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Mion G, Himmelseher S. Esketamine: Less Drowsiness, More Analgesia. Anesth Analg 2024; 139:78-91. [PMID: 38295061 DOI: 10.1213/ane.0000000000006851] [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: 02/02/2024]
Abstract
Racemic ketamine is a 1:1 mixture of 2 enantiomers that turn light in opposite direction: Dextrorotatory esketamine is approximately 4 times more affine for the N-methyl-D-aspartate (NMDA) receptor than levorotatory arketamine, which may explain why esketamine is about twice as potent as an analgesic and anesthetic as the racemate. Esketamine has attracted renewed interest in view of the opioid crisis, racemic ketamine's abuse, and esketamine's approval for expanded use. We evaluated the anesthesia literature concerning mental, cardiovascular, cerebral, and antinociceptive effects of esketamine published in English between 1980 and 2022. The review shows that esketamine and racemic ketamine are not "the same" at clinically equivalent analgesic and anesthetic dose: Psychomimetic effects seem to be essentially related to NMDA receptor blockade and esketamine is not devoid of unwanted mental impact. However, it probably involves less cholinergic inhibition. Cognitive disturbances during arousal, awakening, and recovery from the drug are less, and less pronounced with esketamine. The drug allows for an approximately 50% dose reduction in anesthesia and analgesia which goes along with a higher clearance and shorter recovery time as compared to racemic ketamine. In comparison of esketamine with placebo, esketamine shows cardiocirculatory stabilizing and neuroprotective effects which can be seen in anesthesia induction, cardiac surgery, and analgesia and sedation in brain injury. Evidence of esketamine's antinociceptive efficacy is inconsistent, although a recent meta-analysis reports improved pain relief after surgery in a study with short observation time. To better define esketamine's place, direct head-to-head comparison with the racemate at equi-analgesic/anesthetic dose is warranted.
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Affiliation(s)
- Georges Mion
- From the Department of Anesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre, Université Paris - Cité, Cochin Hospital, Paris, France
| | - Sabine Himmelseher
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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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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Dhawan S, Kerru N, Awolade P, Singh-Pillay A, Saha ST, Kaur M, Jonnalagadda SB, Singh P. Synthesis, computational studies and antiproliferative activities of coumarin-tagged 1,3,4-oxadiazole conjugates against MDA-MB-231 and MCF-7 human breast cancer cells. Bioorg Med Chem 2018; 26:5612-5623. [PMID: 30360952 DOI: 10.1016/j.bmc.2018.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 11/16/2022]
Abstract
A novel library of coumarin tagged 1,3,4 oxadiazole conjugates was synthesized and evaluated for their antiproliferative activities against MDA-MB-231 and MCF-7 breast cancer cell lines. The evaluation studies revealed that compound 9d was the most potent molecule with an IC50 value of <5 µM against the MCF-7 cell line. Interestingly, compounds 10b and 11a showed a similar trend with lower inhibitory concentration (IC50 = 7.07 µM), in Estrogen Negative (ER-) cells than Estrogen Positive (ER+) cells. Structure-activity relationship (SAR) studies revealed that conjugates bearing benzyl moieties (9b, 9c and 9d) had superior activities compared to their alkyl analogues. The most potent compound 9d showed ∼1.4 times more potent activity than tamoxifen against MCF-7 cell line; while the introduction of sulfone unit in compounds 11a, 11b and 11c resulted in significant cytotoxicity against both MCF-7 and MDA-MB-231 cell lines. These results were further supported by docking studies, which revealed that the stronger binding affinity of the synthesized conjugates is due to the presence of sulfone unit attached to the substituted benzyl moiety in their pharmacophores.
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Affiliation(s)
- Sanjeev Dhawan
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa
| | - Nagaraju Kerru
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa
| | - Paul Awolade
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa
| | - Ashona Singh-Pillay
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa
| | - Sourav Taru Saha
- School of Molecular and Cell Biology, University of the Witwatersrand, Private Bag 3, Wits, Johannesburg 2050, South Africa
| | - Mandeep Kaur
- School of Molecular and Cell Biology, University of the Witwatersrand, Private Bag 3, Wits, Johannesburg 2050, South Africa
| | - Sreekantha B Jonnalagadda
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa
| | - Parvesh Singh
- School of Chemistry and Physics, University of KwaZulu-Natal, P/Bag X54001, Westville, Durban 4000, South Africa.
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Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, Viscusi ER, Narouze S, Davis FN, Ritchie EC, Lubenow TR, Hooten WM. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43:521-546. [PMID: 29870458 PMCID: PMC6023575 DOI: 10.1097/aap.0000000000000808] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.
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Affiliation(s)
- Steven P. Cohen
- From the Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine; and
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Eric S. Schwenk
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Ajay D. Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eugene R. Viscusi
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Samer Narouze
- Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
| | - Fred N. Davis
- Procare Pain Solutions and
- Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Elspeth C. Ritchie
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Georgetown University School of Medicine, Bethesda, MD; and
- Howard University College of Medicine, Washington, DC; and
| | | | - William M. Hooten
- Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN
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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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Delage N, Morel V, Picard P, Marcaillou F, Pereira B, Pickering G. Effect of ketamine combined with magnesium sulfate in neuropathic pain patients (KETAPAIN): study protocol for a randomized controlled trial. Trials 2017; 18:517. [PMID: 29100524 PMCID: PMC5670712 DOI: 10.1186/s13063-017-2254-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/10/2017] [Indexed: 11/10/2022] Open
Abstract
Background Neuropathic pain is difficult to treat, and the efficacy of recommended drugs remains limited. N-methyl-d-aspartate receptors are implicated, and antagonists are a pharmacological option. Ketamine is widely used in French pain clinics, but without consensus or recommendations. Furthermore, the association of ketamine with magnesium has been poorly studied. The aim of the present study is to evaluate the benefit of ketamine with or without magnesium in refractory neuropathic pain. Methods/design A randomized, double-blind, crossover, placebo-controlled study will be performed in Clermont-Ferrand University Hospital, Clermont-Ferrand, France. The aim is to evaluate the effect of ketamine with or without magnesium in 22 patients with neuropathic pain. Intravenous ketamine/placebo, ketamine/magnesium sulfate, or placebo/placebo will be administered consecutively to each patient, in random order, once at 5-week intervals. The primary endpoint is the AUC of pain intensity assessed on a 0–10 Numeric Pain Rating Scale for a 5-week period. Data analysis will be performed on an intention-to-treat basis, and all statistical tests (except primary analysis) will be performed with an α risk of 5% (two-sided). Discussion Considering the poor efficacy of the drugs available for neuropathic pain, ketamine with or without magnesium sulfate may be a valuable therapeutic option that needs to be standardized. Trial registration EudraCT number–2015-000142-29. Registered on April 9, 2015; version 1.4 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2254-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Noémie Delage
- Centre d'Evaluation et de Traitement de la Douleur, CHU de Clermont-Ferrand, F-63003, Clermont-Ferrand, France
| | - Véronique Morel
- Centre de Pharmacologie Clinique, Bâtiment 3C, CIC Inserm 1405, CHU Clermont-Ferrand, BP 69, F-63003, Clermont-Ferrand, Cedex 1, France.
| | - Pascale Picard
- Centre d'Evaluation et de Traitement de la Douleur, CHU de Clermont-Ferrand, F-63003, Clermont-Ferrand, France
| | - Fabienne Marcaillou
- Centre d'Evaluation et de Traitement de la Douleur, CHU de Clermont-Ferrand, F-63003, Clermont-Ferrand, France
| | - Bruno Pereira
- CHU de Clermont-Ferrand, Délégation Recherche Clinique & Innovation - Villa annexe IFSI, 58 Rue Montalembert, F-63003, Clermont-Ferrand, Cedex, France
| | - Gisèle Pickering
- Centre de Pharmacologie Clinique, Bâtiment 3C, CIC Inserm 1405, CHU Clermont-Ferrand, BP 69, F-63003, Clermont-Ferrand, Cedex 1, France.,Inserm, U1107 Neuro-Dol, Pharmacologie Fondamentale et Clinique de la Douleur, Laboratoire de Pharmacologie, Faculté de Médecine, Université Clermont Auvergne, F-63000, Clermont-Ferrand, France
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7
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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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8
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[Complex regional pain syndrome following distal fractures of the radius : Epidemiology, pathophysiological models, diagnostics and therapy]. Unfallchirurg 2016; 119:732-41. [PMID: 27488541 DOI: 10.1007/s00113-016-0217-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The complex regional pain syndrome (CRPS) still represents an incompletely etiologically understood complication following fractures of the distal radius. The incidence of CRPS following fractures of the distal radius varies between 1 % and 37 %. Pathophysiologically, a complex interaction of inflammatory, somatosensory, motor and autonomic changes is suspected, leading to a persistent maladaptive response and sensitization of the central and peripheral nervous systems with development of the corresponding symptoms. Decisive for the diagnostics are a detailed patient medical history and a clinical hand surgical, neurological and pain-related examination with confirmation of the Budapest criteria. Among the types of apparatus used for diagnostics, 3‑phase bone scintigraphy and temperature measurement have a certain importance. A multimodal therapy started as early as possible is the most promising approach for successful treatment. As part of a multimodal rehabilitation the main focus of therapy lies on pain relief and functional aspects.
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9
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Xu J, Yang J, Lin P, Rosenquist E, Cheng J. Intravenous Therapies for Complex Regional Pain Syndrome: A Systematic Review. Anesth Analg 2016; 122:843-856. [PMID: 26891396 DOI: 10.1213/ane.0000000000000999] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Compared with spinal cord stimulation and intrathecal targeted therapy, IV treatments are less invasive and less costly. We aimed to systemically review the literature on IV therapies and determine the level of evidence to guide the management of CRPS. We searched PubMed, Embase, Scopus, and the Cochrane databases for articles published on IV therapies of CRPS up through February 2015. The search yielded 299 articles, of which 101 were deemed relevant by reading the titles and 63 by reading abstracts. All these 63 articles were retrieved for analysis and discussion. We evaluated the relevant studies and provided recommendations according to the level of evidence. We conclude that there is evidence to support the use of IV bisphosphonates, immunoglobulin, ketamine, or lidocaine as valuable interventions in selected patients with CRPS. However, high-quality studies are required to further evaluate the safety, efficacy, and cost-effectiveness of IV therapies for CRPS.
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Affiliation(s)
- Jijun Xu
- From the Departments of Pain Management and Pediatric Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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10
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George E, Elman I, Becerra L, Berg S, Borsook D. Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties. Prog Neurobiol 2016; 141:25-44. [PMID: 27084355 DOI: 10.1016/j.pneurobio.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/23/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.
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Affiliation(s)
- E George
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States; Commander, MC, USN (Ret), United States
| | - I Elman
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Psychiatry, Boonshoft School of Medicine and Dayton VA Medical Center, United States; Veterans Administration Medical Center, Dayton, OH, United States
| | - L Becerra
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States
| | - Sheri Berg
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States
| | - D Borsook
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States.
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11
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Grieve S, Jones L, Walsh N, McCabe C. What outcome measures are commonly used for Complex Regional Pain Syndrome clinical trials? A systematic review of the literature. Eur J Pain 2015; 20:331-40. [PMID: 26075938 DOI: 10.1002/ejp.733] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2015] [Indexed: 11/10/2022]
Affiliation(s)
- S. Grieve
- Royal National Hospital for Rheumatic Diseases; Bath UK
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - L. Jones
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - N. Walsh
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - C. McCabe
- Royal National Hospital for Rheumatic Diseases; Bath UK
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
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12
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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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13
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Besson M, Piguet V, Dayer P, Desmeules J. New approaches to the pharmacotherapy of neuropathic pain. Expert Rev Clin Pharmacol 2014; 1:683-93. [PMID: 24422738 DOI: 10.1586/17512433.1.5.683] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pain is one of the most debilitating symptoms that presents with neuropathy. Neuropathic pain syndrome is a challenge to treat and, even with appropriate evidence-based treatment, only a 40% reduction of symptoms can be achieved in approximately half of patients. Furthermore, efficient doses are often difficult to obtain because of adverse effects. These observations underline that the treatment of neuropathic pain is still an unmet medical need. New approaches to the pharmacotherapy of neuropathy embrace different lines of work, including a fundamental mechanism-based approach, a clinical mechanism-based approach and an evidence-based approach. Moreover, interindividual variability in drug response, and genetic polymorphism in particular, is an emerging aspect to consider. Together with reviewing recent evidence-based guidelines as well as briefly discussing genetic polymorphisms that may influence the individual responses to treatments, this article will focus on what a mechanism-based approach is bringing to the clinical setting, on the perspective in fundamental research and on the difficulty of bridging the gap between fundamental notions and positive clinical outcomes.
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Affiliation(s)
- Marie Besson
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospital, Rue Micheli du Crest 24, 1211 Geneva 14, Switzerland.
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14
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Poree L, Krames E, Pope J, Deer TR, Levy R, Schultz L. Spinal cord stimulation as treatment for complex regional pain syndrome should be considered earlier than last resort therapy. Neuromodulation 2013; 16:125-41. [PMID: 23441988 DOI: 10.1111/ner.12035] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 10/30/2012] [Accepted: 11/26/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach. METHODS We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care. RESULTS AND CONCLUSION Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed.
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Affiliation(s)
- Lawrence Poree
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
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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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Notarnicola A, Moretti L, Tafuri S, Panella A, Filipponi M, Casalino A, Panella M, Moretti B. Shockwave therapy in the management of complex regional pain syndrome in medial femoral condyle of the knee. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:874-879. [PMID: 20447749 DOI: 10.1016/j.ultrasmedbio.2010.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 02/20/2010] [Accepted: 03/15/2010] [Indexed: 05/29/2023]
Abstract
The aim of this prospective study was to assess the efficacy of shockwave (SW) therapy in the management of complex regional pain syndrome (CRPS). In this study, 30 patients (pts) who were affected by CRPS of the medial femoral condyle and unresponsive to previous standard physiotherapeutic and pharmacological treatment underwent 3 SW sessions at 72-h intervals, each consisting of 4000 shocks emitted by a MiniLith SL1 Storz electromagnetic generator. An energy flux density (EFD) of 0.035 or 0.09 mJ/mm(2) was used, depending on how well the patient endured the pain during the treatment. Satisfactory results were observed in 76.7% of the cases (23 pts) at the 2-month follow-up (FU) visit, and in 80% (24 pts) at the 6-month FU visit. The therapeutic effects of SW were caused by decreasing pain. The significant improvements we obtained bear witness to the potential value of SW therapy in the management of CRPS.
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Affiliation(s)
- Angela Notarnicola
- Department of Clinical Methodology and Surgical Techniques, Orthopedics Section, Faculty of Medicine and Surgery, University of Bari, General Hospital, Italy.
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Perez RS, Zollinger PE, Dijkstra PU, Thomassen-Hilgersom IL, Zuurmond WW, Rosenbrand KC, Geertzen JH. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurol 2010; 10:20. [PMID: 20356382 PMCID: PMC2861029 DOI: 10.1186/1471-2377-10-20] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 03/31/2010] [Indexed: 02/07/2023] Open
Abstract
Background Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I. Method A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment. Results For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I. Conclusions Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.
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Affiliation(s)
- Roberto S Perez
- VU University Medical Center, Department of Anaesthesiology, Amsterdam, the Netherlands.
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Sakamoto E, Shiiba S, Noma N, Okada-Ogawa A, Shinozaki T, Kobayashi A, Kamo H, Koike K, Imamura Y. A Possible Case of Complex Regional Pain Syndrome in the Orofacial Region. PAIN MEDICINE 2010; 11:274-80. [DOI: 10.1111/j.1526-4637.2009.00777.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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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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Minett CP. Nerve Injury With Reflex Sympathy Dystrophy (RSD). J Oral Maxillofac Surg 2009. [DOI: 10.1016/j.joms.2009.05.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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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Current World Literature. Curr Opin Support Palliat Care 2009; 3:144-51. [DOI: 10.1097/spc.0b013e32832c6adb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schwartzman RJ, Patel M, Grothusen JR, Alexander GM. Efficacy of 5-Day Continuous Lidocaine Infusion for the Treatment of Refractory Complex Regional Pain Syndrome. PAIN MEDICINE 2009; 10:401-412. [DOI: 10.1111/j.1526-4637.2009.00573.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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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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Santamato A, Ranieri M, Panza F, Solfrizzi V, Frisardi V, Stolfa I, Megna M, Fiore P. Role of Biphosphonates and Lymphatic Drainage Type Leduc in the Complex Regional Pain Syndrome (Shoulder–Hand Syndrome). PAIN MEDICINE 2009; 10:179-85. [DOI: 10.1111/j.1526-4637.2008.00539.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Kim C. Complex Regional Pain Syndrome: Mechanism, Diagnosis and Treatment. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2008. [DOI: 10.5124/jkma.2008.51.6.553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chan Kim
- Department of Anesthesiology & Pain Medicine, Ajou University College of Medicine, Korea.
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Kiefer RT, Rohr P, Ploppa A, Altemeyer KH, Schwartzman RJ. Complete recovery from intractable complex regional pain syndrome, CRPS-type I, following anesthetic ketamine and midazolam. Pain Pract 2007; 7:147-50. [PMID: 17559485 DOI: 10.1111/j.1533-2500.2007.00123.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the treatment of an intractable complex regional pain syndrome I (CRPS-I) patient with anesthetic doses of ketamine supplemented with midazolam. METHODS A patient presented with a rapidly progressing contiguous spread of CRPS from a severe ligamentous wrist injury. Standard pharmacological and interventional therapy successively failed to halt the spread of CRPS from the wrist to the entire right arm. Her pain was unmanageable with all standard therapy. As a last treatment option, the patient was transferred to the intensive care unit and treated on a compassionate care basis with anesthetic doses of ketamine in gradually increasing (3-5 mg/kg/h) doses in conjunction with midazolam over a period of 5 days. RESULTS On the second day of the ketamine and midazolam infusion, edema, and discoloration began to resolve and increased spontaneous movement was noted. On day 6, symptoms completely resolved and infusions were tapered. The patient emerged from anesthesia completely free of pain and associated CRPS signs and symptoms. The patient has maintained this complete remission from CRPS for 8 years now. CONCLUSIONS In a patient with severe spreading and refractory CRPS, a complete and long-term remission from CRPS has been obtained utilizing ketamine and midazolam in anesthetic doses. This intensive care procedure has very serious risks but no severe complications occurred. The psychiatric side effects of ketamine were successfully managed with the concomitant use of midazolam and resolved within 1 month of treatment. This case report illustrates the effectiveness and safety of high-dose ketamine in a patient with generalized, refractory CRPS.
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Affiliation(s)
- Ralph-Thomas Kiefer
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany.
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Gallagher RM. Diagnostic Criteria for CRPS: Balancing the Needs of Clinicians and Investigators. PAIN MEDICINE 2007; 8:289-92. [PMID: 17610449 DOI: 10.1111/j.1526-4637.2007.00327.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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