IMpact of PerioperAtive KeTamine on Enhanced Recovery After abdominal Surgery (IMPAKT ERAS): a pragmatic randomised single-cluster trial
Britany L. Raymond, Brian F.S. Allen, Robert E. Freundlich, Matthew D. McEvoy, Crystal G. Parrish, Sydney R Ruble, Kevin H. Scharfman, Jonathan P. Wanderer, Yue Gao, Leena Choi, Mary Lynn Dear, Hiral Master, Todd W. Rice, Miklós D. Kertai, Gordon R. Bernard, Robert S. Dittus, Peter J. Embí, Robert E. Freundlich, Cheryl L. Gatto, Frank E. Harrell, Paul A. Harris, Tina V. Hartert, Catherine H. Ivory, Ruth Kleinpell, Sunil Kripalani, Lee Ann Liska, Patrick Luther, Jay Morrison, Jill M. Pulley, Edward T. Qian, Kris Rehm, Todd W. Rice, Russell L. Rothman, Patti Runyan, Wesley H. Self, Matthew W. Semler, Jennifer Slayton, Robin Steaban, Cosby A. Stone, P.L. Walker, Consuelo H. Wilkins, Adam Wright, Autumn D. Zuckerman, Chad Fitzgerald
Abstract
BACKGROUND: Despite widespread adoption of ketamine into enhanced recovery after surgery (ERAS) protocols, research regarding its specific impact on perioperative outcomes is limited. This pragmatic, randomised, double-blind, placebo-controlled, single-cluster trial evaluated the impact of ketamine on postoperative outcomes in patients undergoing major abdominal surgery within an established ERAS protocol. METHODS: Male and female patients, aged ≥18 yr, were randomised to ketamine or saline placebo bolus at induction of general anaesthesia, followed by an intraoperative and postoperative infusion for 48 h. The primary outcome was hospital length of stay. Secondary outcomes included total opioid consumption and the incidences of side-effects and adverse events. RESULTS: A total of 1522 patients were included. In covariate adjusted analyses, ketamine administration did not decrease length of stay (odds ratio [OR] 1.21; 95% confidence interval [CI] 1.00-1.47) or opioid consumption (OR 0.85; 95% CI 0.71-1.01) compared with placebo. Patients receiving ketamine experienced higher odds of ICU transfer (OR 2.03; 95% CI 1.14-3.63) and lower odds of meeting early discharge milestones (OR 0.68; 95% CI 0.50-0.93). Rapid response activation (OR 1.51; 95% CI 0.85-2.68) and ileus requiring nasogastric decompression (OR 1.26; 95% CI 0.87-1.84) were similar between groups. Patients receiving ketamine experienced higher rates of debilitating dizziness (OR 6.05; 95% CI 3.02-12.11), debilitating hallucinations (OR 2.69; 95% CI 1.09-6.65), and other severe side-effects (OR 1.94; 95% CI 1.27-2.96). CONCLUSIONS: The addition of ketamine to a multimodal abdominal ERAS protocol provided no significant benefits and was associated with worse perioperative outcomes. CLINICAL TRIAL REGISTRATION: NCT04625283.