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Ketamine Reduces Morphine Consumption!; Does Resident Involvement Impact Surgery?; Good News for Scoliosis Patients

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, February 21st, 2018

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Ketamine Reduces Morphine Consumption!

According to new work from California and Switzerland, supplementing morphine with ketamine may be effective at reducing pain in spine surgery. The study, “Perioperative Ketamine for Analgesia in Spine Surgery: A Meta-analysis of Randomized Controlled Trials,” was published in the March 1, 2018 edition of Spine.

Arif Pendi, M.S., co-author of the paper and with the Department of Orthopaedic Surgery at the University of California, Irvine, California, told OTW, “Clinicians at our institution want to reduce our reliance on opiates.”

“Morphine is the standard of care to manage pain postoperatively. But, morphine use is linked to too many side effects and may act as a gateway to prescription opioid abuse. When this paper was submitted for review to Spine, a physician reviewer commented that ‘we’ (i.e., spine surgeons collectively) are interested in looking into ANY ways to reduce our reliance on morphine postoperatively.”

“Meta-analysis is an ideal way to answer the fundamental research question because we have much more power (i.e., patients) than a single study and we are only including the highest quality studies (randomized controlled trials). This means that our study is amongst the highest quality of evidence.”

The authors wrote, “We conducted a comprehensive search of PubMed, the Cochrane Central Register of Controlled Trials for prospective RCTs [randomized controlled trials], Web of Science, and Scopus. Patients who received supplemental ketamine were compared with the control group in terms of postoperative morphine equivalent consumption, pain scores, and adverse events…”

“A total of 14 RCTs comprising 649 patients were selected for inclusion into the meta-analysis. Patients who were administered adjunctive ketamine exhibited less cumulative morphine equivalent consumption at 4, 8, 12, and 24 hours following spine surgery. The ketamine group also reported lower postoperative pain scores at 6, 12, and 24 hours…”

Pendi commented to OTW, “Ketamine consistently reduced morphine consumption and pain scores in the immediate postoperative period (24 hours after surgery). Notably, it did so without significantly increasing the rate of complications.”

“Most clinicians are worried about the side effects of ketamine, which results in delirium at-worst. Although we couldn’t analyze rates of delirium, many of the symptoms of delirium (e.g. hallucinations) were not significantly more common. A lot of these side effects occur when you use very high doses of ketamine.”

“However, ketamine as an additive agent means that we are suggesting adding only a small dose of ketamine to existing pain control regimens which are dominated by morphine use (intravenous patient-controlled analgesia or IV-PCA). This idea (of adding other agents in varying amounts to supplement morphine) is called multi-modal analgesia.”

“My specific advice: try ketamine. In general, I would advise considering supplemental analgesics to reduce reliance on morphine or other opiates as the primary postoperative analgesic.”

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