Anesthesia E-ssential, September 17, 2012

Anesthesia E-ssential

September 17, 2012


Vital Signs

Register Now for Redesigned Fall Assembly Leadership Academy
The Fall Assembly Leadership Academy, to be held Nov. 16-18 at the Broadmoor Hotel in Colorado Springs, Colo., will offer CRNAs a variety of professional development and educational opportunities to choose from. The academy has been redesigned to present leadership workshops formerly delivered as the State President-Elect Boot Camp, State Government Relations Workshop, Federal Political Directors Conference, and Foundation Advocates Workshop. All AANA members are encouraged to attend! Online registration is available now—and couldn't be easier. Read more about the academy and register.
Register before October 26 and receive a $50 discount!


The Pulse

  • Leadership and Governance Videos Available Now
  • Coming in November: Media Training Workshop for State Association Leaders
  • Upcoming Webinars
  • Open Comment Period for AORN Position Statements
  • New Online Submission Process for AANA Foundation Research Grant Proposals
  • AANA Comment Urges Medicare Agency to Protect CRNA Pain Care, Noting Flaws of Alternatives
  • What Have Commenters Said About the Medicare CRNA Pain Care Proposed Rule?
  • Stay Tuned for Updates on Contacting Congress Again about CRNA Pain Care
  • Congress Taking Up 6-Month Budget Package with 8 Percent Cuts to Health and Other Nondefense Accounts
  • Advisory Panel to Medicare Agency on Hospital Outpatient Payment Recommends Lowering Levels for Supervision for 28 Outpatient Therapeutic Services
  • Making CRNA Voices Heard: AANA at the Republican and Democratic National Conventions
  • Where are the Presidential Candidates on Major Health Issues?
  • Help Avert Huge Medicare Cuts AANA Asks Medicare in Comment Letter
  • AANA-backed "One & Only Campaign" for Safe Injection Practices Recognized in Washington Post Supplement
  • AANA and Harm Reduction Coalition Urge HHS to Support Efforts to Reduce Diversion and Misuse of Drugs

Healthcare Headlines

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.
Inside the Association

Hot Topics

    Leadership and Governance Videos Available Now
    Leadership and governance videos from consultant Les Wallace, PhD, are available through the AANA website for state association leaders, program administrators, committees, and members to enhance their leadership and governance capabilities. Wallace, the president of Signature Resources, Inc., is a leadership consultant who works with the AANA Board of Directors and state association leaders.
    Coming in November: Media Training Workshop for State Association Leaders
    November 18-19, 2012, at The Broadmoor
    Following the Fall Assembly Leadership Academy, the AANA is offering a Media Training Workshop to help media spokespersons understand reporters and the interview process, gain confidence in working with the media, and learn proven interviewing techniques. Read more from the workshop program and registration form available on the AANA Meetings Department Assemblies page.

    Upcoming Webinars

Three free webinars are coming up in September:

  • CDC Foundation: “Infection Control and Prevention in Outpatient Oncology Clinics” on Sept. 24, 2012 from 1-2 p.m. ET
  • Premier Safety Institute: “Preventing theft of drugs and controlled substances - A patient safety imperative” on Sept. 26, 2012 from 2-3 p.m. ET
  • Institute for Safe Medication Practices: “Addressing Opioid Safety Risks in Hospitals” on Sept. 28, 2012 from 1:30-3 p.m. ET
Open Comment Period for AORN Position Statements
The Association of periOperative Registered Nurses (AORN) currently has the following recommended practices and position statement open for public comment:
  • Sterile technique
  • Prevention of Transmissible infection
  • Role of the APRN Practicing in the Perioperative Setting
Access the comment page by going to

New Online Submission Process for AANA Foundation Research Grant Proposals
Fall Deadline: October 1
AANA Foundation research grant proposals will now be submitted online through the AANA website. Funding priority will be given to: Science of Anesthesia, Education, Practice, Leadership, and Healthcare Policy.
Visit the following link to learn more about how to apply online for General Research Grants. The deadline for Fall Grant Proposals is October 1.
Visit this link if you are applying for Office Based, Veterans Affairs or Wellness Grants. These three open-submission grants do not have a deadline date.

AANA Comment Urges Medicare Agency to Protect CRNA Pain Care, Noting Flaws of Alternatives
Expressing support for the Medicare agency’s interest in patient access to chronic pain management services provided by CRNAs, the AANA in its Sept. 4 comment letter to Medicare also urged the agency to further clarify and improve its regulatory proposal to ensure that CRNA chronic pain management services are covered for Medicare patients. The letter noted that alternatives to CRNA care impair patient access to care and are costly to patients and to Medicare.
“In summary, the AANA supports the Medicare agency maintaining a consistent national policy authorizing direct reimbursement of chronic pain management services provided by CRNAs, as well as adjunct imaging and evaluation and management services that they are allowed to furnish under state law,” said the AANA comment letter, signed by President Janice Izlar, CRNA, DNAP.
The AANA also provided the agency a series of case analyses from The Lewin Group, summarizing alternatives to CRNA pain management services, particularly in rural areas. “Analysis of costs associated with pain management in these geographically diverse cases shows that total costs of pain care alternatives range between 1.4 to 128 times the costs of a CRNA providing these services in the community,” the paper’s abstract says.

What Have Commenters Said About the Medicare CRNA Pain Care Proposed Rule?
The Medicare agency’s comment period on the CRNA pain care proposed rule concluded Sept. 4, and public comments continue to be posted online at What did other commenters say about this issue that might interest CRNAs?
  • The AARP said, “AARP commends CMS’ proposal to ensure consumers’ access to Certified Registered Nurse Anesthetists’ (CRNA) services including pain management. CRNAs are often the primary providers of these services in rural and medically underserved areas; and Medicare coverage of these CRNA administered services would prevent consumers traveling long distances or being treated by unfamiliar providers.”
  • Echoing the views of several hospital associations, the American Hospital Association said, “The AHA supports CMS’s efforts to establish a consistent national policy among all Medicare contractors as to whether Medicare will reimburse CRNAs directly for chronic pain management services….”
  • The National Rural Health Association said, “By supporting access to CRNA pain care in the community, Medicare will help keep patients from having to consider much less favorable alternatives, such as long distance travel to unfamiliar providers at great cost. CRNAs play a critical role in the delivery of pain management and anesthesia services in rural communities. Rural areas have well documented workforce challenges and must be allowed significant flexibility to meet the needs of their communities. To that end NRHA joins with other groups in calling on CMS to finalize the proposal to allow CRNAs to directly bill Medicare for their pain management services.”
  • The American Nurses Association said, “I write to offer our strong support for restoring Medicare direct reimbursement for chronic pain management services provided by Certified Registered Nurse Anesthetists (CRNAs).”
  • The American Society of Anesthesiologists said, “We urge CMS in the strongest possible terms to withdraw this proposed policy for the following reasons: anesthesia and related care does not include chronic pain care; the training and education of nurse anesthetists is inadequate for safe, effective and appropriate chronic pain care; the exceedingly low number of times nurse anesthetists bill for this care does not support an access issue; the increased risk of fraud and abuse; the potential for misuse, abuse and diversion of controlled substances; and the sometimes ambiguous state scope of practice rules for nurse anesthetists.”
  • The American Medical Association said, “Because chronic pain management poses potentially serious patient health and safety risks, and because Certified Registered Nurse Anesthetists (CRNAs) do not possess the requisite education and training to manage those risks, the AMA strongly urges CMS to rescind its proposal to reimburse CRNAs for chronic pain management services.“
The AANA’s own comments are now available publicly. See all comments to the proposed rule. To date, 2,929 comments to the rule have been posted. Not all relate to pain care. Not all comments provided to Medicare are yet posted on this site.
Stay Tuned for Updates on Contacting Congress Again about CRNA Pain Care
Medicare agency officials state that they are scheduled to publish a final rule on CRNA chronic pain management services on or about Nov. 1, 2012, to take effect Jan. 1, 2013, though there are no guarantees until the final rule actually appears in the Federal Register. What to do until then?
  • Prepare to write your U.S. Representatives and U.S. Senators. Shortly, AANA members will be provided online tools to write Congress once again about protecting CRNA chronic pain management services. AANA members will be asked to urge their lawmakers to contact Medicare and support restoring direct reimbursement of CRNA chronic pain care services as part of their final rule. Members will also be asked to follow up a couple of weeks thereafter.
  • In the meantime, the Medicare agency will be reviewing comments that the public has submitted on the 2013 physician fee schedule proposed rule, which included the proposal on Medicare CRNA pain management services. Favorable comments from legislators at this time are valuable.
  • With Congress headed for a post-election “lame duck” session, the AANA and its allies will also have to protect against having harmful anti-CRNA “poison pill” language included in end-of-year budget bills. Time that CRNAs have spent educating their lawmakers over the past year or so about this issue will be very important during the “lame duck” session.
Congress Taking Up Six-Month Budget Package with Eight Percent Cuts to Health and Other Nondefense Accounts
In the next few days Congress is slated to take up a stopgap budget package funding the U.S. government for six months beginning Oct. 1, 2012, and initiating 8 percent across-the-board cuts to domestic non-security discretionary programs, including many healthcare programs.
The across-the-board cut of 8 percent is ordered by the 2011 Budget Control Act, passed by Congress last year with the objective of driving lawmakers to develop a major budget agreement – and with provisions to cut spending overall if they failed, which they did. The cut takes effect Jan. 1, 2013, and affects healthcare programs of interest to CRNAs like Title 8, but imposes a smaller 2 percent cut to Medicare, and exempts Medicaid and Veterans health programs. National security budgets are exposed to larger cuts than the rest of the government budget. If the stopgap bill is enacted – and it appears likely to be, since it was developed with bipartisan support from both the House and Senate -- agencies would have to report to Congress how they would make the cuts.
However, the impact of the package on Title 8 funding is not completely clear. The stopgap “continuing resolution” bill funds the government for six months, through March 31, 2013 – but the Health Resources and Services Administration usually issues Title 8 grant funds in the late summer of a federal fiscal year, after that March date. Thus, Title 8 funds in particular will be subject to whatever budget agreement the next Congress taking office in January will develop.
Advisory Panel to Medicare Agency on Hospital Outpatient Payment Recommends Lowering Levels for Supervision for 28 Outpatient Therapeutic Services
The Centers for Medicare & Medicaid Services’ (CMS) Advisory Panel on Hospital Outpatient Payment met Aug. 27-28 to advise CMS on Ambulatory Payment Classification (APC) groups and relative payment weights along with the level supervision levels for individual hospital outpatient therapeutic services. The Advisory Panel recommended that the agency lower the supervision level of 28 outpatient services, none of which are related to anesthesia or pain management, from “direct” to “general” supervision.
The action means that those 28 services may be performed without physician or non-physician practitioners' (i.e., physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, or clinical psychologist) presence.
This “supervision” is different from and not to be confused with the physician supervision requirement of CRNAs administering anesthesia under Medicare Part A Conditions of Participation for anesthesia services. AANA FGA staff covered the meeting and will continue monitoring CMS’s decision on these recommendations.
Making CRNA Voices Heard: AANA at the Republican and Democratic National Conventions
Visit the AANA Facebook page for a glimpse of the work of AANA President Janice Izlar, CRNA, DNAP, and the AANA team representing the profession of nurse anesthesia before policy leaders and influencers from around the country at the national political conventions. Photos from AANA activities and people we have met at the Republican National Convention on Aug. 27-30, and the Democratic National Convention on Sep. 4-6, are available to view and for you to comment on.
Where Are the Presidential Candidates on Major Health Issues?
Kaiser Health News has published a helpful summary of President Obama’s healthcare agenda and of Governor Romney’s healthcare agenda.
Help Avert Huge Medicare Cuts, AANA Asks Medicare in Comment Letter
The Centers for Medicare & Medicaid Services (CMS) should continue to clearly indicate to Congress and the public the negative effects that a huge Medicare cut would have on patient access to care and should urge the administration and Congress to seek legislation to reverse these harmful cuts, said the AANA in a Sept. 4 comment letter to the agency regarding the CY 2013 Physician Fee Schedule proposed rule.
The AANA also objected to the Medicare agency increasing payment to primary care at the expense of valuable anesthesia services. In the letter signed by President Janice Izlar, CRNA, DNAP, “We applaud CMS for investing in an increase in payment for primary care services. We certainly do not dispute that these are valuable services. However, we do object that the agency proposes this increase in payment at the direct expense of other valuable services. While providers of primary care services are slated to receive an increase in payment of between 3 to 7 percent, the agency’s estimate of 2013 Part B allowed charges indicates that anesthesia professionals, such as CRNAs, are slated to receive a 4 percent decrease from what CY 2013 charges otherwise would have been.”
The AANA also recommended that CMS:
  • Avoid the use of AHRQ’s Clinical/Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey in use for the Physician Compare website and the Physician Quality Group Practice Reporting Option as this survey tool fails to capture the patient and caregiver experience with APRNs and registered nurses by focusing only on physicians.
  • Clarify that the penalty for not being a meaningful user of electronic health records (EHR) applies only to those who are eligible for the Medicare EHR Incentive Program. CRNAs, who are currently ineligible for federal incentive payments to adopt EHR, must not be penalized in Medicare for not having the EHR systems that federal programs currently deny them.
  • Require that CRNAs be included in the development and valuing of payment codes.
AANA-backed "One & Only Campaign" for Safe Injection Practices Recognized in Washington Post Supplement
The AANA-backed “One & Only Campaign” intended to promote safe injection practices drew attention in Washington last weekend through a supplement supported by the CDC Foundation focusing on hepatitis and liver health. See the ad on page 11 of
AANA and Harm Reduction Coalition Urge HHS to Support Efforts to Reduce Diversion and Misuse of Drugs
The AANA joined the American Medical Association, American Society of Anesthesiologists, and other members of the Harm Reduction Coalition in writing Health and Human Services Secretary Kathleen Sebelius on preventing deaths due to drug overdose. Voicing support for Congress having included overdose prevention language in the FY 2012 Labor, Health and Human Services, and Education appropriations bill and the Food and Drug Administration Safety and Innovation Act, the letter calls for HHS to continue taking action to prevent drug overdose fatalities. Signed by over 15 professional healthcare organizations including the AANA, the letter notes that “deaths from accidental overdose are now at epidemic levels in the United States; yet, currently, there is no federal program or agency tasked with specifically preventing death from overdose, and there is an urgent need for education of health professionals and the public.”
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AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent
A patient-safety project funded by the U.S. Agency for Healthcare Research and Quality has successfully reduced the rate of central line-associated bloodstream infections (CLABSIs) in intensive-care units (ICUs) by 40 percent, preliminary findings show. The project used the Comprehensive Unit-based Safety Program—which combines clinical best practices with improved safety culture and teamwork—to achieve the results, including the prevention of more than 2,000 CLABSIs. This saved about 500 lives and eliminated $34 million in healthcare costs. Key project partners include the American Hospital Association and Johns Hopkins Medicine. The project involved hospital teams at more than 1,100 adult ICUs in 44 states over a four-year period. The preliminary findings show that participating hospitals reduced the rate of CLABSIs nationally from 1.903 infections per 1,000 central-line days to 1.137 infections per 1,000 line days.
From "AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent"
AHRQ Press Release (09/10/2012)

Depression, Abuse Up Risk of Long-Term Pain Meds Use
A new study spearheaded by Dr. Ian Carroll of Stanford University identified several factors—including depression, prior use of pain medications, and a high perceived risk of addiction—that may increase the odds of a person continuing to use opioid drugs long after an operation. "Each of these factors was a better predictor of prolonged opioid use than postoperative pain duration or severity," Carroll noted. His team examined numerous factors tied to long-term use of pain medications in more than 100 patients undergoing a range of procedures. Prior to surgery, patients were scanned for several factors that might influence their use of pain relievers; afterwards, they received regular assessments of their consumption of opioids. The results showed that 6 percent of patients still had a prescription for opioid drugs five months after surgery, and those who were given opioids for pain relief before surgery were 73 percent more likely to still be on the drugs at follow-up. Additionally, researchers said that patients who had rated themselves at higher risk of developing an addiction prior to surgery were more likely to still be using the pain medications for a long period of time. Carroll and his colleagues conceded that some of the drug use may have been justifiable; however, their findings raise concerns about the "disconnect" between non-pain-related risk factors and the reason (pain relief) for which the opioids were prescribed.
From "Depression, Abuse Up Risk of Long-Term Use of Pain Meds"
Psych Central (09/04/2012) Pedersen, Traci

NIH Funded Researchers Identify and Explore Different Aspects of Anesthesia
Despite being in use for over 150 years, doctors and scientists still do not fully understand how anesthetics work in the body. Through research funded by the National Institutes of Health, scientists have made significant advances in knowledge in recent years. Researchers have found that general anesthesia consists of several components: sedation, unconsciousness, immobility, pain relief, and amnesia. Drugs can act on these components separately, which allows anesthesia professionals to tailor their regimens for different patients. Scientists also now know that anesthetics do not act on fatty molecules in cell membranes. Evidence now suggests that the drugs target specific protein molecules embedded in nerve cell membranes. New anesthetics are able to act quickly and exit the bloodstream rapidly, allowing patients to go home sooner and experience fewer side effects. Anesthesia professionals also have the benefit of improvements in patient monitoring, such as electronic devices that continually display vital signs, which improved the safety of general anesthesia. Researchers are also studying the processes of unconsciousness from anesthesia to learn more about the transition between conscious and unconscious states.
From "NIH Funded Researchers Identify and Explore Different Aspects of Anesthesia"
News-Medical.Net (09/05/12)

Nerve Block Anesthesia May Reduce Recovery Time and Hospital Stays
Nerve blocks have emerged as a viable alternative to general anesthesia, which is associated with adverse side effects and longer hospital stays. Clinicians use ultrasound to locate nerves in the affected region and then administer an anesthetic injection to block chemical pain signals from being delivered to the brain. The approach is particularly effective for operations involving the arms and legs but also has demonstrated success with breast cancer surgery, kidney stone removal, hernia correction, vascular surgery, hip replacement, and orthopedic trauma. The benefits of nerve blocks include reduced nausea, vomiting, and itchiness; less postoperative pain and confusion; shorter recovery times and hospital stays; and the patient's choice of whether to remain awake or be sedated during the procedure. The technique is not without its drawbacks, however, including the risk of an allergic reaction to, or side effects from, the anesthetic agent; risk of volatile blood sugar and blood pressure readings; the possibility of mood swings following the surgery; the potential for bleeding in patients on anticoagulants; and possible nerve tissue damage or destruction as well as partial sensory/motor loss.
From "Nerve Block Anesthesia May Reduce Recovery Time and Hospital Stays"
MedCity News (09/03/12) Pelles, Saar
Studies Reveal Causes of Error in Regional Anesthesia
Researchers have found that ampule errors, syringe swaps, and confusion over epidurals and intravenous lines are some of the most common causes of drug-related issues with regional anesthesia. Results came from two studies conducted by Dr. Santosh Patel of Pennine Acute NHS Trust Hospital in Oldham, England. Patel presented his research at the 2012 meeting of the International Anesthesia Research Society. His study team searched databases for incidents involving epidural or intrathecal injections and found cases of drug errors for both obstetric and non-obstetric cases. Many mistakes involved swapped, unlabeled, or incorrectly labeled syringes, but the researchers also found cases of mix-ups over catheters and IV lines. Ampule errors led to the deaths of four patients. Another study looked at obstetric cases and included data on labor and neonatal outcomes. This study showed that lack of provider education, fatigue, poor lighting, and mix-ups in supply or storage could lead to anesthesia-related errors.
From "Studies Reveal Causes of Error in Regional Anesthesia"
Becker's ASC Review (09/12) Fields, Rachel
Study Lnks Method of Anesthesia to In Vitro Success
While conceding that further study is needed, researchers in Argentina believe that in vitro fertilization may be more successful in patients who undergo general anesthesia rather than conscious sedation. The team conducted a retrospective study of fertilization rates among 438 women who were having egg retrieval procedures done. General anesthesia was administered to 105 of the subjects and 333 received conscious sedation. Although the rates of successful impregnation and delivery were the same for both groups at 50 percent and 44 percent, respectively, the investigators documented markedly higher rates of fertilization and embryo development in the general anesthesia cohort. "Our hypothesis is that conscious sedation agents impair the accumulation of substances in the oocyte's cytoplasm and therefore affect subsequent embryonic development," said Gustavo Martinez, PhD, who presented the research results at the 2012 World Congress of Anesthesia. "This effect seems not to exist, or to be lower, in the case of drugs used in general anesthesia." University of Pennsylvania Health Center anesthesiology and critical care professor Robert Gaiser, MD, who interpreted the findings as evidence that neither form of anesthesia is superior to the other, suggested that patients look to other factors—such as cost, provider type, and anesthesia availability—when deciding which to choose.
From "Study Links Method of Anesthesia to In Vitro Success"
Anesthesiology News (08/01/12) Vol. 38, No. 8 Wild, David

Anesthesia for Hand or Face TransplantsInitial Guidelines
While hand and facial transplants are uncommon, the first guidelines for anesthetic management of patients undergoing these procedures are described in the September issue of Anesthesia & Analgesia. The University of Pittsburgh hand transplant group and Dr. R. Scott Lang have developed the "Pittsburgh Upper Extremity Transplant Anesthesiology Protocol" (PUETAP), which includes detailed information on fluid management, intraoperative monitoring, and regional anesthesia strategies to block the nerves supplying the arm and hand. The group emphasized the need to meet with the patient prior to surgery to discuss anesthesia plans and again after surgery to evaluate immediate and long-term pain management. In a second article published in the journal, Dr. Thomas Edrich of Brigham and Women's Hospital presents the results of a worldwide survey of facial transplantation centers regarding their perioperative management. He reports that the median time of surgery and anesthesia for facial transplant patients is 19 hours. Additionally, the team found that blood loss is often "considerable," requiring large amounts of fluids and blood transfusion.
From "Anesthesia for Hand or Face Transplants—Initial Guidelines"
Newswise (08/30/12)

Recall Issued for Hospira Injectable Anesthesia Product
The U.S. Food and Drug Administration has issued a nationwide recall of three lots of Hospira's Propofol Injectable Emulsion. The product is packaged in vials and used to induce anesthesia. The lots were distributed to wholesalers and direct customers between September 2011 and February 2012. The product is being recalled because of a potential for visible particles embedded in the glass to enter the solution. The particles could then be injected into a patient, causing injuries.
From "Recall Issued for Hospira Injectable Anesthesia Product"
Becker's ASC Review (08/12) Linder, Heather
Reduced Pain, Opioid Use, and Opioid-Related Adverse Events in Patients Receiving Exparel Compared with Patients Receiving Bupivacaine HCl
Pacira Pharmaceuticals recently announced the results of a pooled analysis of nine clinical trials that compared cumulative pain scores, opioid consumption, and occurrence of opioid-related adverse events (ORAEs) after administration of either Exparel (bupivacaine liposome injectable suspension) or bupivacaine HCl. Exparel was associated with a statistically significant reduction in cumulative pain scores through 72 hours, longer time to first opioid rescue, decreased opioid requirements, and lower incidence of ORAEs. The study results show that 36 percent of bupivacaine HCl patients experienced at least one ORAE, compared to 20 percent of patients who received Exparel. The analysis of these nine trials included data from a total of 503 patients who received a single administration of Exparel at doses up to 266 mg and 409 patients who received bupivacaine HCl at doses up to 200 mg. Patients underwent surgeries that included inguinal hernia repair, total knee arthroplasty, hemorrhoidectomy, bunionectomy, and breast augmentation. Nausea, constipation, and vomiting were the most commonly reported side effects. The study is published in Current Medical Research and Opinion.
From "Reduced Pain, Opioid Use, and Opioid-Related Adverse Events in Patients Receiving Exparel Compared With Patients Receiving Bupivacaine HCl"
Herald Online (S.C.) (09/05/12)

Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy and Toxicity of Subcutaneous Ketamine in the Management of Cancer Pain
Researchers have found that the anesthetic ketamine has no net clinical benefit when used as an adjunct to opioids and standard coanalgesics for cancer pain. Investigators sought to determine whether ketamine is more effective than placebo when used in conjunction with opioids and standard adjuvant therapy to manage chronic cancer pain. The double-blind, randomized Phase III trial delivered ketamine or placebo subcutaneously to a total of 185 participants over three to five days. The results showed no significant difference between the proportion of positive outcomes in the placebo arm (92 patients) and the intervention arm (93 patients). Pain type, nociceptive versus neuropathic, was not a predictor of response. The incidence of adverse events was almost double in the ketamine group after day one and throughout the study.
From "Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy and Toxicity of Subcutaneous Ketamine in the Management of Cancer Pain"
Journal of Clinical Oncology (09/12) Hardy, Janet; Quinn, Stephen; Fazekas, Belinda; et al.
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