In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • The Cost-Effectiveness of Post-Operative Ketamine in Chiari Decompression

    Final Number:
    619

    Authors:
    Michael Maurice McDowell MD; Ahmad Alhourani MD; Robert Max Friedlander MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: In Chiari I patients, post-operative pain and discomfort slow the transition back to the home setting. We sought to reduce hospital length of stay (LOS) and cost as well as narcotics use via a standardized post-operative ketamine infusion protocol.

    Methods: This quality improvement study enrolled 100 consecutive adult patients undergoing Chiari I decompression by a single provider. Fifty-nine patients were placed on a 2-3mg/hr ketamine drip until post-operative day one. This group was compared a group who received ketamine until post-operative day two (19) and patients who did not receive ketamine at all (22). Clinical characteristics, opiod use, length of stay (LOS), and hospitalization costs were assessed.

    Results: The LOS of the short ketamine group was 46.5 hours when compared to the long ketamine group (66.8 hours) and the no ketamine group (56.9 hours) together (p < 0.001) as well as when compared individually (p = 0.001 and 0.004). The relative total hospital cost was 1.17x the mean for the standard pain control group and 1.14x the mean in the long ketamine group (1.09x the mean for the combined two groups). The relative cost was 0.94x the mean for the short ketamine group, for an absolute difference of 20% of the mean cost when comparing the short ketamine protocol to all other patients (p < 0.001). Mean morphine milligram equivalents used post-operatively was 148mg in the short ketamine group, 196mg in the long ketamine group, and 187mg in the no ketamine group (p=0.65). Only the no ketamine group’s LOS was correlated with narcotic use (r2=0.62, p=0.003). No adverse events from ketamine were noted.

    Conclusions: Ketamine may reduce narcotic tolerance and potentially decreases side effects. Strategic application of supplementary ketamine appears to be an effective tool to allow for early return home post-operatively, and may substantially reduce medical costs.

    Patient Care: 1) Demonstrate the ability to reduce costs without decreasing quality of care 2) Provide new options of post-decompression pain control

    Learning Objectives: 1) Understand the relationship between hospital costs and length of stay 2) Understand the mechanism of pain de-sensitization with ketamine 3) Consider the use of standardized pain regimens to supplement PRN pain control

    References: 1. Alfieri A, Pinna G: Long-term results after posterior fossa decompression in syringomyelia with adult Chiari Type I malformation. J Neurosurg Spine 17:381-387, 2012 2. Aliaga L, Hekman KE, Yassari R, Straus D, Luther G, Chen J, et al: A novel scoring system for assessing Chiari malformation type I treatment outcomes. Neurosurgery 70:656-664; discussion 664-655, 2012 3. Cupitt JM: Pain and opiates following elective craniotomy. Anaesthesia 54:1229, 1999 4. Elia N, Tramer MR: Ketamine and postoperative pain--a quantitative systematic review of randomised trials. Pain 113:61-70, 2005 5. Fischbein R, Saling JR, Marty P, Kropp D, Meeker J, Amerine J, et al: Patient-reported Chiari malformation type I symptoms and diagnostic experiences: a report from the national Conquer Chiari Patient Registry database. Neurol Sci 36:1617-1624, 2015 6. Graham AC, Reid MM, Andrews PJ: Perception of pain experienced and adequacy of analgesia following elective craniotomy. Anaesthesia 54:814-815, 1999 7. Greenberg JK, Milner E, Yarbrough CK, Lipsey K, Piccirillo JF, Smyth MD, et al: Outcome methods used in clinical studies of Chiari malformation Type I: a systematic review. J Neurosurg 122:262-272, 2015 8. Hansen RN, Pham A, Strassels SA, Balaban S, Wan GJ: Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain. Adv Ther, 2016 9. Heffez DS, Ross RE, Shade-Zeldow Y, Kostas K, Shah S, Gottschalk R, et al: Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia. Eur Spine J 13:516-523, 2004 10. Joly V, Richebe P, Guignard B, Fletcher D, Maurette P, Sessler DI, et al: Remifentanil-induced postoperative hyperalgesia and its prevention with small-dose ketamine. Anesthesiology 103:147-155, 2005 11. Kamal RN, Hand Surgery Quality C: Quality and Value in an Evolving Health Care Landscape. J Hand Surg Am 41:794-799, 2016 12. Khullar D, Chokshi DA, Kocher R, Reddy A, Basu K, Conway PH, et al: Behavioral economics and physician compensation--promise and challenges. N Engl J Med 372:2281-2283, 2015 13. Khullar OV, Fernandez FG, Perez S, Knechtle W, Pickens A, Sancheti MS, et al: Time is Money: Hospital Costs Associated With Video-Assisted Thoracoscopic Surgery Lobectomies. Ann Thorac Surg, 2016 14. Long KH, Moriarty JP, Ransom JE, Lennon RJ, Mathew V, Gulati R, et al: Economic and clinical impact of routine weekend catheterization services. Am J Manag Care 22:e233-240, 2016 15. Porter ME: A strategy for health care reform--toward a value-based system. N Engl J Med 361:109-112, 2009 16. Speer MC, Enterline DS, Mehltretter L, Hammock P, Joseph J, Dickerson M, et al: Review Article: Chiari Type I Malformation with or Without Syringomyelia: Prevalence and Genetics. J Genet Couns 12:297-311, 2003 17. Williams LE, Vannemreddy PS, Watson KS, Slavin KV: The need in dural graft suturing in Chiari I malformation decompression: A prospective, single-blind, randomized trial comparing sutured and sutureless duraplasty materials. Surg Neurol Int 4:26, 2013

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy