Use of Ketamine in the control of severe neoplastic pain-case presentation

Dr. Codruța Comșa1,2, Dr. Adriana Bene1,4, Conf univ. dr. Monica Dragomir2,5 
1Institutul Oncologic Prof. Dr. “Al. Trestioreanu” București, România, 2Universitatea de Medicină și Farmacie “Carol Davila”, București, 3Oncologie pediatrică, 4Anestezie și terapie intensivă, 5Oncologie medicală

Primit: 17.09.2021 • Acceptat pentru publicare: 30.09.2021

Abstract

Introduction: Pain occurs frequently in cancer patients (30-40% at diagnosis, 65-85% in advanced stage) and can be controlled in 85-95% of cases using the WHO analgesia scale. Ketamine combined with opioids and coanalgesics, may increase the effectiveness of analgesic treatment in patients with difficult-to-treat pain of neuropathic origin. Material and method: We present the case of a young man with recurrent multiple spinal Ewing sarcoma who has persistent severe neuropathic pain, unresponsive to high doses of opioids and coanalgesics. Results: The combination of Ketamine in subanesthetic doses with major dose opioid and coanalgesics allowed a good control of pain until death. Discussion: The doses of opioid used in this patient have exceeded the usual doses, which means a pain that is difficult to treat. For better pain control we tried: the combination of major opioid (in progressively increased doses) with coanalgesics (maximum doses), rotation and change of opioid route, and, ultimately, the combination with other drugs-Nephopam, Ketamine. The combination of Ketamine in a subanesthetic dose has been shown to be effective in controlling pain, increasing the quality of life; The combination of Morphine+Ketamine+Nephopam in continuous infusion did not cause significant adverse effects in the patient presented. Ketamine is not mentioned in the latest edition of the WHO guide for the treatment of neoplastic pain in adults and adolescents (2018) and there are not enough studies to be recommended in the treatment of chronic pain in children (WHO guide 2012, 2020); Ketamine in subanesthetic doses is currently recommended by some national professional companies for anesthesia and pain treatment and is found in some institutional guidelines for the treatment of chronic refractory pain. Conclusions: Morphine is the major first-line opioid for patients with severe pain. The combination of Morphine + Coanalgesics + Ketamine in subanesthetic dose may be recommended in the treatment of patients with refractory neuropathic pain.

Keywords: cancer, severe neuropathic pain, Ketamine

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