disturbances: A Narrative Review. Front Pharmacol 2022; 12:782457. [PMID: 34970147 PMCID: PMC8712478 DOI: 10.3389/fphar.2021.782457] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/22/2021] [Indexed: 12/24/2022] Open
Abstract
Recently, sleep has been recognized as a crucial factor for health and longevity. The daily sleep/wake cycle provides the basis of biorhythm, which controls whole-body homeostasis and homeodynamics. Sleep disturbances can contribute to several physical and psychological disorders, including cardiovascular disease, obesity, depression, and cognitive dysfunction. The clinical use of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine began in the 1970s. Over the years, physicians have used it as a short-acting anesthetic, analgesic, and antidepressant; however, in-depth research has revealed new possible applications for ketamine, such as for treating sleep disturbances and circadian rhythm disorders. The aim of this narrative review is to examine the literature on the mechanistic role of the antidepressant ketamine in affecting sleep disturbance. Additionally, we discuss the pharmacologic and pharmacokinetic mechanisms of ketamine as an antidepressant and the predictive biomarkers for ketamine’s effect on sleep and cognitive function.
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Affiliation(s)
- Bijia Song
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun-Chao Zhu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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2
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Chitneni A, Patil A, Dalal S, Ghorayeb JH, Pham YN, Grigoropoulos G. Use of Ketamine Infusions for Treatment of Complex Regional Pain Syndrome: A Systematic Review. Cureus 2021; 13:e18910. [PMID: 34820225 PMCID: PMC8601938 DOI: 10.7759/cureus.18910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/06/2022] Open
Abstract
This systematic review aims to review clinical studies on the use of ketamine infusion for patients with treatment-resistant complex regional pain syndrome (CRPS). The following systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021228470). Studies for the systematic review were identified through three databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Reviews. Inclusion criteria for studies consisted of randomized clinical trials or cohort studies that conducted trials on the use of ketamine infusion for pain relief in patients with CRPS. Exclusion criteria for studies included any studies that were systematic reviews, meta-analyses, case reports, literature reviews, or animal studies. In the included studies, the primary outcome of interest was the post-drug administration pain score. In this systematic review, 14 studies met the inclusion criteria and were reviewed. In these studies, the dosage of ketamine infusion used ranged from 0.15 mg/kg to 7 mg/kg with the primary indication being the treatment of CRPS. In 13 of the studies, ketamine infusion resulted in a decrease in pain scores and relief of symptoms. Patients who received ketamine infusion for treatment-resistant CRPS self-reported adequate pain relief with treatment. This suggests that ketamine infusion may be a useful form of treatment for patients with no significant pain relief with other conservative measures. Future large-scale studies, including randomized double-blind placebo-controlled trials on the use of ketamine infusion for CRPS, must be conducted in a large-scale population to further assess the effectiveness of ketamine infusion in these populations.
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Affiliation(s)
- Ahish Chitneni
- Family Medicine, Peconic Bay Medical Center/Northwell Health, Riverhead, USA.,Physical Medicine & Rehabilitation, New York-Presbyterian Hospital, New York City, USA
| | - Anand Patil
- Internal Medicine, Touro University California, Vallejo, USA
| | - Suhani Dalal
- Internal Medicine, Loma Linda University Medical Center, Loma Linda, USA
| | - Joe H Ghorayeb
- Physical Medicine & Rehabilitation, University of Medicine and Health Sciences, New York City, USA
| | - Yolanda N Pham
- Internal Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Gregory Grigoropoulos
- Internal Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, USA
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3
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Boyd NL, Navathe PD. An Update to Aircrew Grounding Periods After Ketamine Use. Aerosp Med Hum Perform 2021; 92:670-675. [PMID: 34503619 DOI: 10.3357/amhp.5764.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION: Ketamine is a rapidly acting general anesthetic which is globally used in surgical analgesia, as well as in the management of pain. It is also used as a recreational drug. Because of its widespread use in surgical settings, the use of this drug presents an aeromedical problemin addition, of course, to the underlying condition for which it has been used. The literature around the mechanisms and side effects of ketamine is reasonably mature, and it is possible to make fairly dependable risk management decisions about return to flying based on the information available. Accordingly, following ketamine use it is recommended that aviators be grounded for 48 h following Aviation Medical Examiner review. If review is unavailable, the aviator should be grounded for 1 wk to allow sufficient time to identify the existence of prolonged side effects, such as psychomimetic effects or cognitive changes.Boyd NL, Navathe PD. An update to aircrew grounding periods after ketamine use. Aerosp Med Hum Perform. 2021; 92(8):670-675.
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Schwenk ES, Pradhan B, Nalamasu R, Stolle L, Wainer IW, Cirullo M, Olsen A, Pergolizzi JV, Torjman MC, Viscusi ER. Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity. Curr Pain Headache Rep 2021; 25:57. [PMID: 34269883 DOI: 10.1007/s11916-021-00977-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. RECENT FINDINGS Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.
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Affiliation(s)
- Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA.
| | - Basant Pradhan
- Psychiatry & Pediatrics, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Michael Cirullo
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Olsen
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | | | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
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5
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Xu J, Herndon C, Anderson S, Getson P, Foorsov V, Harbut RE, Moskovitz P, Harden RN. Intravenous Ketamine Infusion for Complex Regional Pain Syndrome: Survey, Consensus, and a Reference Protocol. PAIN MEDICINE 2020. [PMID: 29534218 DOI: 10.1093/pm/pny024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To find and reach a consensus on the usage of ketamine in the treatment of complex regional pain syndrome and to determine a reference protocol for future studies. DESIGN Three hundred fifty-one medical professionals participated in our survey on practice procedures, with 104 respondents providing information on their usage of ketamine for treating the pain associated with complex regional pain syndrome. Respondents answered questions about inpatient treatment, outpatient treatment, children vs adults, safety, and basic demographic information. An expert group then met to reach a consensus for a reference protocol. RESULTS There is a difference in how inpatients are treated compared with outpatients, making it necessary to have two different reference protocols. The duration of pain relief varied from one to 10 days to one to six months, with a correlation between the duration of pain relief and total infusion hours per round. CONCLUSIONS The consensus reference protocols are made up of nine recommended topics. Reference protocols need to be validated by extensive research before guidelines can be created.
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Affiliation(s)
- Jijun Xu
- Department of Pain Management, Anesthesiology Institute.,Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Herndon
- School of Pharmacy, Southern Illinois University Edwardsville.,School of Medicine, St. Louis University, St. Louis, Missouri
| | - Samantha Anderson
- Department of Orthopaedic Surgery and Neurological Surgery, George Washington University. Washington, DC; Reflex Sympathetic Dystrophy Syndrome Association, Milford, Connecticut
| | - Philip Getson
- Department of Neurology, Drexel University, Philadelphia, Pennsylvania; **Infusion Centers of America, Little Rock, Arkansas
| | - Victor Foorsov
- Department of Pain Management, Anesthesiology Institute.,George Washington University, Washington, DC
| | | | - Peter Moskovitz
- Department of Orthopaedic Surgery and Neurological Surgery, George Washington University. Washington, DC; Reflex Sympathetic Dystrophy Syndrome Association, Milford, Connecticut
| | - R Norm Harden
- Departments of ††Physical Medicine and Rehabilitation.,Physical Therapy and Movement Sciences, Northwestern University, Chicago, Illinois, USA
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6
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Fischer M, Abd-Elsayed A. Ketamine Infusion Therapy. INFUSION THERAPY 2019:17-26. [DOI: 10.1007/978-3-030-17478-1_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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7
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Pickering G, Morel V, Micallef J. Kétamine et douleur chronique : une revue narrative de son efficacité et sécurité. Therapie 2018; 73:529-539. [DOI: 10.1016/j.therap.2018.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/27/2018] [Accepted: 06/12/2018] [Indexed: 01/19/2023]
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8
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Eldufani J, Nekoui A, Blaise G. Nonanesthetic Effects of Ketamine: A Review Article. Am J Med 2018; 131:1418-1424. [PMID: 29753795 DOI: 10.1016/j.amjmed.2018.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 04/11/2018] [Accepted: 04/11/2018] [Indexed: 12/13/2022]
Abstract
Ketamine is considered a dissociative anesthetic medication, and it is commonly administered by a parenteral route. It works mainly by blocking the N-methyl-D-aspartate receptor. It inhibits the voltage-gated Na and K channels and serotonin and dopamine reuptake; also, it affects specific receptors, such as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, kainate, and aminobutyric acid A receptors. Ketamine appears to have particular mechanisms that are potentially involved during analgesic induction, including enhancing of descending inhibition and antiinflammatory effects. More recently, it has been shown that ketamine has potential in clinical practice for the management of chronic pain, cognitive function, depression, acute brain injury, and disorders of the immune system.
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Affiliation(s)
- Jabril Eldufani
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.
| | - Alireza Nekoui
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Gilbert Blaise
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada; Department of Anesthesiology and Pain Management, Centre Hospitalier de l'université de Montréal (CHUM), Montreal, Quebec, Canada
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Greenwald JD, Shafritz KM. An Integrative Neuroscience Framework for the Treatment of Chronic Pain: From Cellular Alterations to Behavior. Front Integr Neurosci 2018; 12:18. [PMID: 29875641 PMCID: PMC5974053 DOI: 10.3389/fnint.2018.00018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/04/2018] [Indexed: 12/21/2022] Open
Abstract
Chronic pain can result from many pain syndromes including complex regional pain syndrome (CRPS), phantom limb pain and chronic low back pain, among others. On a molecular level, chronic pain syndromes arise from hypersensitization within the dorsal horn of the spinal cord, a process known as central sensitization. Central sensitization involves an upregulation of ionotropic and metabotropic glutamate receptors (mGluRs) similar to that of long-term potentiation (LTP). Regions of the brain in which LTP occurs, such as the amygdala and hippocampus, are implicated in fear- and memory-related brain circuity. Chronic pain dramatically influences patient quality of life. Individuals with chronic pain may develop pain-related anxiety and pain-related fear. The syndrome also alters functional connectivity in the default-mode network (DMN) and salience network. On a cellular/molecular level, central sensitization may be reversed through degradative glutamate receptor pathways. This, however, rarely happens. Instead, cortical brain regions may serve in a top-down regulatory capacity for the maintenance or alleviation of pain. Specifically, the medial prefrontal cortex (mPFC), which plays a critical role in fear-related brain circuits, the DMN, and salience network may be the driving forces in this process. On a cellular level, the mPFC may form new neural circuits through LTP that may cause extinction of pre-existing pain pathways found within fear-related brain circuits, the DMN, and salience network. In order to promote new LTP connections between the mPFC and other key brain structures, such as the amygdala and insula, we propose a holistic rehabilitation program including cognitive behavioral therapy (CBT) and revolving around: (1) cognitive reappraisals; (2) mindfulness meditation; and (3) functional rehabilitation. Unlike current medical interventions focusing upon pain-relieving medications, we do not believe that chronic pain treatment should focus on reversing the effects of central sensitization. Instead, we propose here that it is critical to focus on non-invasive efforts to promote new neural circuits originating from the mPFC.
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Affiliation(s)
- Jess D. Greenwald
- Department of Psychology, Hofstra University, Hempstead, NY, United States
| | - Keith M. Shafritz
- Department of Psychology, Hofstra University, Hempstead, NY, United States
- Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, United States
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10
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Zhang Y, Sha R, Wang K, Li H, Yan B, Zhou N. Protective effects of tetrahydropalmatine against ketamine-induced learning and memory injury via antioxidative, anti-inflammatory and anti-apoptotic mechanisms in mice. Mol Med Rep 2018; 17:6873-6880. [PMID: 29512789 DOI: 10.3892/mmr.2018.8700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/31/2017] [Indexed: 11/06/2022] Open
Abstract
Tetrahydropalmatine exerts numerous pharmacological activities, including analgesic and narcotic effects; anti-arrhythmic, blood pressure lowering and cardioprotective effects; protective effects against cerebral ischemia-reperfusion injury; inhibition of platelet aggregation; prevention of ulcerative diseases and inhibition of gastric acid secretion; antitumor effects; and beneficial effects on the withdrawal symptoms associated with drug addiction. The present study aimed to investigate the protective effects of tetrahydropalmatine against ketamine‑induced learning and memory impairment in mice. The Morris water maze test and open field test were used to analyzed learning and memory impairment in mice. ELISA kits and western blotting were used to analyze oxidative stress, inflammation factors, caspease‑3 and caspase‑9, iNOS, glial fibrillary acidic protein (GFAP), glial cell‑derived neurotrophic factor (GDNF), cytochrome c and phospholipase C (PLC)‑γ1 protein expression. The results demonstrated that tetrahydropalmatine treatment significantly decreased escape latency in the learning phase and increased the number of platform site crossings in ketamine‑induced mice. In addition, tetrahydropalmatine significantly inhibited oxidative stress, inflammation and acetylcholinesterase activity, and decreased acetylcholine levels in ketamine‑induced mice. Tetrahydropalmatine also suppressed iNOS protein expression, weakened caspase‑3 and caspase‑9 activation, inhibited nuclear factor‑κB, glial fibrillary acidic protein, cytochrome c and phospholipase C‑γ1 protein expression, and induced glial cell‑derived neurotrophic factor protein expression in ketamine‑induced mice. Taken together, these results indicated that tetrahydropalmatine may protect against ketamine‑induced learning and memory impairment in mice via antioxidative, anti‑inflammatory and anti‑apoptotic mechanisms. The present study provided an experimental basis for the clinical application of tetrahydropalmatine to reduce the severe side effects associated with ketamine therapy in future studies.
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Affiliation(s)
- Yonglai Zhang
- Department of Anesthesiology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Rui Sha
- Department of Anesthesiology, Oncology Ward, Chinese Medicine Hospital in Shandong Province, Jinan, Shandong 250117, P.R. China
| | - Kaiguo Wang
- Department of Anesthesiology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Hao Li
- Department of Anesthesiology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Bo Yan
- Department of Anesthesiology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Naibao Zhou
- Department of Anesthesiology, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
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Zhao J, Wang Y, Wang D. The Effect of Ketamine Infusion in the Treatment of Complex Regional Pain Syndrome: a Systemic Review and Meta-analysis. Curr Pain Headache Rep 2018; 22:12. [PMID: 29404715 DOI: 10.1007/s11916-018-0664-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Complex regional pain syndrome (CRPS) is a painful debilitating neurological condition that accounts for approximately 1.2% of adult chronic pain population. Ketamine, an NMDA receptor antagonist, is an anesthetic agent that has been used by some pain specialists for CRPS. There is a growing body of clinical evidence to support the use of ketamine in the treatment of neuropathic pain, especially CRPS. This meta-analysis study was aimed to examine the efficacy of ketamine in the treatment of CRPS. RECENT FINDINGS A search of Embase, Pubmed, Web of Knowledge, Cochrane, Clinical Trial.gov , and FDA.gov between Jan 1, 1950, and August 1, 2017, was conducted to evaluate ketamine infusion therapy in the treatment of CRPS. We selected randomized clinical trials or cohort studies for meta-analyses. I 2 index estimates were calculated to test for variability and heterogeneity across the included studies. The primary outcome is pain relief. The effect of ketamine treatment for complex regional pain syndrome was assessed by 0-10 scale numerical rating pain score. The secondary outcome is the pain relief event rate, which is defined as the percentage of participants who achieved 30% or higher pain relief in each of the qualified studies. Our meta-analysis results showed that the Ketamine treatment led to a decreased mean of pain score in comparison to the self-controlled baseline (p < 0.000001). However, there is a statistical significance of between-study heterogeneity. The immediate pain relief event rate was 69% (95% confidence interval (CI) 53%, 84%). The pain relief event rate at the 1-3 months follow-ups was 58% (95% CI 41%, 75%). The current available studies regarding ketamine infusion for CRPS were reviewed, and meta-analyses were conducted to evaluate the efficacy of ketamine infusion in the treatment of CRPS. Our findings suggested that ketamine infusion can provide clinically effective pain relief in short term for less than 3 months. However, because of the high heterogeneity of the included studies and publication bias, additional random controlled trials and standardized multicenter studies are needed to confirm this conclusion. Furthermore, studies are needed to prove long-term efficacy of ketamine infusion in the treatment of CRPS.
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Affiliation(s)
- Jianli Zhao
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
- Department of Anesthesiology, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yajing Wang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Dajie Wang
- Jefferson Pain Center, Department of Anesthesiology, Thomas Jefferson University, Philadelphia, USA.
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12
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Side-effects associated with ketamine use in depression: a systematic review. Lancet Psychiatry 2018; 5:65-78. [PMID: 28757132 DOI: 10.1016/s2215-0366(17)30272-9] [Citation(s) in RCA: 307] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 12/31/2022]
Abstract
This is the first systematic review of the safety of ketamine in the treatment of depression after single and repeated doses. We searched MEDLINE, PubMed, PsycINFO, and Cochrane Databases and identified 288 articles, 60 of which met the inclusion criteria. After acute dosing, psychiatric, psychotomimetic, cardiovascular, neurological, and other side-effects were more frequently reported after ketamine treatment than after placebo in patients with depresssion. Our findings suggest a selective reporting bias with limited assessment of long-term use and safety and after repeated dosing, despite these being reported in other patient groups exposed to ketamine (eg, those with chronic pain) and in recreational users. We recommend large-scale clinical trials that include multiple doses of ketamine and long-term follow up to assess the safety of long-term regular use.
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13
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Pasek TA, Crowley K, Campese C, Lauer R, Yang C. Case Study of High-Dose Ketamine for Treatment of Complex Regional Pain Syndrome in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2017; 29:177-186. [PMID: 28460699 DOI: 10.1016/j.cnc.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Complex regional pain syndrome (CRPS) is a life-altering and debilitating chronic pain condition. The authors are presenting a case study of a female who received high-dose ketamine for the management of her CRPS. The innovative treatment lies not only within the pharmacologic management of her pain, but also in the fact that she was the first patient to be admitted to our pediatric intensive care unit solely for pain control. The primary component of the pharmacotherapy treatment strategy plan was escalating-dose ketamine infusion via patient-controlled-analgesia approved by the pharmacy and therapeutics committee guided therapy for this patient. The expertise of advanced practice nurses blended exquisitely to ensure patient and family-centered care and the coordination of care across the illness trajectory. The patient experienced positive outcomes.
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Affiliation(s)
- Tracy Ann Pasek
- Pain, Pediatric Intensive Care Unit, Evidence-Based Practice and Research, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Kelli Crowley
- Department of Pharmacy, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catherine Campese
- Department of Anesthesiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rachel Lauer
- Department of Anesthesiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Charles Yang
- Department of Anesthesiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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14
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Maher DP, Chen L, Mao J. Intravenous Ketamine Infusions for Neuropathic Pain Management. Anesth Analg 2017; 124:661-674. [DOI: 10.1213/ane.0000000000001787] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Kim M, Cho S, Lee JH. The Effects of Long-Term Ketamine Treatment on Cognitive Function in Complex Regional Pain Syndrome: A Preliminary Study. PAIN MEDICINE 2016; 17:1447-51. [PMID: 26921891 DOI: 10.1093/pm/pnv112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This preliminary study aimed to investigate the effects of long-term frequent ketamine treatment on cognitive function in [AQ-A] CRPS patients. DESIGN A total of 30 CRPS patients were divided into two groups based on both the duration and frequency of ketamine treatment; the long-term frequent ketamine treatment (LF) group (N = 14) and the Non-LF group (N = 16). Participants were asked to complete a questionnaire packet including demographic and clinical characteristics and potential variables affecting cognitive function. Then, they performed the neuropsychological test. RESULTS Results indicated that the LF group performed significantly poorer than the Non-LF group on the digit span, digit symbol, Controlled Oral Word Association Test, and Trail Making Test, but not the Stroop task. CONCLUSIONS Patients with CRPS receiving long-term frequent ketamine treatment showed impairment in cognitive function (specifically executive function) compared with those who do not. These findings may have implications for clinical assessment and rehabilitation of cognitive function in CRPS patients.
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Affiliation(s)
- Minseung Kim
- *Department of Psychology, Chung-Ang University, Seoul, Korea
| | - Sungkun Cho
- Department of Psychology, Chungnam National University, Daejeon, Korea
| | - Jang-Han Lee
- Department of Psychology, Chungnam National University, Daejeon, Korea
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Abstract
Despite the severe pain and disability associated with complex regional pain syndrome (CRPS), the lack of understanding of the pathophysiological mechanisms supporting this enigmatic condition prevents the rational design of new therapies, a situation that is frustrating to both the physician and the patient. The review highlights some of the mechanisms thought to be involved in the pathophysiology of CRPS in preclinical models and CRPS patients, with the ultimate goal that understanding these mechanisms will lead to the design of efficacious, mechanism-based treatments available to the clinic.
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Affiliation(s)
- Maral Tajerian
- Veterans Affairs Palo Alto Health Care System Palo Alto, CA, USA,Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - J David Clark
- Veterans Affairs Palo Alto Health Care System Palo Alto, CA, USA,Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author: J David Clark, MD, PhD., Anesthesia Service, Veterans Affairs Palo Alto Health Care, System, 3801 Miranda Ave., Palo Alto, CA 94304, USA, Tel: 650-493-5000 ext. 60479, Fax: 650-852-3423,
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17
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Douglas SR, Shenoda BB, Qureshi RA, Sacan A, Alexander GM, Perreault M, Barrett JE, Aradillas-Lopez E, Schwartzman RJ, Ajit SK. Analgesic Response to Intravenous Ketamine Is Linked to a Circulating microRNA Signature in Female Patients With Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2015; 16:814-24. [PMID: 26072390 DOI: 10.1016/j.jpain.2015.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/04/2015] [Accepted: 05/28/2015] [Indexed: 11/15/2022]
Abstract
Although ketamine is beneficial in treating complex regional pain syndrome (CRPS), a subset of patients respond poorly to therapy. We investigated treatment-induced microRNA (miRNA) changes and their predictive validity in determining treatment outcome by assessing miRNA changes in whole blood from patients with CRPS. Blood samples from female patients were collected before and after 5 days of intravenous ketamine administration. Seven patients were responders and 6 were poor responders. Differential miRNA expression was observed in whole blood before and after treatment. In addition, 33 miRNAs differed between responders and poor responders before therapy, suggesting the predictive utility of miRNAs as biomarkers. Investigation of the mechanistic significance of hsa-miR-548d-5p downregulation in poor responders showed that this miRNA can downregulate UDP-glucuronosyltransferase UGT1A1 mRNA. Poor responders had a higher conjugated/unconjugated bilirubin ratio, indicating increased UGT1A1 activity. We propose that lower pretreatment levels of miR-548d-5p may result in higher UDP-GT activity, leading to higher levels of inactive glucuronide conjugates, thereby minimizing the therapeutic efficacy of ketamine in poor responders. Differences in miRNA signatures can provide molecular insights distinguishing responders from poor responders. Extending this approach to other treatment and outcome assessments might permit stratification of patients for maximal therapeutic outcome. Perspective: This study suggests the usefulness of circulating miRNAs as potential biomarkers. Assessing miRNA signatures before and after treatment demonstrated miRNA alterations from therapy; differences in miRNA signature in responders and poor responders before therapy indicate prognostic value. Mechanistic studies on altered miRNAs can provide new insights into disease.
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Affiliation(s)
- Sabrina R Douglas
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Botros B Shenoda
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Rehman A Qureshi
- School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Ahmet Sacan
- School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Guillermo M Alexander
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Marielle Perreault
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - James E Barrett
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Robert J Schwartzman
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Seena K Ajit
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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Connolly SB, Prager JP, Harden RN. A Systematic Review of Ketamine for Complex Regional Pain Syndrome. PAIN MEDICINE 2015; 16:943-69. [DOI: 10.1111/pme.12675] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Brain neuroplastic changes accompany anxiety and memory deficits in a model of complex regional pain syndrome. Anesthesiology 2014; 121:852-65. [PMID: 25093591 DOI: 10.1097/aln.0000000000000403] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful condition with approximately 50,000 annual new cases in the United States. It is a major cause of work-related disability, chronic pain after limb fractures, and persistent pain after extremity surgery. Additionally, CRPS patients often experience cognitive changes, anxiety, and depression. The supraspinal mechanisms linked to these CRPS-related comorbidities remain poorly understood. METHODS The authors used a previously characterized mouse model of tibia fracture/cast immobilization showing the principal stigmata of CRPS (n = 8 to 20 per group) observed in humans. The central hypothesis was that fracture/cast mice manifest changes in measures of thigmotaxis (indicative of anxiety) and working memory reflected in neuroplastic changes in amygdala, perirhinal cortex, and hippocampus. RESULTS The authors demonstrate that nociceptive sensitization in these mice is accompanied by altered thigmotactic behaviors in the zero maze but not open field assay, and working memory dysfunction in novel object recognition and social memory but not in novel location recognition. Furthermore, the authors found evidence of structural changes and synaptic plasticity including changes in dendritic architecture and decreased levels of synaptophysin and brain-derived neurotrophic factor in specific brain regions. CONCLUSIONS The study findings provide novel observations regarding behavioral changes and brain plasticity in a mouse model of CRPS. In addition to elucidating some of the supraspinal correlates of the syndrome, this work supports the potential use of therapeutic interventions that not only directly target sensory input and other peripheral mechanisms, but also attempt to ameliorate the broader pain experience by modifying its associated cognitive and emotional comorbidities.
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Niesters M, Martini C, Dahan A. Ketamine for chronic pain: risks and benefits. Br J Clin Pharmacol 2014; 77:357-67. [PMID: 23432384 DOI: 10.1111/bcp.12094] [Citation(s) in RCA: 274] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022] Open
Abstract
The anaesthetic ketamine is used to treat various chronic pain syndromes, especially those that have a neuropathic component. Low dose ketamine produces strong analgesia in neuropathic pain states, presumably by inhibition of the N-methyl-D-aspartate receptor although other mechanisms are possibly involved, including enhancement of descending inhibition and anti-inflammatory effects at central sites. Current data on short term infusions indicate that ketamine produces potent analgesia during administration only, while three studies on the effect of prolonged infusion (4-14 days) show long-term analgesic effects up to 3 months following infusion. The side effects of ketamine noted in clinical studies include psychedelic symptoms (hallucinations, memory defects, panic attacks), nausea/vomiting, somnolence, cardiovascular stimulation and, in a minority of patients, hepatoxicity. The recreational use of ketamine is increasing and comes with a variety of additional risks ranging from bladder and renal complications to persistent psychotypical behaviour and memory defects. Blind extrapolation of these risks to clinical patients is difficult because of the variable, high and recurrent exposure to the drug in ketamine abusers and the high frequency of abuse of other illicit substances in this population. In clinical settings, ketamine is well tolerated, especially when benzodiazepines are used to tame the psychotropic side effects. Irrespective, close monitoring of patients receiving ketamine is mandatory, particularly aimed at CNS, haemodynamic, renal and hepatic symptoms as well as abuse. Further research is required to assess whether the benefits outweigh the risks and costs. Until definite proof is obtained ketamine administration should be restricted to patients with therapy-resistant severe neuropathic pain.
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Affiliation(s)
- Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, the Netherlands
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Pickering AE, McCabe CS. Prolonged ketamine infusion as a therapy for complex regional pain syndrome: synergism with antagonism? Br J Clin Pharmacol 2014; 77:233-8. [PMID: 23701138 PMCID: PMC3992840 DOI: 10.1111/bcp.12157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/28/2013] [Indexed: 12/18/2022] Open
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Libon DJ, Alexander G, Schwartzman RJ. Neuropsychology and complex regional pain syndrome. Pain 2012; 153:1128. [DOI: 10.1016/j.pain.2012.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 11/02/2011] [Accepted: 01/31/2012] [Indexed: 11/26/2022]
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Azari P, Lindsay DR, Briones D, Clarke C, Buchheit T, Pyati S. Efficacy and safety of ketamine in patients with complex regional pain syndrome: a systematic review. CNS Drugs 2012; 26:215-28. [PMID: 22136149 DOI: 10.2165/11595200-000000000-00000] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite being a recognized clinical entity for over 140 years, complex regional pain syndrome (CRPS) remains a difficult-to-treat condition. While there have been multiple therapies explored in the treatment of CRPS, NMDA antagonists such as ketamine continue to hold significant interest because of their potential ability to alter the central sensitization noted in chronic pain states. The objective of this review is to identify published literature for evidence of the efficacy and safety of ketamine in the treatment of CRPS. PubMed and the Cochrane Controlled Trials Register were searched (final search 26 May 2011) using the MeSH terms 'ketamine', 'complex regional pain syndrome', 'analgesia' and 'pain' in the English literature. The manuscript bibliographies were then reviewed to identify additional relevant papers. Observational trials were evaluated using the Agency for Healthcare Research and Quality criteria; randomized trials were evaluated using the methodological assessment of randomized clinical trials. The search methodology yielded three randomized, placebo-controlled trials, seven observational studies and nine case studies/reports. In aggregate, the data available reveal ketamine as a promising treatment for CRPS. The optimum dose, route and timing of administration remain to be determined. Randomized controlled trials are needed to establish the efficacy and safety of ketamine and to determine its long-term benefit in CRPS.
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Affiliation(s)
- Pari Azari
- Department of Anesthesiology, Division of Pain Management, Duke University School of Medicine, Durham, NC 27710, USA
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Schwartzman RJ, Alexander GM, Grothusen JR. The use of ketamine in complex regional pain syndrome: possible mechanisms. Expert Rev Neurother 2011; 11:719-734. [DOI: 10.1586/ern.11.31] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Response to Drs. Bell and Moore commentary regarding the use of intravenous ketamine for CRPS. Pain 2010; 151:554-555. [DOI: 10.1016/j.pain.2010.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 08/14/2010] [Indexed: 11/19/2022]
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Gregory-Roberts EM, Naismith SL, Cullen KM, Hickie IB. Electroconvulsive therapy-induced persistent retrograde amnesia: could it be minimised by ketamine or other pharmacological approaches? J Affect Disord 2010; 126:39-45. [PMID: 20060172 DOI: 10.1016/j.jad.2009.11.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 11/28/2009] [Accepted: 11/28/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Certain pharmacological agents administered during electroconvulsive therapy may have the potential to prevent persistent retrograde amnesia induced during electroconvulsive therapy. This review examines mechanisms for electroconvulsive therapy-induced retrograde amnesia, and evaluates the suitability of the anaesthetic ketamine for preventing this amnestic outcome. METHODS A review of human studies, animal models and theoretical models in light of memory dysfunction following electroconvulsive therapy was conducted. MEDLINE was searched from 1950 to April 2009 using the MeSH terms "electroconvulsive therapy", "memory", "memory short term", "memory disorders", "excitatory amino acid antagonists", and "ketamine". PREMEDLINE was searched using the terms "electroconvulsive therapy", "amnesia" and "ketamine". Additional keyword and reference list searches were performed. No language, date constraints or article type constraints were used. RESULTS Disruption of long term potentiation as a mechanism for electroconvulsive therapy-induced retrograde amnesia is well supported. Based on this putative mechanism, an N-methyl-D-aspartate receptor antagonist would appear suitable for preventing the retrograde amnesia. Available evidence in animals and humans supports the prediction that ketamine, an anaesthetic agent and N-methyl-D-aspartate receptor antagonist, could effectively prevent electroconvulsive therapy-induced persistent retrograde amnesia. Whilst there are concerns about the use of ketamine with electroconvulsive therapy, such as possible psychotomimetic effects, on balance this anaesthetic agent may improve or hasten clinical response to electroconvulsive therapy. CONCLUSIONS A clinical trial is warranted to determine if ketamine anaesthesia during electroconvulsive therapy can lessen persistent retrograde amnesia and improve therapeutic response. Electroconvulsive therapy with ketamine anaesthesia may provide effective antidepressant action with minimal side effects.
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Abstract
We sought to elucidate the existence of neuropsychological subtypes in Complex Regional Pain Syndrome (CRPS). One hundred thirty seven patients with CRPS were administered tests that assess executive control, naming/lexical retrieval, and declarative memory. A 2-step cluster analysis that does not require any a priori specification regarding the number of clusters, classified patients into three groups. Group 1 obtained scores that were in the average range on all tests (n = 48; normal CRSP group). Group 2 (n = 58; dysexecutive CRSP group) presented with mild impairment or statistically low average test performance on working memory/verbal fluency tests. Group 3 (n = 31; global CRSP group) produced scores in the statistically low average/borderline range on all tests with particularly reduced scores on naming/declarative memory tests. Between-group analyses found that the CRPS group 1 obtained higher scores than CRPS groups 2 and 3 on all tests. However, groups 2 and 3 were equally impaired on executive tests. CRPS group 3 was impaired on tests of naming/memory tests compared to the other groups. Significant neuropsychological deficits are present in 65% of patients, with many patients presenting with elements of a dysexecutive syndrome and some patients presenting with global cognitive impairment.
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Finch PM, Knudsen L, Drummond PD. Reduction of allodynia in patients with complex regional pain syndrome: A double-blind placebo-controlled trial of topical ketamine. Pain 2009; 146:18-25. [DOI: 10.1016/j.pain.2009.05.017] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/22/2009] [Accepted: 05/19/2009] [Indexed: 01/14/2023]
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Munts AG, Voormolen JHC, Marinus J, Delhaas EM, van Hilten JJ. Postdural puncture headache in complex regional pain syndrome: a retrospective observational study. PAIN MEDICINE 2009; 10:1469-75. [PMID: 19863745 DOI: 10.1111/j.1526-4637.2009.00727.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the unusual course of postdural puncture headache (PDPH) after pump implantation for intrathecal baclofen (ITB) administration in patients with complex regional pain syndrome (CRPS)-related dystonia. DESIGN Case series based on data collected from 1996 to 2005. Setting. Movement disorders clinic, university hospital. PATIENTS A total of 54 patients with CRPS-related dystonia who were treated with ITB. RESULTS A high incidence (76%) and prolonged course (median 18 days, range 2 days to 36 months) of PDPH was found. Radionuclide studies performed in two patients with long-lasting symptoms (12-16 months) did not reveal cerebrospinal fluid (CSF) leakage. In patients without signs of CSF leakage (N = 38), epidural blood patches administered in 24 patients were effective in 54%, while ketamine infusions administered in six patients were effective in 67%. CONCLUSIONS Our observations may suggest that other mechanisms besides intracranial hypotension play a role in the initiation and maintenance of PDPH in CRPS and stimulate new directions of research on this topic.
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Affiliation(s)
- Alexander G Munts
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
OBJECTIVE Complex regional pain syndrome (CRPS) is a severe chronic pain condition characterized by sensory, autonomic, motor, and dystrophic signs and symptoms. This study was undertaken to expand our current knowledge of the evolution of CRPS signs and symptoms with duration of disease. METHOD This was a retrospective, cross-sectional analysis using data extracted from a patient questionnaire to evaluate the clinical characteristics of CRPS at different time points of disease progression. Data from the questionnaire included pain characteristics and associated symptoms. It also included autonomic, motor, and dystrophic symptoms and also initiating events, ameliorating and aggravating factors, quality of life, work status, comorbid conditions, pattern of pain spread, family history, and demographics. Comparisons were made of different parameters as they varied with disease duration. RESULTS A total of 656 patients with CRPS of at least 1-year duration were evaluated. The average age of all participants was 37.5 years, with disease duration varying from 1 to 46 years. The majority of participants were white (96%). A total of 80.3% were females. None of the patients in this study demonstrated spontaneous remission of their symptoms. The pain in these patients was refractory showing only modest improvement with most current therapies. DISCUSSION This study shows that although CRPS is a progressive disease, after 1 year, the majority of the signs and symptoms were well developed and although many variables worsen over the course of the illness, the majority demonstrated only moderate increases with disease duration.
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Schwartzman RJ, Alexander GM, Grothusen JR, Paylor T, Reichenberger E, Perreault M. Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: a double-blind placebo controlled study. Pain 2009; 147:107-15. [PMID: 19783371 DOI: 10.1016/j.pain.2009.08.015] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 07/16/2009] [Accepted: 08/18/2009] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is a severe chronic pain condition that most often develops following trauma. The pathophysiology of CRPS is not known but both clinical and experimental evidence demonstrate the important of the NMDA receptor and glial activation in its induction and maintenance. Ketamine is the most potent clinically available safe NMDA antagonist that has a well established role in the treatment of acute and chronic pain. This randomized double-blind placebo controlled trial was designed to evaluate the effectiveness of intravenous ketamine in the treatment of CRPS. Before treatment, after informed consent was obtained, each subject was randomized into a ketamine or a placebo infusion group. Study subjects were evaluated for at least 2 weeks prior to treatment and for 3 months following treatment. All subjects were infused intravenously with normal saline with or without ketamine for 4h (25ml/h) daily for 10 days. The maximum ketamine infusion rate was 0.35mg/kg/h, not to exceed 25mg/h over a 4h period. Subjects in both the ketamine and placebo groups were administered clonidine and versed. This study showed that intravenous ketamine administered in an outpatient setting resulted in statistically significant (p<0.05) reductions in many pain parameters. It also showed that subjects in our placebo group demonstrated no treatment effect in any parameter. The results of this study warrant a larger randomized placebo controlled trial using higher doses of ketamine and a longer follow-up period.
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Affiliation(s)
- Robert J Schwartzman
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Borsook D. Ketamine and chronic pain--going the distance. Pain 2009; 145:271-272. [PMID: 19573988 DOI: 10.1016/j.pain.2009.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 05/22/2009] [Indexed: 01/08/2023]
Affiliation(s)
- David Borsook
- P.A.I.N. Group, Massachusetts General, McLean and Children's Hospitals, Harvard Medical School, Boston, MA 02478, USA
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Becerra L, Schwartzman RJ, Kiefer RT, Rohr P, Moulton EA, Wallin D, Pendse G, Morris S, Borsook D. CNS Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome. PAIN MEDICINE 2009. [DOI: 10.1111/j.1526-4637.2009.00559.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kiefer RT, Rohr P, Ploppa A, Dieterich HJ, Grothusen J, Koffler S, Altemeyer KH, Unertl K, Schwartzman RJ. Efficacy of Ketamine in Anesthetic Dosage for the Treatment of Refractory Complex Regional Pain Syndrome: An Open-Label Phase II Study. PAIN MEDICINE 2008; 9:1173-201. [DOI: 10.1111/j.1526-4637.2007.00402.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sunder RA, Toshniwal G, Dureja GP. Ketamine as an adjuvant in sympathetic blocks for management of central sensitization following peripheral nerve injury. J Brachial Plex Peripher Nerve Inj 2008; 3:22. [PMID: 18950516 PMCID: PMC2584055 DOI: 10.1186/1749-7221-3-22] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 10/25/2008] [Indexed: 12/04/2022] Open
Abstract
Proliferation of NMDA receptors and role of glutamate in producing central sensitization and 'wind up' phenomena in CRPS [complex regional pain syndrome] forms a strong basis for the use of Ketamine to block the cellular mechanisms that initiate and maintain these changes. In this case series, we describe 3 patients of CRPS Type II with debilitating central sensitization, heat/mechano allodynia and cognitive symptoms that we termed 'vicarious pain'. Each of these patients had dramatic relief with addition of Ketamine as an adjuvant to the sympathetic blocks after conventional therapy failed. Case Reports All 3 patients suffered gunshot wounds and developed characteristic features of CRPS Type II. Within 2–3 weeks they developed extraterritorial symptoms typical of central sensitization. The generalized mechanical allodynia and debilitating heat allodynia described to be rare in human subjects had life altering affect on their daily life. Case 2 and 3 also described an unusual cognitive phenomenon i.e. visual stimuli of friction would evoke severe pain in the affected limb that we have termed as 'vicarious pain'. They responded positively to sympathetic blocks but the sympatholysis did not bring relief to the heat and mechanical allodynia. Addition of Ketamine 0.5 mg/kg to the sympathetic blocks elicited resulted in marked relief in the allodynia. Conclusion Ketamine has a special role in patients with debilitating heat allodynia and positive cognitive symptoms via its action on central pain pathway. As an adjuvant in sympatholytic blocks it has a targeted action without significant neuropsychiatric side effects.
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Affiliation(s)
- Rani A Sunder
- Dept of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
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Wesseldijk F, Fekkes D, Huygen FJPM, van de Heide-Mulder M, Zijlstra FJ. Increased plasma glutamate, glycine, and arginine levels in complex regional pain syndrome type 1. Acta Anaesthesiol Scand 2008; 52:688-94. [PMID: 18419723 DOI: 10.1111/j.1399-6576.2008.01638.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Various inflammatory mediators have been identified as potential contributors to complex regional pain syndrome type 1 (CRPS1), but these mediators do not entirely explain certain manifestations of the syndrome, such as pain. The objective of this study was to investigate the role of amino acids in the pathogenesis of CRPS1. METHODS We used HPLC to determine plasma concentrations of 16 amino acids, especially those related to the NMDA receptor (e.g., glutamate and glycine) and nitric oxide (NO) synthesis (e.g., arginine and citrulline) in patients with CRPS1 (n=64) and age- and sex-matched healthy controls (n=51). Patients rated pain intensity (visual analog scale) and the subjective experience of pain intensity (McGill Pain Questionnaire). Psychological dysfunction was assessed using the SCL-90. RESULTS Relative to controls, in CRPS1 patients, plasma levels of glutamate, arginine, taurine, and glycine were increased, and plasma levels of glutamine and the ratio of citrulline to arginine were decreased. Remarkably, in CRPS1 patients there was a highly significant inverse correlation between glutamine and glutamate, although the sum of molar concentrations of glutamate and glutamine remains unchanged. Subjective measures of pain and indicators of psychoneuroticism and emotional instability did not correlate with amino acid levels. CONCLUSION This study shows for the first time a pronounced increase in amino acid levels in this chronic pain syndrome. The marked differences in glutamate, glutamine, glycine, taurine and arginine levels between patients and controls suggest the involvement of both the NDMA receptor and the endothelium-dependent arginine-NO system in CRPS1.
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Affiliation(s)
- F Wesseldijk
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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Suh JH, Koo MS, Nahm FS, Shin HY, Choi YM, Jo JY, Lee SC, Kim YC. Pain Management via a Subcutaneous Infusion of Ketamine in a Patient with Complex Regional Pain Syndrome - A case report -. Korean J Pain 2007. [DOI: 10.3344/kjp.2007.20.2.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeong Hun Suh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Suk Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hwa Yong Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Min Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Yon Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chul Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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