Today's Veterinary Practice

JUL-AUG 2011

Today's Veterinary Practice provides comprehensive information to keep every small animal practitioner up to date on companion animal medicine and surgery as well as practice building and management.

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FOCUS ON PHARMACOLOGY | A quantitative and qualitative systematic review. Anesth Analg 2004; 99(2):482-495. 2. Slingsby LS, Waterman-Pearson AE. The postoperative analgesic effects of ketamine after canine ovariohysterectomy – a comparison between pre- and post-operative administration. Res Vet Sci 2000; 69(2):147-152. 3. Gramke HF, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital. Clin J Pain 2007; 23(6):543-548. 4. Bell RF, Dahl JB, Moore RA, Kalso E. Peri- operative ketamine for acute post-operative pain: A quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005; 49(10):1405-1428. 5. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 2006; 25(1). ers ketamine at 10 mcg/kg/min UÊ onÌinÕin}ÊvlÕi`ÃÊ«oÃÌo«iÀ>ÌiÛilÞÊ at standard maintenance rates of 2 mL/kg/hr, resulting in a ket- amine CRI rate of 2 mcg/kg/min. In order to rapidly achieve plasma levels, it is recommended that the CRI follow an initial ketamine IV bolus of 0.25 to 0.50 mg/kg. Ketamine CRI can be administered concurrently with CRIs of opioids, such as fentanyl, mor- phine, and/or lidocaine.11 Duration of Administration The ideal duration of CRI ketamine is uncertain, although in the studies cited (both very aggressive surgeries with a high predictability for discom- fort), it was continued for 20 (fore- limb amputation) and 6 (mastectomy) hours. It is interesting to note that the pain-modifying improvements in the ketamine CRI groups in both studies extended even after discontinuation of the CRI—until the studies were completed (3 days and 20 hours, respectively). WHY ADMINISTER KETAMINE? The ideal veterinary patient, surgery, or procedure for which subanesthetic ketamine CRI is indicated has not been identified. However, while the most optimum situations for ketamine administration are not known at this time, the existing evidence suggests that ketamine has a potential role in perioperative pain management. The evidence, however, is strong that ketamine CRI at subanesthetic doses: UÊ ÃÊÃ>viÊ>n`Ê>niÃÌhiÌiV-ë>Àin} UÊ m«ÀoÛiÃÊ>niÃÌhiÌiVÊV>À`ioÛ>ÃVÕ- lar and respiratory parameters UÊ m«ÀoÛiÃÊ>n>l}iÃiVÊivviVÌÃÊovÊ other drugs UÊ il«ÃÊ «ÀiÛinÌÊ iÝ>}}iÀ>Ìi`Ê >n`Ê sustained pain states. In summary, ketamine is one of the most potent drugs available for -LloVk>`i]ÊÜhiVhÊ >VVoÕnÌÃÊ voÀÊ its efficacy as an inhibitor of central hypersensitization and hyperalgesia. ÕiÊ ÌoÊ iÌÃÊ loÜÊ VoÃÌÊ >n`Ê hi}hÊ Ã>viÌÞÊ margin at subanesthetic CRI doses, it appears to be a useful adjunct to many surgical procedures, and may have future applications for the treatment of central or peripheral hypersensiti- zation. Q CRI = constant rate infusion; NMDA = N-methyl-D-aspartate References 1. Subramaniam K, Subrmaniam B, Steinbrook RA. Ketamine as adjuvant analgesic to opioids: 6. Hayes C, Armstrong-Brown A, Burstal R. Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: A randomized, controlled trial. Anaesth Int Care 2004; 32(3):330-338. 7. Carr DB (ed). Ketamine: Does life begin at 40? IASP Pain Clinical Updates 2007; XV(3). 8. Wagner AE, Walton JA, Hellyer PW, et al. Use of low doses of ketamine administered by constant rate infusion as an adjunct for postoperative analgesia in dogs. JAVMA 2002; 221(1):72-75. 9. Sarrau S, Jourdan J, Dupuis-Soyris F, Verwaerde P. Effects of postoperative ketamine infusion on pain control and feeding behaviour in bitches undergoing mastectomy. J Small Anim Pract 2007; 48(12):670-676. 10. Boscan P, Pypendop BH, Solano AM, Ilkiw JE. Cardiovascular and respiratory effects of ketamine infusions in isoflurane-anesthetized dogs before and during noxious stimulation. Am J Vet Res 2005; 66(12):2122-2129. 11. Muir WW, Wiese AJ, March PA. Effects of morphine, lidocaine, ketamine, and morphine- lidocaine-ketamine drug combination on minimum alveolar concentration in dogs anesthetized with isoflurane. Am J Vet Res 2003; 64(9):1155-1160. 12. Zhang GH, Min SS, Seol GH, et al. Inhibition of NMDA R unmasks the antinociception of endogenous opioids in the periphery. Pain 2009; 143:233-237. 13. Seeman P, Ko F, Tellerico T. Dopamine receptor contribution to the action of PCP, LSD and ketamine psychotomimetics. Mol Psychiatry 2005; 10(9):877-883. Mark Epstein, DVM, Diplomate ABVP (C/F), CVPP, & dAAPM, is the senior partner and medical director of TotalBond Veterinary Hospitals and Carolinas Animal Pain Management, a group of AAHA-accredited practices in the Charlotte and Gastonia, North Carolina, area. He is the president of the International Veterinary Academy of Pain Management and the past president of the American Board of Veterinary Practitioners. Dr. Epstein is an author and frequent lecturer on the recognition, prevention, and treatment of pain in the veterinary clinical setting. He received his DVM from University of Georgia. July/August 2011 Today’s Veterinary Practice 49 Ketamine: To Use or Not to Use for Pain Management

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