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Discussion in 'Pain Medicine' started by oliveoil532, Dec 17, 2006.
Is anyone familiar with the "Ketamine Coma" and it's role in pain mngmt?
It was very useful and effective for Dr. House. He even stopped using his cane for a few episodes.
But no real world experience here.
However, a Neurologist at MCP in Phila (Schwartzman) is looking into this in Germany. Not available in USA as far as I've read.
Look here: http://www.rsdfoundation.org/en/CNN_RSD.htm
A few minutes scouring the internet and some good info arises...
Below is from a Phila newspaper and provides the basic details on who/what/where/and how many.
A number of U.S. doctors use ketamine in small doses to treat pain while patients are awake, but Schwartzman and two German colleagues, Ralph-Thomas Kiefer and Peter Rohr, are the first to infuse it in comatose patients for up to seven days.
So far, the trio has treated 26 American patients in Germany. All patients received significant temporary pain relief, and nine remain completely pain-free from nine months to three years after the infusion.
Ketamine is FDA-approved in the United States for two-day use when the patient is awake, but Schwartzman holds out little hope that the coma procedure will ever be allowed here.
At Hahnemann University Hospital in Philadelphia, Schwartzman studies ketamine use for less severe patients and as boosters for those who have returned from Germany.
He just finished a study of 50 patients who were awake during five days of ketamine use - also not enough, he said - and plans to go back to the FDA in a couple of months for approval to try 10-day outpatient infusions.
It may seem strange for a mind-altering substance to be used medically, but the history of ketamine is like many other drugs - if it works for one thing, scientists say, let's see if it works for another.
"The problem unfortunately is that we have so many horrible diseases related to the brain and so few drugs," said Bita Moghaddam, neuroscience professor at the University of Pittsburgh who uses ketamine in rats to mimic schizophrenic symptoms. "If you have a drug you think is relatively safe, you have to use what you have."
Ketamine has also been used to study alcoholism and dementia, and explored as a treatment for sleep apnea and addictions and an aid in psychotherapy.
While many severe pain sufferers are enthusiastic about the ketamine coma, researchers are more cautious.
"Initial observations are exciting," said Srinivasa Raja, director of pain medicine at Johns Hopkins University School of Medicine. "But it has to be tempered with the fact that they are not blinded observations. They have to be followed through over time."
Timothy Lubenow, a pain specialist at Rush University Medical Center in Chicago, had a patient who went to Germany and "had great pain relief up until the plane ride back," he said. "She bumped her knee, which was the affected part, and the pain came back."
Schwartzman hopes that continuing research on treatments for severe pain will yield alternatives to the ketamine coma and that in the future "we won't need the ketamine sleep."
I am aware that it helped Dr. House.. but I was more interested in its usage on REAL people!!
Thanks for the info.. same stuff I came up with, I was just wondering if there was anyone in the U.S. trying it. I believe it has been used to treat pain, but at much lower doses.
Apparently it is also used recreationally...called "Special K"
one of my patients with horrible RSD went to mexico for 4 days in a row of ketamine coma (monitored, intubated , the works) , it seems to work and she comes to our practice for maintenance treatments every few months or so....
we usually give her some light anxiolytic (2 of versed ) together with 0.1 of kytril. we then give a loadingdose of 50 mg K i.v. followed by 200mg through a pump, titrated to effect over 1 hour. it seems to help her, i cannot explain the mechanism but speculate that K is a NMDA receptor antagonist, similar to methadone....
Thank you Sgt Landen for sharing your perspective and experiences.
Good luck to you and thank you for your service!
This is one thing that makes me so interested in pharmaceuticals targeted at the nervous system- there's a lot of experimentation. For example, dextromethorphan (active ingredient in Robitussin) used for levodopa-induced dyskinesia in Parkinson's and GHB approved for narcolepsy use. The drugs are just chemicals that produce a response in the nervous system, and the goodness or badness comes from how those effects relate to us.
Anyway I know our neurology dept uses ketamine for CRPS, although not to a multi-day coma effect. If the mechanism is really via the drug's role as NMDA antagonist, I wonder if Namenda would be useful at all. Does anyone know if Namenda is used off label for pain control or if any research has been done to that effect?
I have used it in several patients with some success. Typically I use if for opioid hyperalgesia. I escalate the namenda until the patients get sleepy, then back off on the opioid. I've managed to taper a lot of patients by 50% or more this way, with no significant change in analgesia (or lack thereof). The other group I use it in includes patients with "weird refractory neuropathic pain problems". Again, I've seen some impressive effects. One of the local neurologists got into prescribing it too based on what it did for the patients he referred to me (trainwrecks, always). I would recommend the Sgt who posted earlier ask about trying it as a means to transition away from ketamine infusions.
I'm a resident at a military Anesthesiology program, and several attendings on our Acute Pain Service use memantine on our injured soldiers as an adjunct for severe neuropathic or phantom limb pain. From what I recall, the data behind memantine as a clinically-relevant NMDA antagonist is pretty weak, but we tend to use it when we've tried everything else (neurontin or lyrica, TCAs or cymbalta, methadone, clonidine, ketamine), and figure adding it can't hurt.
A subethical doctor nearby hospitalized several patients in the ICU for continuous ketamine infusions for pain. They did not help long term....only for a day or two. The patients had to eat the cost of the hospitalization since this was clearly experimental by insurance determination.
I have tried oral ketamine on many patients but have found the dosing to be quite tricky, and since there is not a sustained release available (except through compounding pharmacies that really have no idea how much is released over time), I have abandoned its use in clinical medicine.
I have run into two patients who get these treatments. I almost laughed and asked if they were serious when they told me what was involved and the out-of-pocket cost. One woman spent over 100K of her own money to go to Mexico where she was admitted to a private clinic, hooked up to monitors, induced and intubated and literally kept on a vent that way for 4 or 5 days. The second, both had CRPS (RSD back then), would go to a neurologist in Philly to get similar treatments, went once a month. They swore it worked but from their demeanor and symptoms it wasn't doing alot when I saw them.