Maher Dermot P, Chen Lucy, Mao Jianren
From the Division of Pain Medicine, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts.
Anesth Analg. 2017 Feb;124(2):661-674. doi: 10.1213/ANE.0000000000001787.
Intravenous ketamine infusions have been used extensively to treat often-intractable neuropathic pain conditions. Because there are many widely divergent ketamine infusion protocols described in the literature, the variation in these protocols presents a challenge for direct comparison of one protocol with another and in discerning an optimal protocol. Careful examination of the published literature suggests that ketamine infusions can be useful to treat neuropathic pain and that certain characteristics of ketamine infusions may be associated with better clinical outcomes. Increased duration of relief from neuropathic pain is associated with (1) higher total infused doses of ketamine; (2) prolonged infusion durations, although the rate of infusion does not appear to be a factor; and (3) coadministration of adjunct medications such as midazolam and/or clonidine that mitigate some of the unpleasant psychomimetic side effects. However, there are few studies designed to optimize ketamine infusion protocols by defining what an effective infusion protocol entails with regard to a respective neuropathic pain condition. Therefore, despite common clinical practice, the current state of the literature leaves the use of ketamine infusions without meaningful guidance from high-quality comparative evidence. The objectives of this topical review are to (1) analyze the available clinical evidence related to ketamine infusion protocols and (2) call for clinical studies to identify optimal ketamine infusion protocols tailored for individual neuropathic pain conditions. The Oxford Center for Evidence-Based Medicine classification for levels of evidence was used to stratify the grades of clinical recommendation for each infusion variable studied.
静脉输注氯胺酮已被广泛用于治疗通常难以治疗的神经性疼痛病症。由于文献中描述了许多差异很大的氯胺酮输注方案，这些方案的差异给直接比较一种方案与另一种方案以及确定最佳方案带来了挑战。对已发表文献的仔细研究表明，氯胺酮输注可用于治疗神经性疼痛，并且氯胺酮输注的某些特征可能与更好的临床结果相关。神经性疼痛缓解持续时间的增加与以下因素有关：（1）氯胺酮的总输注剂量较高；（2）输注持续时间延长，尽管输注速度似乎不是一个因素；（3）联合使用辅助药物，如咪达唑仑和/或可乐定，以减轻一些令人不快的拟精神病副作用。然而，很少有研究旨在通过确定针对各自神经性疼痛病症的有效输注方案需要什么来优化氯胺酮输注方案。因此，尽管这是常见的临床实践，但目前的文献状况使得氯胺酮输注的使用缺乏来自高质量比较证据的有意义的指导。本专题综述的目的是：（1）分析与氯胺酮输注方案相关的现有临床证据；（2）呼吁进行临床研究，以确定针对个体神经性疼痛病症量身定制的最佳氯胺酮输注方案。使用牛津循证医学中心的证据水平分类来对所研究的每个输注变量的临床推荐等级进行分层。
