018 Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More w/Sergey Motov, MD!

Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD 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.