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. 2025 Sep 2:S0007-0912(25)00508-2.
doi: 10.1016/j.bja.2025.08.001. Online ahead of print.

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

Britany L Raymond  1 , Brian F S Allen  2 , Robert E Freundlich  3 , Matthew D McEvoy  4 , Crystal G Parrish  2 , Sydney R Ruble  2 , Kevin H Scharfman  5 , Jonathan P Wanderer  3 , Yue Gao  6 , Leena Choi  6 , Mary L Dear  7 , Hiral Master  7 , Todd W Rice  7 , Miklos D Kertai  2 ; Vanderbilt Learning Healthcare System Platform Investigators
Collaborators, Affiliations
Free article

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

Britany L Raymond et al. Br J Anaesth. .
Free article

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.

Keywords: enhanced recovery after surgery; ketamine; length of stay; multimodal analgesia; perioperative outcomes; pragmatic trial.

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Conflict of interest statement

Declarations of interest MDM serves on the scientific advisory board for Takeda Pharmaceuticals, and the role is unrelated to this work. REF owns stock in 3M, and he serves as a consultant for Oak Hill Clinical Informatics and Phillips. He declares no conflicts of interest with this work. TWR has relations with Cumberland Pharmaceuticals, Inc. (Director of Medical Affairs), Cytovale, Inc. (Consultant), and Sanofi, Inc. (Member of the Data Safety and Monitoring Board). No conflicts or relationships are related to this work. All other authors declare that they have no conflicts of interest.

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