Use of Subcutaneous Ketamine for Refractory Pain in Home Hospice Patients: A Case Report

Document Type

Conference Proceeding

Publication Date

5-1-2024

Publication Title

J Pain Symptom Manage

Abstract

Outcomes: 1. Participants will learn different dosing intervals used in two cases where subcutaneous ketamine was used to treat opioid refractory pain. 2. Participants will be exposed to outcomes related to pain relief when using subcutaneous ketamine in the home hospice setting.

Key Message: Sub-anesthetic ketamine has been used to treat opioid refractory pain in palliative care patients. It is typically administered intravenously in a monitored setting which is a barrier for home hospice patients. These cases suggest subcutaneous ketamine administration is safe and feasible in the home hospice setting.

Background: Sub-anesthetic ketamine is effective for opioid refractory pain. It is typically administered intravenously in a monitored ambulatory or inpatient setting which is a barrier for home hospice patients as transportation to an infusion center and obtaining IV access are oftentimes not feasible at the end of life.

Case Description: Ms. G is a 58-year-old female with vulvar melanoma with osseous and hepatic metastases. She had severe cancer pain refractory to a multimodal treatment regimen including high-dose opioids of up to 255 OME daily. She received an initial 0.5 mg/kg sub-anesthetic ketamine infusion given as three equally divided subcutaneous injections every 15-minutes (time 0, 15-minutes, and 30-minutes). The infusion was tolerated well with rapid improvement in pain and without side effect or hemodynamic changes. She received three additional infusions on a weekly basis and was then rotated to an oral regimen.

Case 2: Ms. M is a 72-year-old female with inclusion body myositis causing severe bilateral leg pain refractory to high dose opioids including methadone and a hydromorphone PCA totaling 947.5 daily OME. A 0.5 mg/kg sub-anesthetic ketamine infusion was administered subcutaneously in the patient's home in the same fashion as case #1. The infusion was well tolerated with rapid improvement in pain, and without side effects or significant hemodynamic changes. Her pain worsened 48 hours later along with terminal agitation requiring a general inpatient level of care. Her symptoms were ultimately managed with an intravenous 0.3 mg/kg ketamine bolus followed by 0.1 mg/hg/hr continuous infusion, hydromorphone PCA, and intravenous chlorpromazine until her death 48-hours later.

Conclusion: These cases suggest subcutaneous ketamine administration is safe and feasible in the home hospice setting. Treatment response was rapid but short and highlights future area of research in dosing intervals for subcutaneous ketamine.

Volume

67

Issue

5

First Page

e628

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