HSS Journal

, Volume 4, Issue 1, pp 62–65 | Cite as

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial

  • Michael K. UrbanEmail author
  • Jacques T. Ya Deau
  • Barbara Wukovits
  • Jane Y. Lipnitsky
Original Article


Management of acute postoperative pain is challenging, particularly in patients with preexisting narcotic dependency. Ketamine has been used at subanesthetic doses as a N-methyl d-aspartate (NMDA) receptor antagonist to block the processing of nociceptive input in chronic pain syndromes. This prospective randomized study was designed to assess the use of ketamine as an adjunct to acute pain management in narcotic tolerant patients after spinal fusions. Twenty-six patients for 1–2 level posterior lumbar fusions with segmental instrumentation were randomly assigned to receive ketamine or act as a control. Patients in the ketamine group received 0.2 mg/kg on induction of general anesthesia and then 2 mcg kg−1 hour−1 for the next 24 hours. Patients were extubated in the operating room and within 15 minutes of arriving in the Post Anesthesia Care Unit (PACU) were started on intravenous patient-controlled analgesia (PCA) hydromorphone without a basal infusion. Patients were assessed for pain (numerical rating scale [NRS]), narcotic use, level of sedation, delirium, and physical therapy milestones until discharge. The ketamine group had significantly less pain during their first postoperative hour in the PACU (NRS 4.8 vs 8.7) and continued to have less pain during the first postoperative day at rest (3.6 vs 5.5) and with physical therapy (5.6 vs 8.0). Three patients in the control group failed PCA pain management and were converted to intravenous ketamine infusions when their pain scores improved. Patients in the ketamine group required less hydromorphone than the control group, but the differences were not significant. Subanesthetic doses of ketamine reduced postoperative pain in narcotic tolerant patients undergoing posterior spine fusions.

Key words

ketamine postoperative pain 


  1. 1.
    Mao J, Price DD, Mayer DJ (1995) Mechanisms of hyperalgesia and morphine tolerance; a current view of their possible interactions. Pain 62:259–274PubMedCrossRefGoogle Scholar
  2. 2.
    Guignard B, Coste C, Costes H et al (2002) Supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements. Anesth Analg 95:103–108PubMedCrossRefGoogle Scholar
  3. 3.
    Kohrs R, Durieux ME (1998) Ketamine; teaching an old drug new tricks. Anesth Analg 87:1186–1193PubMedCrossRefGoogle Scholar
  4. 4.
    Hocking G, Cousins MJ (2003) Ketamine in chronic pain management: an evidence based review. Anesth Analg 97:1730–1739PubMedCrossRefGoogle Scholar
  5. 5.
    Kock MD, L’homme P, Waterloos H (2001) Balanced analgesia in the perioperative period: is there a place for ketamine? Pain 92:373–380PubMedCrossRefGoogle Scholar
  6. 6.
    Jarvey KB, Ussery TW, Steger HG et al (1996) Comparison of morphine and morphine with ketamine for postoperative analgesia. Can J Anaesth 43:212–215Google Scholar
  7. 7.
    Urban MK, Jules-Elysee K, Urquhart B et al (2007) Reduction in postoperative pain after spinal fusion with instrumentation using intrathecal morphine. Spine 27:535–537CrossRefGoogle Scholar
  8. 8.
    Inuoye SK, Van Dyck CH, Alessi CH et al (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 113:941–948Google Scholar
  9. 9.
    Mao J (2002) Opioid-induced abnormal pain sensitivity; implications in clinical opioid therapy. Pain 100:213–217PubMedCrossRefGoogle Scholar
  10. 10.
    Kehlet H, Werner M, Perkins F (1999) Balanced analgesia: what is it and what are its advantages in postoperative pain? Drugs 58:793–797PubMedCrossRefGoogle Scholar
  11. 11.
    Price DD, Mayer DJ, Mao J et al (2000) NMDA-receptor antagonists and opioid receptor interactions as related to analgesia and tolerance. J Pain Symptom Manage 19(Suppl 1):7–15CrossRefGoogle Scholar
  12. 12.
    White PF, Way WL, Trevor AJ (1982) Ketamine: its pharmacology and therapeutic uses. Anesthesiology 56:119–136PubMedCrossRefGoogle Scholar
  13. 13.
    Schmid RL, Sandler AN, Katz J (1999) Use and efficacy of low-dose ketamine in the management of acute postoperative pain; a review of current techniques and outcomes. Pain 82:111–125PubMedCrossRefGoogle Scholar
  14. 14.
    Bell RF, Dahl JB, Moore RA et al (2005) Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anesthesiol Scand 49:1405–1428CrossRefGoogle Scholar
  15. 15.
    Stubhaug A, Brievik H, Eide PK et al (1997) Mapping of punctuate hyperalgesia around a surgical incision demonstrates that ketamine is a powerful suppressor of central sensitization to pain following surgery. Acta Anesthesiol Scand 41:1124–1132CrossRefGoogle Scholar
  16. 16.
    Illkjaer S, Nikolajsen L, Hansen TM et al (1998) Effect of i.v. ketamine in combination with epidural bupivacaine and morphine on postoperative pain and wound tenderness after renal surgery. Br J Anaesth 81:707–712Google Scholar
  17. 17.
    Guillou N, Tanguy M, Sequin P et al (2003) The effects of small-dose Ketamine on morphine consumption in surgical intensive care unit patients after major abdominal surgery. Anesth Analg 97:843–847PubMedCrossRefGoogle Scholar
  18. 18.
    Argiriadou H, Himmelscher S, Papagiannopoulau P et al (2004) Improvement of pain treatment after major abdominal surgery by intravenous S+-ketamine. Anesth Analg 98:1413–1418PubMedCrossRefGoogle Scholar
  19. 19.
    Elia N, Tramer MR (2005) Ketamine and postoperative pain: a quantitative systematic review of randomized trials. Pain 113:61–70PubMedCrossRefGoogle Scholar
  20. 20.
    Urban MK, Jules-Elysee K, Urquhart B et al (2002) Reduction in postoperative pain after spinal fusion with instrumentation using intrathecal morphine. Spine 27:535–537PubMedCrossRefGoogle Scholar
  21. 21.
    Kudoh A, Takahira Y, Katagai H et al (2002) Small-dose ketamine improves the postoperative state of depressed patients. Anesth Analg 95:114–118PubMedCrossRefGoogle Scholar
  22. 22.
    Wolf K, Winstock AR (2006) Ketamine: from medicine to misuse. CNS Drugs 20:199–218CrossRefGoogle Scholar
  23. 23.
    Mortero RF, Clark LD, Tolan MM et al (2001) The effects of small dose ketamine on propofol sedation: respiration, postoperative mood, perception, cognition, and pain. Anesth Analg 92:1465–1469PubMedCrossRefGoogle Scholar
  24. 24.
    Reeves M, Lindholm DE, Myles PS et al (2001) Adding ketamine to morphine for patient-controlled analgesia after major abdominal surgery: a double-blinded, randomized controlled trial. Anesth Analg 93:116–120PubMedCrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2007

Authors and Affiliations

  • Michael K. Urban
    • 1
    Email author
  • Jacques T. Ya Deau
    • 1
  • Barbara Wukovits
    • 1
  • Jane Y. Lipnitsky
    • 1
  1. 1.Department of AnesthesiologyHospital for Special SurgeryNew YorkUSA

Personalised recommendations