IMpact of PerioperAtive KeTamine on Enhanced Recovery After abdominal Surgery (IMPAKT ERAS): a pragmatic randomised single-cluster trial.

Summary

In a pragmatic double-blind randomized trial of 1,522 ERAS abdominal surgery patients, ketamine did not shorten hospital stay or reduce opioid use compared with placebo. Ketamine increased ICU transfers, hindered early discharge milestones, and led to more severe neuropsychiatric side effects. These data challenge routine ketamine use within ERAS pathways.

Key Findings

• No reduction in hospital length of stay with ketamine versus placebo (adjusted OR 1.21; 95% CI 1.00–1.47).
• No significant reduction in opioid consumption (OR 0.85; 95% CI 0.71–1.01).
• Increased ICU transfers with ketamine (OR 2.03; 95% CI 1.14–3.63).
• Lower odds of meeting early discharge milestones with ketamine (OR 0.68; 95% CI 0.50–0.93).
• Higher rates of debilitating dizziness (OR 6.05) and hallucinations (OR 2.69) with ketamine.

Clinical Implications

Avoid routine ketamine in ERAS abdominal surgery pathways; prioritize multimodal regimens without ketamine and monitor for neuropsychiatric adverse effects if used.

Limitations

• Single-cluster design may limit generalizability across diverse institutions.
• Trial tested a specific dosing and infusion strategy; other regimens were not evaluated.

Future Directions

Head-to-head trials of alternative multimodal analgesia without ketamine, subgroup analyses to identify patients at risk of ketamine adverse effects, and mechanistic studies on neuropsychiatric toxicity.