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Discussion

Chronic pain

I just went to the California Assoc Nurse Anesthetists Spring meeting in Palm Springs. One of the lecturers was about pain management by Chuck Griffis (I think). He talked about NMDA receptors and the positive feedback of the pain cycle in chronic pain patients. Really detailed and more than you'd want to see here!

But, when I talked to my peers, I found many of the old school anesthetists add 15-25mg of ketamine to their propofol when they induce a patient. They say that it helps with stopping/slowing down the chronic pain cycle, and they wake up nicer since they don't have to use much versed, etc. Anyone else doing this? What are your reasons? Have you found the patients easy to wake up? (Of course not with eye cases!!)

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I have mixed Propofol and Ketamine (Only because some of the CRNA's that I have worked with like to do so). My experience with this technique was not intended for chronic pain management though, rather for a level plane of anesthesia during unconscious sedation cases. If the pt. becomes a little light from the propofol, at least they have a little ketamine on board to keep them relaxed as well as pain free. I'm not a real fan of this; would rather just push it as needed.

I am not a CRNA yet, just an aspiring one. With that being said, I want to add that I have heard of using Ketamine in chronic pain patients. There is actually an experimental protocol now where they will put patients who suffer from chronic pain into a Ketamine induced coma for a couple of days. Not 100% clear on the science behind this, but from my understanding the Ketamine is supposed to "reboot" the nervous system so to speak in hopes of reducing the chronic pain.

http://en.wikipedia.org/wiki/Ketamine#Treatment_of_reflex_sympathetic_dystrophy

The science behind the use of NMDA receptor blockers is that LTP (long term potentiation) of pain transmission at the dorsal horn is predominately mediated by glutamate activity. There is some compelling evidence that acute pain states that persist can induce neuroplasticity (actually new dendritic/synapses sprouting in this case) that sets up a chronic pain state.

Best,

Art Zwerling

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