Key Message

What Is the Issue? Doctors use ketamine to induce loss of consciousness as general anesthesia during surgery. At low doses that do not produce dissociation, practitioners use ketamine to relieve acute or chronic pain. The previous Canada's Drug Agency report published in 2020 found that IV ketamine, compared to placebo, could only provide short-term pain relief in patients with chronic non-cancer pain, with increased risks of nausea, vomiting, and psychomimetic effects. The included guidelines did not provide definitive recommendations due to insufficient evidence. Decision-makers want to know if there is any new evidence to support the use of ketamine for treating of chronic non-cancer pain in adults.

What Did We Do? To inform decisions about the use of ketamine for treating of chronic non-cancer pain, Canada's Drug Agency sought to update the previous report by identifying and summarizing literature comparing the clinical effectiveness and cost-effectiveness of ketamine with placebo or other pharmacological therapies for chronic non-cancer pain. We also attempted to identify evidence-based recommendations from most recent guidelines for the use of ketamine for chronic non-cancer pain. A research information specialist conducted a literature search of the peer-reviewed and grey literature with a search strategy focused on ketamine, chronic non-cancer pain, and adults. The search was limited to English-language documents published since 2020 up to November 06, 2023. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find? We found 3 SRs and 1 randomized controlled trial on the use of ketamine for the treatment of patients with neuropathic pain, complex regional pain syndrome, fibromyalgia, and other chronic pain conditions. Collective evidence from the included studies suggests that ketamine treatment was associated with short-term pain reduction in patients with chronic non-cancer pain. However, the long-term efficacy of ketamine in pain relief remains unclear. Adverse events (AEs) associated with ketamine treatment were with psychedelic effects, discomfort, dizziness, fatigue, headache, and nausea; all of those events appeared to be short-lasting. There were mixed results regarding the effect of ketamine on quality of life and functional improvement. We did not find any studies on the cost-effectiveness of ketamine or new evidence-based guidelines on the use of ketamine for treating chronic non-cancer pain.

What Does It Mean? The findings in this review are consistent with the previous Canada's Drug Agency report published in 2020. Well-controlled studies with larger populations and longer follow-ups are needed to determine the optimal treatment protocol of ketamine for each specific type of chronic pain. Given that ketamine is a dissociative drug that could be associated with the development of a substance use disorder, decision-makers may wish to consider the use of ketamine for long-term treatment of chronic non-cancer pain. The long-term effects and dangers of ketamine remain to be determined.

Key Message

This review focused on the perspectives and experiences of adults with end-stage renal disease (referred to as "patients"), their families, and their health care providers regarding accessing, offering, deciding about, undergoing, performing, and recovering from procedures to create arteriovenous fistulas (AVFs) for hemodialysis. AVFs are connections between an artery and vein used for vascular access, a process that allows a hemodialysis machine to access a patient's blood. A total of 8 qualitative studies were synthesized.

• Patients and health care providers mostly valued shared decision-making (SDM) when deciding to undergo procedures to create AVFs. The perceived benefits of SDM include patients' increased knowledge of their condition, satisfaction, greater sense of control, and improved coping abilities. Yet, some health care providers continue to practice traditional prescriptive approaches to decision-making. Contextual factors influenced decision-making approaches and patients' agency to access or refuse procedures to create AVFs. These factors included values, beliefs, and attitudes; the timing of decision-making; and human, structural, financial, and informational resources. People who are racialized and those experiencing poverty, houselessness, or language barriers may disproportionately experience difficulties engaging in timely and informed SDM; as a result, they may make uninformed decisions or experience traumatic unplanned dialysis initiation using a form of vascular access they did not choose.
• Decision-makers may consider promoting SDM practices by integrating SDM criteria in health care performance measures and SDM reimbursement models. They may also consider providing decision aids and SDM coaching to health care providers. They may also consider tailored interventions based on unique social, financial, and language-related needs to promote equitable access to procedures to create AVFs.
• During decision-making, patients weigh factors such as trust in their health care providers, past experiences, the invasive nature of procedures to create AVFs, and the anticipated outcomes of these procedures. Patients' fears of being "cut" or experiencing pain and complications could hinder their engagement in these procedures. Patients' concerns about an AVF being dysfunctional or hard to maintain and the anticipated pain of needles could also prevent them from wanting AVFs. Additional concerns included the risk of bleeding and an AVF's impact on physical appearance.
• The included literature provided limited insights into the perspectives and experiences of undergoing, performing, and recovering from procedures to create AVFs. However, some patients and their families experienced financial and emotional burdens while accessing these procedures in Canada. This can be exacerbated by prolonged surgical wait times and rescheduling. People in rural communities, who often had to travel long distances for care, experienced these burdens more than those living in urban areas. Additionally, 1 study reported that surgeons often lead decision-making regarding anesthesia for surgical AVF creation procedures. While considering patient preferences, some health care providers perceive that regional anesthesia made these surgeries easier to perform, potentially resulting in better-quality AVFs. However, barriers to implementing regional anesthesia include limited human resources, funding, and time.

[Please refer to the main report for the Key Messages]

Key Message

What Is the Issue?

• Parastomal hernia is a common complication that can occur following ostomy surgery. They can have a negative impact on a person's quality of life, affecting them both physically and psychologically. One intervention that may be used to help prevent or manage parastomal hernias are hernia support garments.
• To help inform decisions about the most appropriate use for hernia support garments, it is important to understand the current best practices as well as potential benefits and harms of using these garments.

What Did We Do?

• We searched for clinical and cost-effectiveness literature comparing hernia support garments to alternative hernia prevention or management strategies or no intervention. We also searched for evidence-based guidelines that provide recommendations about the use of hernia support garments for the prevention or management of parastomal hernias.
• An information specialist searched for peer-reviewed and grey literature sources published between January 1, 2013, and November 1, 2023.
• We engaged with an individual who has lived experience of an ostomy and parastomal hernia and who wears a hernia belt regularly. They shared thoughts on the physical and psychological benefits, impact on quality of life, and challenges of using a hernia belt. This gave Canada's Drug Agency a more nuanced understanding of the literature.

What Did We Find?

• We did not find any studies directly evaluating the clinical or cost-effectiveness of hernia support garments versus alternative hernia prevention or management interventions or no treatment that met the inclusion criteria for this review.
• Three evidence-based guidelines made recommendations related to using hernia support garments to prevent and manage parastomal hernia. One guideline recommends that individuals with an ostomy should be assessed to determine the type and level of support required to prevent or manage hernia. Another guideline recommends that health providers provide postoperative education on using support garments. The third guideline recommends that stoma care nurses provide lifestyle advice about support garments to individuals with a stoma. This guideline also recommends that these nurses should be available to advise on non-operative management options for parastomal hernias more generally.

What Does This Mean?

• Decision-makers might wish to consider ways to ensure that individuals who have had or are scheduled to have an ostomy surgery have timely access to parastomal hernia risk assessment, education, and advice on the use of hernia support garments from nurses specialized in wound, ostomy, and continence care. They may also want to consider out-of-pocket costs that may be a barrier to this care.