Effects of initial pain treatment on sedation recovery time in pediatric emergency care

Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial

IMPORTANCE

Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative.

OBJECTIVE

To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries.

DESIGN, SETTING, AND PARTICIPANTS

The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017.

INTERVENTIONS

Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg).

MAIN OUTCOMES AND MEASURES

The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10.

RESULTS

Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, -6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6).

CONCLUSIONS AND RELEVANCE

Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02778880.

Management of Pain in the Emergency Department

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate

OBJECTIVES

Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations.

METHODS

This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors.

RESULTS

Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea.

CONCLUSIONS

This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

STUDY OBJECTIVE

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

METHODS

We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

RESULTS

In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.

CONCLUSION

Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Non-anesthesiologist-provided pediatric procedural sedation: an update

PURPOSE OF REVIEW

This review evaluates the past year's literature on the provision of pediatric procedural sedation outside of the operating room, especially as performed by non-anesthesiologist healthcare providers.

RECENT FINDINGS

Research on pediatric procedural sedation practice continues to be limited by small case series and single institution study design. However, some exciting developments have occurred. Recent guideline revisions and safety initiatives are reported that impact positively on practice. Efforts to analyze the elements of sedation systems that result in greater safety, efficiency, and patient satisfaction are increasing, including evaluations of tiered systems utilizing the skills of various healthcare providers. Dexmedetomidine and etomidate are the subjects of investigation on their utility for procedural sedation. A multicentered study, adequately powered to provide meaningful evaluation of adverse events, has been completed and provides valuable insight on pediatric procedural sedation as practiced by a variety of healthcare providers.

SUMMARY

Pediatric procedural sedation practice as performed by non-anesthesiologists continues to grow. Ongoing efforts to understand the elements of sedation systems that lead to best practice, with the subsequent development of uniform practice approaches, are essential. A collaborative relationship between anesthesiologists and non-anesthesiologist providers of procedural sedation is essential for meeting common goals.

Low-dose ketamine: efficacy in pediatric sedation

OBJECTIVES

Intravenous (IV) ketamine has gained widespread use in the emergency department (ED) for procedural sedation. The most commonly recommended starting dose is 1.5 mg/kg. We examined whether lower doses of ketamine in the range of 0.5 to 1.0 mg/kg could successfully sedate pediatric patients.

METHODS

We retrospectively reviewed quality assurance data of patients sedated with IV ketamine in a pediatric ED. Patients were administered 0.02 mg/kg of IV atropine, 0.05 mg/kg of IV midazolam, and then 0.5 mg/kg of IV ketamine. Additional aliquots of 0.25 to 0.5 mg/kg of ketamine were given as necessary, to a maximum of 2.0 mg/kg. Efficacy of sedation was assessed after every dose by pediatric emergency medicine attendings or fellows.

RESULTS

Seventy-two patients had quality assurance forms completed. The total ketamine dose administered ranged from 0.5 to 2 mg/kg. Adequate procedural sedation was obtained for 70 (97%) of 72 patients. Forty-four percent of patients required 0.75 mg/kg or less of ketamine to obtain adequate initial sedation; 25% of subjects required only 0.5 mg/kg; 43% of patients required 1.0 mg/kg of IV ketamine. We found that 88% of our patients could be successfully sedated at initial doses of 1 mg/kg or less.

CONCLUSIONS

Our study suggests a potential role for low-dose IV ketamine in the range of 0.5 to 1.0 mg/kg for pediatric procedural sedation. Most pediatric ED patients can be successfully sedated with 1 mg/kg of ketamine.