Ketamine as Part of a Multimodal Approach to Postoperative Pain Management

Some surgeries present increased challenges for adequate perioperative pain management, which require innovative methods to prevent development of chronic postsurgical pain (CPSP). Ketamine is an adjunct to traditional pain management methods and is an effective analgesic. The potent antihyperalgesic effects of ketamine represent an interesting option for those searching for multimodal approaches. This case report describes pain management for a 73-year old man scheduled for surgical excision of a sacral chordoma who was at high risk of development of CPSP. The intraoperative pain management plan consisted of T9-10 epidural anesthesia with continuous infusion of ropivacaine and hydromorphone, intravenous low-dose ketamine infusion, and intermittent intravenous hydromorphone boluses for breakthrough pain. Post-operatively the epidural infusion was continued for 4 days. The ketamine infusion rate was decreased on transfer to the intensive care unit and titrated to off by postoperative day 3. An intravenous hydromorphone patient-controlled analgesia pump was available to the patient for breakthrough pain postoperatively. This multimodal approach controlled the patient's pain postoperatively without reported complications. At his 1-year postsurgical follow-up visit, the patient reported some generalized "dull aching pain" that was well controlled with oral ibuprofen. Overall, the patient was satisfied with his pain control, and CPSP did not develop.