Abstract
1. Participants will be able to assess the role of ketamine infusion in treating opioid-refractory pain associated with radiation necrosis, including its mechanism of action and clinical effectiveness.
2. Participants will be able to develop comprehensive treatment plans that incorporate ketamine infusion for patients with opioid-refractory pain from radiation necrosis, taking into account each patient's unique medical history, potential side effects, and monitoring strategies.
We report our experience using ketamine for treatment of opioid-refractory pain secondary to radiation necrosis in a patient who was ineligible for steroids. Following ketamine infusion, our patient had a significant reduction in her opioid requirement, demonstrating ketamine as a successful treatment strategy for optimizing pain control in this setting.
We present the case of a 36-year-old female with recurrent metastatic melanoma, complicated by radiation necrosis of the left distal thigh musculature, who presented with intractable, debilitating pain approximately 7 months following completion of local radiation therapy. Palliative Medicine was consulted for assistance with pain management. Prior to admission, patient had failed to respond to escalating doses of opioid therapy, given in conjunction with a multimodal regimen including acetaminophen, baclofen, celecoxib, duloxetine, and pregabalin. Just before presentation, the patient completed a prednisone taper for treatment of immune checkpoint inhibitor colitis, with suspicion that steroids were likely masking or partially treating pain before discontinuation. She was not a candidate for steroid re-initiation due to upcoming plans for tumor-infiltrating lymphocyte therapy. Despite escalating opioid dosing (up to OME 598.75 mg), our patient continued to experience uncontrolled pain along with progressive sedation. Given this, we started patient on ketamine 0.1mg/kg/hr and titrated this over the next 24 hours to a final dose of 0.3 mg/kg/h, which was then continued for 48 additional hours. Following completion of a 3-day ketamine infusion, patient's OME was reduced by 45% to 327.5 mg. In the months following hospital discharge, patient was subsequently weaned off long-acting opioids and was able to return to her baseline functional status. No previous cases have been reported of the use of ketamine for treatment of opioid-refractory pain secondary to radiation necrosis. In this case, we have demonstrated ketamine infusion as a successful treatment strategy for reducing our patient's opioid requirement, optimizing pain control, and helping to improve functional status and quality of life.
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