Sergey M. Motov, MD, FAAEM

Twitter @painfreeED

Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally

Missed the Low Dose Ketamine for Pain – Administration Explained! Episode? Click Here

We wanted to do a Follow-Up Episode about Sub-Dissociative or Low-Dose Ketamine (SDK) Infusions.

Then this research got published…

Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department

Authors: Motov, Sergey; Drapkin, Jefferson; Likourezos, Antonios; Beals, Tyler; Monfort, Ralph; Fromm, Christian; Marshall, John

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Publication Date: March 3, 2018

Sergey is back and talks about his research and findings…

Impressive Pain Reduction >3 on Numeric Pain Scale

• 60 Minutes, 65% of Patients
• 120 Minutes, 68% of Patients

How does Continuous SDK Infusion Work?

“Ketamine’s rapid onset, and super rapid saturation of N-methyl-D-aspartate (NMDA) receptors and will give you an initial jolt of pain relief.

But if you do it relatively slowly, the saturation will be a little slower, but it will last much, much longer.

That’s why I believe the results of patients experiencing significant reduction of pain at 60 and 120 minutes, a direct consequence of this particular way of giving ketamine.”

– Sergey Motov, MD

Most Patients Enrolled in Study Received a Loading/Short Bolus Infusion prior to Continuous SDK Infusion

Who received the most benefits? Patients with…

Oncology/Cancer Pain (Chronic and Metastatic)

• Oncology patients normally have multiple modalities to treat their pain.
• Can have very high baseline PO opioid doses (i.e. morphine 300mg PO, fentanyl patches). Administering morphine 4mg or hydromorphone 1mg IVP will do absolutely nothing for these patients.
• The opioid dose needed is so high that the side effects are intolerable (i.e. nausea, vomiting). Increase CNS depression, respiratory depression, morbidity, and mortality in very high, inhumane doses.
• Continuous Sub-Dissociative Ketamine Infusions can be used as an adjunct therapy
• FYI: Ketamine comes in PO form (pill and liquid)
  • Ethical Alert!
  • Concern for abuse is real, don’t prescribe it. Highly addictive and highly abused.
  • Just know that it’s out there, may have application to some chronic oncology patient population.

Abdominal Pain (Pancreatitis, Intractable, Unknown Etiology)

• Sub-Dissociative Ketamine is the most beneficial modality for chronic intractable pain with or without non opioid adjunct therapy with functional abdominal pain (i.e. secondary to toxicology emergency).
• Psyche component for unknown etiology abdominal pain?
  • Simple conversation with biofeedback, psycho-social counseling, encouragement, and reassurance
  • Normal Physical Exam
  • May not need any interventions

Sickle Cell Crisis Pain

• Use of continuous SDK infusion decreases opioid needs by 50%
• Barriers:
  • Admitted Sickle Cell Crisis Patients will not get SDK infusions on inpatient units and will go back to hydromorphone PCA pumps
  • Inpatient Providers’ and Nurses’ familiarity and understanding of SDK infusions
  • Convincing Patients to try SDK as adjunct therapy for pain
  • Interdepartmental protocol.
• Work Around:
  • Admit patients to an observation unit with SDK protocols in place.
  • Utilize Clinical Nurse Educators to develop nursing policy.
  • Interdisciplinary SDK protocol can be developed with ED Medical Director, ED Nursing Director, and Pharmacy.

Additional Barriers Identified

• Continuous SDK infusions limited to Emergency Department.
• If a Pt needs a diagnostic MRI, have to stop drip to go off unit. When the Pt comes back, have to start all over again.
• Other services/units unfamiliarity of SDK for pain (i.e. hematology-oncology, pain management)

Geriatrics…Really? Sneak Preview of Upcoming Geriatric Ketamine Trial Results!

• 70% of Patients 65 year old and older had psycho perceptual effects at 0.3mg/kg for the short infusion bolus dose.
• Need to optimize short infusion bolus dose for geriatric population.
  • Unknown optimal short infusion bolus dose for geriatric population.
  • 0.1mg/kg or 0.2mg/kg dose may be more appropriate for short infusion bolus in geriatric population.
  • More research needed for optimized SDK dosing in geriatric population.
• Consider skipping loading or short bolus infusion dose all together in geriatric population.
• *Will update with results once research is published.

Ketamine Addiction Alert!

Chronic/dependent/addicted recreational ketamine user can have irreversible bladder damage, Interstitial Cystitis.

• Presentation:
  • Young Males (20s, 30s)
  • Dysuria/UTI Symptoms (burning or painful urination)
  • Multiple Negative Work-Ups
• Must Ask! Do you use ketamine recreationally? How often?
• If they can stop using ketamine early enough, it is reversible.
• Otherwise, treatment for Interstitial Cystitis is Cystectomy with Ileal Conduit.

How to Administer Continuous Sub-Dissociative Ketamine Infusion?

1. Loading/Short Infusion Bolus Dose

• Max dose 30mg

2. Start with weight-based dose for Initial Starting Infusion Dose

Initial Starting Infusion Dose: 0.1-0.15mg/kg/hr

• Ex: 70kg x 0.1mg/kg/hr = 7mg/hr
• 0.4-0.7mg/kg/hr –> you’ve now entered a recreational dose – Clinical Pearl!

Preparation:

Ketamine 100mg in NS 100mL = 1:1 ratio

3. Titrate every 30 minutes

Increase infusion dose by 2.5mg/hr or 5mg/hr until optimized.

How to Optimize Infusion Dose? Ask the patient!

• How do you feel?
• Would you like more pain medication?
  • No–>Pt is optimized. Keep Patient on infusion for 1-2 hours
  • Yes-->Continue down pathway below.
• Determine if the patient is having psycho-perceptual component.
  • Are you feeling weird?
  • Having an out of body experience?
  • Nauseous?
  • Is your dizziness driving you crazy?
• Yes –> Increase infusion dose by 2.5mg/hr
• No –> Increase infusion dose by 5mg/hr

4. Clinical Pearls!

• First 1 – 1.5 hours is challenging to optimize dose
• Once Optimized, you’re good and can run the continuous SDK infusion for 1-2 hours
• Usual continuous SDK infusion dose range is 8-14mg/hr
• Unknown max dose – but Sergey hasn’t administered past 20mg/hr
• Weening is not important – you can just stop the infusion
  • No massive rebound of pain or psycho perceptual component observed
• Continue adjunct medications while on continuous SDK infusions
  • non-opioid and opioid analgesia

5. Disposition

Ready for Discharge?

• Tolerates PO and someone can take them home.
• No nausea or vomiting.
• Load with PO medication (ibuprofen or acetaminophen)
• Wait 30 minutes for PO medication to kick in.
• Then Discharge.

Not ready for Discharge?

• Nausea, vomiting – must address
• Unable to tolerate PO
• Has Psycho perceptual effect
  • Titrate down
• Still in Pain
  • Give adjunct medications
  • Give breakthrough medications
  • More time on Continuous SDK Infusion – consider an observation unit with protocol

Reference:

Motov, S., Drapkin, J., Likourezos, A., Beals, T., Monfort, R., Fromm, C., & Marshall, J. (2018). Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. Retrieved from https://escholarship.org/uc/item/78d9r96c

Yun Cee Dirsa. Low-dose ketamine for pain administration explained! w/Sergey M. Motov, MD. Resus Nurse Podcast and Blog. Published on October 13, 2017. Date accessed April 27, 2018. Available at https://resusnurse.com/2017/10/13/low-dose-ketamine-pain-administration-explained-wsergey-m-motov-md/.

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