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Treatment of Refractory Pain with IV Lidocaine and Ketamine

Explore the use of intravenous lidocaine and ketamine in managing complex, refractory pain. Understand mechanisms, dosing, and clinical considerations for effective pain relief.

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Treatment of Refractory Pain with IV Lidocaine and Ketamine

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  1. Emmeline Tran, PharmD, BCPS Medical University of South Carolina PGY2 Internal Medicine Resident Treatment of Refractory Pain: A Focus on IV Lidocaine and Ketamine

  2. Objective • Develop a therapeutic plan for the treatment of refractory pain using intravenous lidocaine or ketamine

  3. Background • Pain • Complex • Subjective Psychological Biological Social Institute of Medicine. 2011.

  4. Patient Case • 34 year old male • Past medical history • Sickle cell disease • Chronic pain • Pain medications • ibuprofen 800 mg PO TID • gabapentin 800 mg PO TID • hydromorphone PCA • Total daily dose = 300 mg

  5. WHO Pain Ladder Can Fam Physician. 2010 Jun;56(6):514-7, e202-5.

  6. WHO Pain Ladder Can Fam Physician. 2010 Jun;56(6):514-7, e202-5.

  7. Lidocaine • Adjunctive agent • High degree of opioid tolerance • Neuropathic pain Pain Physician. 2013 May-Jun;16(3):231-49.

  8. Lidocaine • Mechanism of Action perception cortex modulation transmission thalamus primary afferent neuron dorsal root Pain Physician. 2013 May-Jun;16(3):231-49.

  9. Lidocaine • Mechanism of Action perception cortex modulation transmission thalamus primary afferent neuron dorsal root Pain Physician. 2013 May-Jun;16(3):231-49.

  10. Lidocaine • Mechanism of Action • Non-selective sodium channel blocker sodium extracellular fluid sodium channel potassium channel intracellular fluid potassium Pain Physician. 2013 May-Jun;16(3):231-49.

  11. Lidocaine • Mechanism of Action • Non-selective sodium channel blocker sodium extracellular fluid sodium channel potassium channel intracellular fluid potassium Pain Physician. 2013 May-Jun;16(3):231-49.

  12. Lidocaine LexiComp. Accessed February 29, 2016. Micromedex. Accessed February 29, 2016. Pain Physician. 2013 May-Jun;16(3):231-49.

  13. Lidocaine LexiComp. Accessed February 29, 2016. Micromedex. Accessed February 29, 2016. Pain Physician. 2013 May-Jun;16(3):231-49.

  14. Lidocaine • Clinical Pearls • No formal renal or hepatic dose adjustments, use caution • Telemetry is not necessary for patients with no previous cardiac conditions • Cardiac arrhythmias and hemodynamic instability are possible, but not found in trials when used in pain management LexiComp. Accessed February 29, 2016. Micromedex. Accessed February 29, 2016. J Palliat Med. 2015 Apr;18(4):373-7.

  15. Ketamine • Adjunctive agent • High degree of opioid tolerance • Opioid-induced hyperalgesia • Neuropathic pain Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  16. Ketamine • Mechanism of Action perception cortex modulation transmission thalamus primary afferent neuron dorsal root Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83.

  17. Ketamine • Mechanism of Action perception cortex modulation transmission thalamus primary afferent neuron dorsal root Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83.

  18. Ketamine • Mechanism of Action • N-methyl-D-aspartate (NMDA) antagonist calcium extracellular fluid calcium NDMA receptor NMDA receptor intracellular fluid Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83.

  19. Ketamine • Mechanism of Action • N-methyl-D-aspartate (NMDA) antagonist calcium extracellular fluid calcium NDMA receptor NMDA receptor intracellular fluid Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83.

  20. Ketamine Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  21. Ketamine • Clinical Pearls • IV: PO conversion = 1:1 • IV product is used orally • No consensus on a uniform ketamine protocol or dose • Reduce the long acting opioid dose by ~25 to 50% Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  22. Ketamine • Clinical Pearls • No formal renal or hepatic dose adjustments, use caution • Elderly patients may warrant dose reductions Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  23. Ketamine Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8. LexiComp. Accessed February 29, 2016. Micromedex. Accessed February 29, 2016.

  24. Ketamine • Clinical Pearls • Not well-studied for breakthrough pain • Give one-tenth to one-sixth of oral dose or 5 to 10 mg IV for breakthrough pain • Discontinuation can be done safely without concerns for withdrawal Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  25. Ketamine Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  26. Ketamine • Clinical Pearls • Most common side effects are psychomimetic • Test dose of 5 mg IV or 20 mg PO • Use benzodiazepine or butyrophenone to help prevent or manage • Cardiovascular side effects and respiratory depression are rare Pain Physician. 2013 May-Jun;16(3):231-49. J Palliat Med. 2012 Apr;15(4):474-83. Pain Physician. 2007 May;10(3):493-500. Biomed Pharmacother. 2006 Aug;60(7):341-8.

  27. Patient Case • 34 year old male • Past medical history • Sickle cell disease • Chronic pain • Pain medications • ibuprofen 800 mg PO TID • gabapentin 800 mg PO TID • hydromorphone PCA • Total daily dose = 300 mg Which of the following would you try next? a. Lidocaine IV b. Ketamine PO c. Ketamine IV d. None of the above

  28. Patient Case • 34 year old male • Past medical history • Sickle cell disease • Chronic pain • Pain medications • ibuprofen 800 mg PO TID • gabapentin 800 mg PO TID • hydromorphone PCA • Total daily dose = 300 mg Which of the following would you try next? a. Lidocaine IV b. Ketamine PO c. Ketamine IV d. None of the above

  29. Conclusions • Pain is difficult to treat • Utilize medications with unique mechanisms of action in the treatment of refractory pain

  30. Good Resources • Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. • KosharskyyB, Almonte W, Shaparin N, Pappagallo M, Smith H. Intravenous infusions in chronic pain management. Pain Physician. 2013 May-Jun;16(3):231-49. • OkonT. Ketamine: an introduction for the pain and palliative medicine physician. Pain Physician. 2007 May;10(3):493-500. • PrommerEE. Ketamine for pain: an update of uses in palliative care. J Palliat Med. 2012 Apr;15(4):474-83.

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