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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 8-9

Intravenous ketamine for pain relief in a patient with supraglottic laryngeal cancer (Stage IV-C)


1 Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
2 Desousa Foundation, Mumbai, Maharashtra, India

Date of Submission15-Aug-2020
Date of Acceptance27-Oct-2020
Date of Web Publication08-Mar-2021

Correspondence Address:
Sagar Karia
Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Sion, Mumbai - 400 022, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrap.jrap_8_20

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  Abstract 


Patients diagnosed with cancer often suffer from chronic pain. Management of pain is essential to improve the quality of life of patients. When the standard methods for pain management fail, novel techniques can be implemented. Ketamine is a dissociative anesthetic agent which acts by reducing the central sensitization to pain. We report the case of a patient suffering from intractable pain as a result of Stage IV-C supraglottic laryngeal malignancy that responded well to intravenous ketamine.

Keywords: Cancer, pain, ketamine, supraglottic laryngeal cancer


How to cite this article:
Chaudhari P, Shah B, Karia S, Shah N, Sousa AD. Intravenous ketamine for pain relief in a patient with supraglottic laryngeal cancer (Stage IV-C). J Recent Adv Pain 2020;6:8-9

How to cite this URL:
Chaudhari P, Shah B, Karia S, Shah N, Sousa AD. Intravenous ketamine for pain relief in a patient with supraglottic laryngeal cancer (Stage IV-C). J Recent Adv Pain [serial online] 2020 [cited 2021 Jun 25];6:8-9. Available from: http://www.jorapain.com/text.asp?2020/6/2/8/310954




  Introduction Top


Cancer is the second leading cause of death worldwide.[1] It is a disorder often associated with intractable pain, leading to poor quality of life. Alleviating the pain improves the prognosis and mitigates the suffering of many patients.[2] There are various drugs and protocols to manage pain in cancer patients, and the pain at times requires aggressive and occasionally innovative management techniques. There has been growing evidence supporting the role of N-methyl-D-aspartate (NMDA) receptors in pain.[3] This has led to evaluating the use of ketamine, an NMDA receptor antagonist for intractable pain of malignancy.[4] We report the case of a 70-year-old male with Stage IV-C supraglottic laryngeal cancer where intravenous ketamine helped relieve the pain.


  Case Report Top


A 70-year-old male was brought to the outpatient section of a psychiatry department of a tertiary general hospital at a metropolitan city in India. He presented with increased tremulousness, difficulty in falling asleep, confusion, and muttering to himself. On history, he was a known case of alcohol use and nicotine use disorder for the past 40 years. He was diagnosed with Stage IV-C supraglottic laryngeal cancer. The tumor was locally invasive and was declared inoperable. Debulking surgery had been performed in the patient previously at a private hospital. He experienced dysphagia and pain, particularly over the neck, jaw, and both the shoulders for the last 6 months. The patient was prescribed 2000 mg of paracetamol, 100 mg of diclofenac, 300 mg of tramadol, and 20 mg of oral morphine per day. Despite these medications, his pain aggravated, remained the same, but did not subside. In order to cope with the excruciating pain in his jaw, neck, and shoulders, he had increased his alcohol consumption over the past 5 months. He drank more than four quarters a day which prompted his family to intervene and stop his alcohol for 2 days before the presentation.

As the pain was unresponsive to the prescribed medications, we decided to evaluate him further. We managed his alcohol withdrawal symptoms and then assessed him for psychopathology and study the severity of his pain using a numerical analog scale (NAS).[5] On the NAS, the patient rated his pain as 9. On mental status examination, he appeared to have a depressed mood and felt hopeless regarding the prognosis of his ailment. The other routine investigations done were unremarkable. We applied the Edmonton Classification System for cancer pain. It describes the mechanism of pain which could be nociceptive, neuropathic, or a combination of the two, the incident pain which refers to the background pain of moderate intensity and the presence of psychological distress, addictive behavior, and cognitive dysfunction.[6] The patient had neuropathic pain, with psychological distress and addictive behavior and without any incident pain or cognitive dysfunction scoring Ne Io Pp Aa Co. It underscored psychological distress and addictive behavior in the form of relief drinking. The need for effective pain relief was highlighted, which prompted us to use ketamine for its rapid relief. After obtaining necessary consent and educating the patient and his relatives, ketamine was started at a dose of 0.5 mg/kg in 100-mL normal saline over 40 min, given in three sessions per week. The patient reported rapid relief of pain. Other analgesics were continued along with ketamine, that is, tramadol 200 mg and morphine 15 mg per day. By the fourth session, the patient scored the pain as 2 on the NAS. By the sixth session, the patient reported complete resolution of the pain. The patient was managed for alcohol withdrawal and sent home at the same time. He is currently free of pain and has been following up regularly. His drinking has reduced to just 60-mL alcohol on weekends.


  Discussion Top


Chronic cancer pain is often intractable and difficult to manage.[4] The Edmonton Classification System for cancer pain serves as a standardized instrument for a thorough evaluation of cancer pain symptom and helps in guiding therapeutics. Ketamine is a versatile drug. It is commonly used as a dissociative anesthetic medication. There is evidence for its use in the management of chronic pain; it acts as a novel antidepressant and its use in chronic pain due to malignancy which is unresponsive to opioids is now being reviewed.[7] It is most commonly used as an oral, intravenous, subcutaneous, or intrathecal formulation. The cytochrome P-450 enzymes metabolize ketamine.[7] It acts by reducing the central sensitization to decrease the pain. It decreases temporal summation, primary and secondary hyperalgesia, and secondary mechanical hyperalgesia.[4] Due to its adverse effects, it should be used with caution. The most commonly occurring adverse effects are nausea, vomiting, and sedation. Co-administering low-dose benzodiazepines with ketamine can curb the central nervous system-related effects such as derealization, hallucinations, panic attack, and paranoid ideas.[7] However, while using it intrathecally, one should keep its neurotoxic adverse effects in mind. The use of ketamine over a long period reduces the requirement of morphine in refractory pain.[4] A recent meta-analysis recognizes ketamine as an essential drug for intractable pain in palliative care.[8] We report this case for the use of ketamine as an agent for chronic cancer pain, not responding to other modalities, and this is an option worth exploring in future. Oncologists and palliative care specialists need to be aware of ketamine as an option for cancer-related pain as an adjunct to opioids when all other medications fail.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nagai H, Kim YH. Cancer prevention from the perspective of global cancer burden patterns. J Thorac Dis 2017;9:448-51.  Back to cited text no. 1
    
2.
Mantyh PW, Clohisy DR, Koltzenburg M, Hunt SP. Molecular mechanisms of cancer pain. Nat Rev Cancer 2002;2:201-9.  Back to cited text no. 2
    
3.
Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother 2006;60:341-8.  Back to cited text no. 3
    
4.
Bredlau AL, Thakur R, Korones DN, Dworkin RH. Ketamine for pain in adults and children with cancer: A systematic review and synthesis of the literature. Pain Med 2013;14:1505-17.  Back to cited text no. 4
    
5.
Kahl C, Cleland JA. Visual analogue scale, numeric pain rating scale and the McGill Pain Questionnaire: An overview of psychometric properties. Phys Ther Rev 2005;10:123-8.  Back to cited text no. 5
    
6.
Lawlor PG, Lawlor NA, Reis-Pina P. The Edmonton classification system for cancer pain: A tool with potential for an evolving role in cancer pain assessment and management. Exp Rev Qual Life Cancer Care 2018;3:47-64.  Back to cited text no. 6
    
7.
Jonkman K, Dahan A, van de Donk T, Aarts L, Niesters M, van Velzen M. Ketamine for pain. F1000Res. 2017;6:F1000 Faculty Rev-1711. pages 1-8.  Back to cited text no. 7
    
8.
Orhurhu V, Orhurhu MS, Bhatia A, Cohen SP. Ketamine infusions for chronic pain: A Systematic review and meta-analysis of randomized controlled trials. Anesth Analg 2019;129:241-54.  Back to cited text no. 8
    




 

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