Intranasal ketamine for acute traumatic pain in the Emergency Department: a prospective, randomized clinical trial of efficacy and safety

Efficacy of intranasal ketamine in controlling pain caused by bone fractures: A single-center double blind randomized controlled trial

INTRODUCTION

Bone fractures are recognized as the second most prevalent cause of pain for patients seeking treatment in medical facilities. This study aims to evaluate the efficacy of intranasal and intravenous ketamine in comparison to intravenous morphine in alleviating severe pain in patients presenting to emergency departments with various bone fractures.

METHOD & MATERIAL

The clinical trial was conducted on patients over the age of 18 who presented at the emergency department of Imam Reza Educational and Medical Center with bone fractures. These patients were divided into three groups for treatment: intranasal ketamine at a dose of 1 mg/kg body weight, intravenous ketamine at a dose of 0.5 mg/kg body weight, and intravenous morphine at a dose of 0.1 mg/kg body weight. The severity of pain experienced by patients was documented using the numerical pain rating scale at the time of admission, and then at 15 min, 30 min, and 60 min after drug administration.

RESULTS

The results of the study revealed that there was no statistically significant difference in the efficacy of pain relief among the three study groups (p=0.77). The interaction of (time*type of drug) had no significant effect on pain intensity (p=0.58). There was no statistically significant difference in side effects reported by patients between the three study groups, with the intranasal ketamine group reporting only minor side effects.

CONCLUSION

The results of this study showed significant effects of intranasal ketamine and intravenous ketamine in reducing pain in patients with bone fractures. The findings further suggest that the analgesic effect of intranasal ketamine is comparable to that of intravenous ketamine and morphine, with no significant adverse effects observed.

Significant room for improvement in the prehospital assessment and treatment of acute abdominal pain: a retrospective observational study

BACKGROUND

Acute abdominal pain (AAP) is a common reason for calling emergency medical services (EMS). Despite the widely acknowledged importance of effective prehospital pain management, described by patients as crucial regardless of any other factor, studies on prehospital pain management in AAP patients are limited and suggest room for improvement. This is particularly relevant given the long-standing controversy surrounding the use of analgesia in AAP patients before a final diagnosis is made, which may still influence the prehospital pain management.

METHODS

A retrospective cohort study of pain management in EMS patients with AAP in a central Swedish region. The region had a population density of 15.7 inhabitants per square kilometer spread over a mix of small urban and rural settings. Patient records were manually reviewed and scanned for written assessments or numeric ratings of pain. The analysis focused on proportions of assessment, treatment and reassessment of pain as well as median pain intensity, pain reduction and proportion of patients with a low last recording of pain.

RESULTS

816 patients were included. Pain was assessed in 55% (n = 447) of all cases. The median initial pain intensity was eight units (IQR 6.0-9.0) on the Numerical Rating Scale (NRS), and 90% (n = 403) of the assessed patients experienced moderate or severe pain. Of those, 62% (n = 249) received pharmacological treatment. In 50% (n = 158) of all cases receiving treatment, pain was reassessed afterwards. The median pain reduction was four units (IQR 2.0-5.0) on the NRS scale. Among all cases, 10% (n = 84) had a last recorded pain assessment indicating low pain.

CONCLUSIONS

Significant room for improvement in the prehospital management of acute abdominal pain was found. The proportions of pain assessment, treatment and reassessment were low with nine out of ten patients leaving prehospital care with unknown, moderate or severe pain. Among the cases where pain assessment, treatment and reassessment were made and recorded, four out of five patients experienced significant pain relief, indicating the potential of better prehospital pain management.

Management of mass casualty incidents: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to generate evidence- and consensus-based recommendations for the management of mass casualty incidents (MCIs) based on current evidence. This guideline topic is part of the 2022 update of the German guideline on the treatment of patients with severe/multiple injuries.

METHODS

MEDLINE and Embase were systematically searched to August 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, cross-sectional studies, prospective cohort studies, and comparative registry studies were included if they compared triage algorithms, interventions for MCI training, logistics or transport, decontamination, diagnosis or therapy during MCIs in the prehospital and hospital settings. We considered patient-relevant clinical outcomes such as mortality, diagnostic outcomes including sensitivity and specificity, rates of undertriage and overtriage as well as resource use. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Population, intervention, comparison, and outcome (PICO) questions from clinical questions were developed by clinical experts and guideline methodologists.

RESULTS

We screened 321 records in the original guideline version and 4225 during this update. Twenty-five studies were included, all of them from the updated search from 2009 to 2021. Twenty-five new studies were identified. Interventions covered were triage training (n = 7 studies), prehospital triage (n = 6), secondary triage (n = 2), transport/logistics (n = 3), decontamination (n = 5), and therapy (n = 2) during MCIs. Three new recommendations were developed. All achieved strong consensus.

CONCLUSION

Due to unsatisfactory evidence, recommendations could only be made on training for improving triage quality and regular exercises for testing a hospital's emergency response plan. No triage algorithm can be scientifically proven to be superior in all aspects. The key recommendation is the following: To improve triage quality, exercises or (virtual) training should be conducted in-house using verified triage systems and algorithms.

Pain management in acute musculoskeletal injury: Effect of opioid vs nonopioid medications

BACKGROUND

The use of opioids for pain is linked to an increased risk of developing opioid use disorder, and has resulted in the emergence of the opioid crisis over the last few years.

AIM

The systematic review question is "How does the use of opioid medications in pain management, compared with non-opioid medications, affect pain intensity over the short, intermediate, and long-term in adults with acute traumatic pain?".

METHODS

The protocol was prospectively registered on the International Prospective Register of Systematic Reviews: CRD42021279639. Medline and Google Scholar were electronically searched for controlled peer-reviewed studies published in full, with the PICO framework: P: Adult patients with traumatic injuries, I: Opioid medications, C: Non-opioid medications, O: A minimum clinically important difference (MCID) in pain.

RESULTS

After full-text screening, we included 14 studies in the qualitative synthesis. Of these 14 studies, 12 were randomized clinical trials (RCTs) and 2 were pseudo-RCTs with a total of 2347 patients enrolled. There was heterogeneity in both medication utilized and outcome in these studies; only two studies were homogeneous regarding the type of study conducted, the opioid used, its comparator, and the outcome explored. The MCID was evaluated in 8 studies, while in 6 studies, any measured pain reduction was considered as an outcome. In 11 cases, the setting of care was the Emergency Department; in 2 cases, care occurred out-of-hospital; and in one case, the setting was not well-specified. The included studies were found to have a low-moderate risk of bias.

CONCLUSION

Non-opioids can be considered an alternative to opioids for short-term pain management of acute musculoskeletal injury. Intravenous ketamine may cause more adverse events than other routes of administration.

Anesthesia Management in Emergency and Trauma Surgeries: A Narrative Review

Emergency and trauma surgeries present unique challenges for anesthesiologists due to the acuity of patient conditions and the need for rapid intervention. This review aims to provide insights into the optimal management of anesthesia in emergency and trauma surgery settings. We searched the National Institute of Health PubMed, Scopus, MEDLINE, and Web of Science databases between 2014 and 2024 to synthesize current evidence and best practices for anesthesia management during emergency and trauma surgeries. This literature review examines the evolving role of anesthesia in emergency and trauma surgeries, focusing on key considerations such as patient management, hemodynamic stability, and the choice of anesthetic agents. The review discusses recent advancements in anesthesia techniques, including the use of regional anesthesia and multimodal analgesia, to optimize patient outcomes while minimizing complications. Additionally, it discusses the importance of interdisciplinary collaboration among anesthesiologists, surgeons, and other healthcare professionals in delivering timely and effective care to critically injured patients.

Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search

Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.

Low-dose ketamine versus morphine in the treatment of acute pain in the emergency department: A meta-analysis of 15 randomized controlled trials

OBJECTIVE

To compare the effectiveness and safety of ketamine and morphine in adult patients with acute pain in emergency department (ED) by using a meta-analysis method.

METHODS

This study was based on the Cochrane methodology for conducting a meta-analysis. Only randomized controlled trials (RCTs) were eligible for this study, with an experimental group that received low-dose ketamine and a control group that received morphine. The participants were adults who had acute pain in the ED. The primary outcome measures were the numeric rating scale (NRS) and visual analog scale (VAS). The secondary outcome measures were the complete resolution of pain, NRS reduction ≥3 points, NRS reduction ≥50% or 60%, change of NRS score, change of VAS score, rescue analgesia, satisfaction and adverse events. Subgroup analysis was performed for studies with intravenous and intranasal administration of ketamine. The Review Manager Database was used to analyze the included studies.

RESULTS

15 RCTs involving 1768 patients were included. The ketamine group had lower NRS scores than morphine group at 30 min (MD, -0.77 [95% CI, -0.93 to -0.61]; p < 0.00001), while the morphine had better analgesic effects at 120 min after treatment (MD, 0.33 [95% CI, 0.15 to 051]; p = 0.0003). The subjects of complete resolution of pain in the ketamine group performed better than those in the morphine group at 15 min (RR 3.18, 95% CI 1.75 to 5.78; p = 0.0001). Compared with the morphine group, the ketamine group had a lower incidence of adverse events requiring intervention (RR, 0.34 [95% CI, 0.18 to 0.66]; p = 0.001). Subgroup analysis of intravenous ketamine showed that ketamine had lower VAS score than the morphine group at 30 min. However, also on the 30-min VAS score, intranasal ketamine analgesia was less effective than morphine.

CONCLUSIONS

Ketamine had better analgesic effects in the early stages after treatment, while morphine maintained more durable effects. Compared with morphine, ketamine had a lower incidence of adverse events requiring intervention. The results of subgroup analysis showed that intravenous administration of ketamine was more effective than intranasal administration.

Effectiveness of Intranasal Analgesia in the Emergency Department

In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.

Efficacy and Safety of Ketamine Versus Opiates in the Treatment of Patients with Renal Colic: A Systematic Review and Meta-analysis

INTRODUCTION

Renal colic is one of the most common urological emergencies, and is usually caused by ureteral colic spasms. Pain management in renal colic remains the central focus of emergency treatment. The purpose of this meta-analysis is to identify the efficacy and safety of ketamine versus opioids in the treatment of patients with renal colic.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and Web of Science databases for published randomized controlled trials (RCTs) that referred to the use of ketamine and opioids for patients with renal colic. The methodology was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI) was used to analyze the data. The results were pooled using a fixed-effects model or random-effects model. The primary outcome measure was patient-reported pain scores 5, 15, 30, and 60 min after drug administration. The secondary outcome measure was side effects.

RESULTS

The data analysis revealed that ketamine was similar to opioids in pain intensity at the time of 5 min post-dose (MD = - 0.40, 95% CI - 1.82 to 1.01, P = 0.57), 15 min post-dose (MD = - 0.15, 95% CI - 0.82 to 0.52, P = 0.67), 30 min post-dose (MD = 0.38, 95% CI - 0.25 to 1.01, P = 0.24). Also, the pain score of ketamine was better than that of opioids at 60 min after administration (MD = - 0.12, 95% CI - 0.22 to - 0.02, P = 0.02). As for safety, the ketamine group was linked to a significant decrease in the incidence of hypotensive (OR = 0.08, 95% CI 0.01-0.65, P = 0.02). The two groups did not statistically differ in the incidence of nausea, vomiting, and dizziness.

CONCLUSIONS

Compared with opioids, ketamine showed a longer duration of analgesia in renal colic, with satisfactory safety.

TRIAL REGISTRATION

The PROSPERO registration number is CRD42022355246.

Narrative Review: Low-Dose Ketamine for Pain Management

Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.

Drug delivery to the brain via the nasal route of administration: exploration of key targets and major consideration factors

Background

Cranial nerve-related diseases such as brain tumors, Alzheimer's disease, and epilepsy are serious diseases that continue to threaten human. Brain-related diseases are increasing worldwide, including in the United States and Korea, and these increases are closely related to the exposure to harmful substances and excessive stress caused by rapid industrialization and environmental pollution. Drug delivery to the brain is very important for the effective prevention and treatment of brain-related diseases. However, due to the presence of the blood-brain barrier and the extensive first-pass metabolism effect, the general routes of administration such as oral and intravenous routes have limitations in drug delivery to the brain. Therefore, as an alternative, the nasal-brain drug delivery route is attracting attention as a route for effective drug delivery to the brain.

Areas covered

This review includes physiological factors, advantages, limitations, current application status, especially in clinical applications, and the necessary factors for consideration in formulation development related to nasal-brain drug delivery.

Expert opinion

The nasal-brain drug delivery route has the advantage of enhancing drug delivery to the brain locally, mainly through the olfactory route rather than the systemic circulation. The nasal-brain lymphatic system has recently attracted attention, and it has been implied that the delivery of anticancer drugs to the brain nervous system is possible effectively. However, there are limitations such as low drug permeability, as well as nasal mucosa and the mucociliary system, as obstacles in nasal-brain drug delivery. Therefore, to overcome the limitations of nasal-brain drug delivery, the use of nanocarriers and mucoadhesive agents is being attempted. However, very few drugs have been officially approved for clinical application via the nasal-brain drug delivery route. This is probably because the understanding of and related studies on nasal-brain drug delivery are limited. In this review, we tried to explore the major considerations and target factors in drug delivery through the nasal-brain route based on physiological knowledge and formulation research information. This will help to provide a mechanistic understanding of drug delivery through the nasal-brain route and bring us one step closer to developing effective formulations and drugs in consideration of the key factors for nasal-brain drug delivery.

Effect of Intranasal Ketamine on Pain Intensity after Cesarean Section: A Single-Center, Double Blind, Randomized Controlled Trial

Background

Although intravenous or intramuscular opioids are widely used for managing postoperative pain after cesarean section (CS), their side effects are bothering and limit their use. The aim of this study was to determine the effect of intranasal ketamine on pain intensity after CS.

Methods

In a single-center, double-blind, parallel-group, randomized controlled trial, a total of 120 patients who were scheduled for elective CS were randomly assigned into two groups. After birth, 1 mg of midazolam was administered to all patients. In addition, 1 mg/kg intranasal ketamine was administered to patients in the intervention group. For patients in control group, normal saline was administered intranasally as a placebo. The severity of pain and nausea in the two groups was evaluated after 15, 30 and 60 minutes, as well as 2, 6 and 12 hours after the initial administration of the medications.

Results

The trend of changes in pain intensity was decreasing and these changes were statistically significant (time effect; P<0.001). The pain intensity in the placebo group was higher than the intervention and the observed difference was statistically significant, regardless of the time studied (group effect; P<0.001). In addition, it was shown that regardless of the study group, the trend of changes in nausea severity was decreasing and these changes were statistically significant (time effect; P<0.001). Regardless of the time studied, the severity of nausea in the placebo group was higher than the intervention group (group effect; P<0.001).

Conclusions

According to the results of this study, it seems that the using of intranasal ketamine (1 mg/kg), can be considered as an effective, well tolerated and safe method in reducing pain intensity as well as the need for postoperative opioid consumption after CS.

Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis

BACKGROUND

The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain.

PURPOSE

To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting.

DATA SOURCES

Electronic databases and registries from inception to 7 February 2022.

STUDY SELECTION

Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED.

DATA EXTRACTION

Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

DATA SYNTHESIS

Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics.

LIMITATIONS

Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes.

CONCLUSION

The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42021275293).

Low-dose ketamine as an analgesic agent in the emergency department: Efficacy and safety

Introduction

Interest in using low-dose ketamine (LDK) as an alternative analgesic to manage acute pain in the emergency department (ED) has increased. The aim of this systematic review was to compare and evaluate the analgesic effect and safety of LDK for the management of acute pain in the ED.

Method

Databases were searched and all published articles that met the inclusion criteria were used. Electronic research was conducted on a total of 85 articles, and 13 articles that were relevant in terms of content, topic, and aim were selected for further review. The studies were analyzed and categorized after review.

Results

The results demonstrated that in 53.84% (7 of 13) of articles, a significant reduction or more than 50% reduction in pain in the group of patients treated with ketamine (alone or combined with other analgesics) was reported. However, in 46.15% (6 out of 13) of the reviewed articles, no significant difference was observed between the pain reduction in the groups treated with ketamine alone and ketamine with other analgesics. The highest decrease in numerical rating scale (NRS) score was 6 and the lowest was 1. There was also a 100% reduction in NRS score in 14 of 30 patients treated with 0.15 mg/kg ketamine and 0.5 mg/kg hydromorphone.

Conclusion

According to the results of the present study, the use of LDK as an analgesic with low side effects can be suggested. However, further research is needed to determine the appropriate concentration with fewer side effects.

Ketamine Compared With Fentanyl for Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE

To compare patient satisfaction with anesthesia after first-trimester surgical abortion among patients receiving intravenous (IV) ketamine compared with IV fentanyl for procedural sedation.

METHODS

This was a randomized noninferiority trial comparing IV ketamine to IV fentanyl for first-trimester surgical abortion up to 13 6/7 weeks of gestation. Patients were randomized to receive either ketamine 200-500 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved, or fentanyl 0.5-1 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved. All patients received midazolam 2 mg IV. The primary outcome, patient satisfaction, was measured using the Iowa Satisfaction with Anesthesia Scale immediately postprocedure. Secondary outcomes included postoperative pain, additional pain medication necessary during the procedure and on discharge, physician satisfaction, and time to discharge. We calculated a sample size of 84 with a noninferiority margin of 0.6 on the Iowa Satisfaction with Anesthesia Scale with 80% power, one-sided type 1 error of 0.025, and further increased this number to 110 to account for potential dropout.

RESULTS

From April to October 2021, 184 patients were screened and 110 were randomized (57 to ketamine and 53 to fentanyl). Demographics were similar between groups. The primary outcome, patient satisfaction with anesthesia, was noninferior in the ketamine group (mean score 2.4, SD 0.8) as compared with the fentanyl group (mean score 2.2, SD 0.9) with a risk difference of 0.20 (95% CI 0.11-0.52). More hallucinations were reported in the ketamine group. Otherwise, secondary outcomes were similar between the groups.

CONCLUSION

Compared with IV fentanyl, IV ketamine is noninferior for patient satisfaction with anesthesia when used for procedural sedation for first-trimester outpatient surgical abortion.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04871425.

Novel uses of ketamine in the emergency department

INTRODUCTION

: Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting.

AREAS COVERED

: This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation.

EXPERT OPINION

: Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.

Battlefield Pain Summit 2022: Expert Consensus Statements

BACKGROUND

Battlefield pain occurs in combat casualties who suffer multiple severe injuries The nature of battlefield scenarios requires a distinct approach to battlefield pain research. A Battlefield Pain Summit was thus convened to identify shortcomings in current understanding of battlefield pain management, review the current state of battlefield pain research, and shape the direction of future research.

METHODS

On 10-11 January 2022, a hybrid in-person and virtual meeting hosted by the United States Army Institute of Surgical Research (USAISR) defined research priorities for the Combat Casualty Care Research Program's Battlefield Pain research portfolio. Summit participants identified key focus areas under the umbrella of battlefield pain research: battlefield injury patterns; use of ketamine and non-opioid analgesics; analgesic delivery systems; the impact of analgesia on performance, cognition, and survival; training methods; battlefield regional anesthesia; and research models. Preliminary statements presented during the summit refined and rank ordered through a Delphi process.

RESULTS

A total of seven statements achieved consensus addressing ideal analgesic properties, delivery systems, operational performance concerns, and pain training. Ketamine was identified as safe and effective for battlefield use, and further research into non-opioid analgesics represented a high priority.

CONCLUSIONS

The seven consensus statements that emerged from this Battlefield Pain Summit serve as a template to define the near-term research priorities for military-specific battlefield pain research.

Pain management in the emergency department: a clinical review

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

Intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients

Background:

Given the inadequate control of pain in patients with the trauma that refer to the emergency departments, the rapid onset of action of intranasal administration in pain management, and the avoidance of administering opioid medications, the present study aimed at evaluating the effect of intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients.

Materials and Methods:

The current study was performed on 125 patients that were divided into the following three groups: control group (n = 41), 1 mg/kg intranasal ketamine group (n = 40), and 1 μg/kg intranasal fentanyl group (n = 44). Then pain scores, heart rate, respiratory rate, blood pressure, and oxygen saturation were recorded at baseline, 5, 10, 15, 30, and 40 min after the intervention.

Results:

Visual analog scale (VAS) scores of patients in the intranasal ketamine group 5 and 10 min after the intervention were 61.50 ± 20.45 and 55.00 ± 21.96, respectively. The mentioned scores were significantly lower than the VAS scores of patients in the control group with the mean of 72.44 ± 22.11 and 66.59 ± 24.25 and the VAS scores of patients in the intranasal fentanyl group with the mean of 71.59 ± 22.09 and 65.00 ± 22.87 at 5 and 10 min after the intervention, respectively (P < 0.05).

Conclusion:

Given the onset of action in < 10 min, intranasal ketamine can be proposed as an appropriate analgesic medication in pain reduction of patients with isolated limb injuries. Moreover, the incidence rate and severity of adverse effects were insignificantly higher in the intranasal ketamine group as compared with the intranasal fentanyl group.

Use of Intranasal Ketamine in Pediatric Patients in the Emergency Department

OBJECTIVES

Ketamine is a safe and widely used sedative and analgesic in the pediatric emergency department (ED). The use of intranasal (IN) ketamine in exchange for the administration of intravenous sedatives or analgesics for procedural sedation in pediatric patients is not commonplace. The goal of this study was to evaluate provider perceptions and patient outcomes at varying doses of IN ketamine for anxiolysis, agitation, or analgesia.

METHODS

From January 2018 to May 2018, we performed a prospective survey and chart review of pediatric patients receiving IN ketamine. The primary outcome was to determine provider satisfaction with using IN ketamine. Secondary objectives included comparing outcomes stratified by dose, adverse events, assessing for treatment failure, and ED length of stay (LOS). As a secondary comparison, patients receiving IN ketamine whom otherwise would have required procedural sedation with intravenous sedatives or analgesics were placed into a subgroup. This subgroup of patients was compared with a cohort who received intravenous sedatives or analgesics for procedural sedation during a similar period the preceding year (January 2017 to June 2017).

RESULTS

Of the 196 cases, 100% of the providers were comfortable using IN ketamine. The median overall provider satisfaction was 90 out of 100, the perception of patient comfort was 75 out of 100, and perceived patient comfort was maximized when using doses between 3 and 5 mg/kg. There were 15 (7.7%) patients who experienced ketamine treatment failure. Overall, the rate of adverse events was 6%, but were considered minor [nausea (n = 3; 1.5%), dizziness (n = 2; 1%), and drowsiness (n = 2; 1%)]. No patients required respiratory support or intubation. The mean LOS was 237.9 minutes, compared with those who underwent procedural sedation with an LOS of 332.4 minutes (P < 0.001).

CONCLUSIONS

This study demonstrates that IN ketamine was able to provide safe and successful analgesia and anxiolysis in pediatric patients in an ED setting. In addition, providers expressed a high degree of satisfaction with using IN ketamine (90 out of 100) in addition to a high degree of patient comfort during the procedure (75 out of 100). Intranasal ketamine provides an alternative to intravenous medication normally requiring more resource-intensive monitoring. Procedural sedations are resource and time intensive activities that increase ED LOS. Intranasal ketamine used for anxiolysis and analgesia offers the benefits of freeing up resources of staff and monitoring while enhancing overall throughput through a pediatric ED.

Efficacy and Safety of Intranasal Ketamine for Acute Pain Management in the Emergency Setting: A Systematic Review and Meta-Analysis

Due to overcrowding, personnel shortages, or problematic intravenous (IV) cannulation, acute pain management is often sub-optimal in emergency departments (EDs). The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of intranasal (IN) ketamine for adult acute pain in the emergency setting. We searched and identified studies up to 21 May 2021 via PubMed, Scopus, Web of Science, Cochrane Database, and Google Scholar. The random-effects model with 95% confidence intervals (CIs) was used to estimate mean differences (MDs) and odds ratios (ORs). The I² statistic and Cochran’s Q test were used to determine heterogeneity. The protocol was registered in PROSPERO (CRD42020213391). Seven randomised controlled trials were included with a total of 1760 patients. There was no significant difference in pain scores comparing IN ketamine with IV analgesics or placebo at 5 (MD 0.94, p = 0.26), 15 (MD 0.15, p = 0.74), 25 (MD 0.24, p = 0.62), 30 (MD −0.05, p = 0.87), and 60 (MD −0.42, p = 0.53) minutes. There was also no significant difference in the need for rescue analgesics between IN ketamine and IV analgesics (OR 1.66, 95% CI: 0.57−4.86, p = 0.35, I² = 70%). Only mild adverse effects were observed in patients who received IN ketamine. Our results suggest that IN ketamine is non-inferior to IV analgesics and may have a role in acute pain management among adults in the ED.

Effect on Opioids Requirement of Early Administration of Intranasal Ketamine for Acute Traumatic Pain

OBJECTIVES

To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine on reducing the need for opioid and nonopioid analgesic agents in emergency department (ED) patients with acute moderate to severe acute limbs' trauma pain.

PATIENTS AND METHODS

This is a double-blind, randomized, prospective, controlled study conducted in the ED. The included patients were randomly assigned to intranasal pulverization of ketamine or placebo. Protocol treatment was given at the triage. The primary outcome is the need for opioids during ED stay. Secondary outcome included the requirement of nonopioid analgesic agents and the percentage of patients discharged from the ED with a visual analog scale (VAS) <30. A combined outcome score including the 3 outcome items was constructed.

RESULTS

The authors included 1102 patients, 550 patients in the placebo group, and 552 in the intranasal ketamine group. The groups were similar regarding demographics, clinical characteristics, and baseline VAS. The need for opioids was decreased in the intranasal ketamine group compared with the placebo group (17.2% vs. 26.5%; P<0.001). The need for nonopioid analgesics was significantly lower in the intranasal ketamine group compared with the placebo group (31.1% vs. 39.6%; P=0.003). The percentage of patients discharged with a VAS score <30 was significantly higher in the intranasal ketamine group (P<0.001). The mean combined outcome score was 0.97 in the placebo group and 0.67 in the intranasal ketamine group (P<0.001).

CONCLUSION

Intranasal ketamine administered early in the triage was associated with a decrease in opioids and nonopioid analgesics need in patients with acute limb trauma-related pain.

The impact of adherence to a guideline for minimizing opioid use for treatment of pain in an urban emergency department

INTRODUCTION

The opioid epidemic has significantly evolved over the last three decades. The initiation and continuation of prescription opioids for pain control were one of the primary contributors, across different medical settings. The emergency department (ED) is typically the first place patients go to for management of acute pain, and often where opioid naïve patients first become exposed to opioids. In 2018, the ED of University Hospital located in Newark, NJ implemented a pain guideline to ensure that patients are not unnecessarily exposed to opioids. The goal of our study was to determine whether provider adherence was successful in reducing opioid administration.

METHODS

We conducted a retrospective review of pharmacy records of patients treated for pain in the ED within the time frame January 1, 2017 and December 31, 2019. We analyzed the change in our practice by comparing the amount of opioid and non-opioid medications administered and the number of patients administered each type, as well as the change in our utilization of specific medications. The t-test or the χ² test were used as applicable.

RESULTS

There were decreases in the mean number of opioid doses administered in 2017 (1273) compared to 2019 (498; p = 0.027). There was an increase in non-opioid analgesics administered, (mean 2017: 1817, mean 2019: 2432.5, p = 0.018). There was also an increase in the proportion of patients given non-opioid analgesics (mean 2017: 22%, mean 2019: 28%, p < 0.0001). There were increases in administrations of acetaminophen (40% to 52%) and ibuprofen (30% to 35.1%), and decreases in administrations of hydromorphone (2.5% to 0.03%), morphine (11.5% to 5.6%), oxycodone (10.6% to 5.3%), and tramadol (5.7% to 1.9%) (all p < 0.0001).

DISCUSSION

A guideline that emphasizes the use of non-opioid analgesics first line treatment for acute pain can be effective for reducing opioid administration in the ED. Through the use of our guideline, we reduced the number of patients who have received opioid analgesics and, at the same time, increased non-opioid analgesic administration. Future studies should explore readmission rates, duration of pain relief in patients managed with non-opioid versus opioid analgesics, and perception of relief through the use of satisfaction scores.

Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis

OBJECTIVE

Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain.

METHOD

This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity.

RESULTS

Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min.

CONCLUSION

NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.

Review of nonopioid multimodal analgesia for surgical and trauma patients

Purpose

Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.

Summary

In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.

Conclusion

Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations

BACKGROUND

In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind.

METHODS

With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings.

RESULTS AND CONCLUSIONS

This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Ketamine for pain control of snake envenomation in Guinea: A case series

Snakebite envenomation is a global health crisis and is classified as a Category A neglected tropical disease by the World Health Organization (WHO). Snakebite envenomations account for a significant amount of morbidity and morbidity in tropical and subtropical regions. Recently, publications have illustrated the potential for snake envenomations causing post-traumatic stress disorder (PTSD) in a significant number of patients. Ketamine is on the WHO's list of essential medications and is used for a variety of pharmacologic applications including anesthesia and acute pain management. To date it has not been assessed for pain control in snakebite envenomations. Twelve patients who presented with severe pain secondary to Bitis, Causus, and Atractaspis envenomations were treated with low-dose intravenous ketamine. The patients included 7 males and 5 females with a median age of 37.5 (range 14-64) and a median presentation time of 5.75 h (range 5 min-96 h) after the initial bite occurred. Ten envenomations were presumed to have been caused by Bitis species resulting in extensive swelling and blistering of the affected extremities. One envenomation was presumedC. maculatus causing local swelling and pain. One envenomation was a presumed Atractaspis species causing significant local pain with minimal swelling. All patients expressed having significant pain but could not express the degree of their pain using an analogue pain scale. An initial median dose of 5 mg of ketamine (range 2.5-15 mg) was administered intravenously for pain control. Every patient expressed decreased pain and felt more comfortable within 1 min after administration of ketamine. Nine of the twelve patients only required a single dose. There were no adverse side effects. Ketamine appears to be an effective means of pain control for those suffering from painful envenomations. With minimal risk of significant side effects at acute pain management doses and the average cost per effective dose averaging between US$0.03-0.06, this may provide a cheap, safe, and effective solution for Sub-saharan Africa and other resource-limited settings. Controlled studies need to be done to critically assess our observations.

Intranasal ketamine versus intravenous morphine for pain management in patients with renal colic: a double-blind, randomized, controlled trial

BACKGROUND

Urinary stones are a common urologic problem that can be manifested as an intense pain, known as renal colic. Pain control is an important intervention for the emergency treatment of renal colic patients. Intranasal ketamine can form a crucial part of such interventions by offering a new route for a widely-used analgesic drug.

METHODS

In a double-blind, randomized, clinical trial, adults with renal colic admitted to a tertiary hospital emergency department were examined. The intervention group received 1 mg/kg intranasal (IN) ketamine and 1 ml of saline as a placebo. The control group received 0.1 mg/kg intravenous (IV) morphine and four puffs of saline as the placebo. The pain score was measured on the Numerical Rating Scale (NRS) 0, 15, 30 and 60 min after the drug administration.

RESULTS

A total of 184 patients enrolled in this study in two parallel groups. The two groups did not differ significantly in terms of pain intensity at the time of their referral (P = 0.489), 15 min post-dose (P = 0.204), 30 min post-dose (P = 0.978) and 60 min post-dose (P = 0.648).

CONCLUSION

IN ketamine is as effective as IV morphine for pain control in renal colic patients. No remarkable side-effects were observed for IN ketamine use in these patients.

Pharmacokinetics, absolute bioavailability and tolerability of ketamine after intranasal administration to dexmedetomidine sedated dogs

Intranasal ketamine has recently gained interest in human medicine, not only for its sedative, anaesthetic or analgesic properties, but also in the management of treatment resistant depression, where it has been shown to be an effective, fast acting alternative treatment. Since several similarities are reported between human psychiatric disorders and canine anxiety disorders, intranasal ketamine could serve as an alternative treatment for anxiety disordered dogs. However, to the authors knowledge, intranasal administration of ketamine and its pharmacokinetics have never been described in dogs. Therefore, this study aimed to examine the pharmacokinetics, absolute bioavailability and tolerability of intranasal ketamine administration compared with intravenous administration. Seven healthy, adult laboratory Beagle dogs were included in this randomized crossover study. The dogs received 2 mg/kg body weight ketamine intravenously (IV) or intranasally (IN), with a two-week wash-out period. Prior to ketamine administration, dogs were sedated intramuscularly with dexmedetomidine. Venous blood samples were collected at fixed times until 480 min post-administration and ketamine plasma concentrations were determined by liquid chromatography-tandem mass spectrometry. Cardiovascular parameters and sedation scores were recorded at the same time points. Non-compartmental pharmacokinetic analysis revealed a rapid (Tmax = 0.25 ± 0.14 h) and complete IN bioavailability (F = 147.65 ± 49.97%). Elimination half-life was similar between both administration routes (T1/2el IV = 1.47 ± 0.24 h, T1/2el IN = 1.50 ± 0.97 h). Heart rate and sedation scores were significantly higher at 5 and 10 min following IV administration compared to IN administration, but not at the later time-points.

KEA-1010, a ketamine ester analogue, retains analgesic and sedative potency but is devoid of Psychomimetic effects

Background

Ketamine, a widely used anaesthetic and analgesic agent, is known to improve the analgesic efficacy of opioids and to attenuate central sensitisation and opioid-induced hyperalgesia. Clinical use is, however, curtailed by unwanted psychomimetic effects thought to be mediated by N-methyl-D-aspartate (NMDA) receptor antagonism. KEA-1010, a ketamine ester-analogue designed for rapid offset of hypnosis through hydrolysis mediated break-down, has been shown to result in short duration sedation yet prolonged attenuation of nociceptive responses in animal models. Here we report on behavioural effects following KEA-1010 administration to rodents.

Methods

KEA-1010 was compared with racemic ketamine in its ability to produce loss of righting reflex following intravenous injection in rats. Analgesic activity was assessed in thermal tail flick latency (TFL) and paw incision models when injected acutely and when co-administered with fentanyl. Tail flick analgesic assessment was further undertaken in morphine tolerant rats. Behavioural aberration was assessed following intravenous injection in rats undergoing TFL assessment and in auditory pre-pulse inhibition models.

Results

KEA-1010 demonstrated an ED₅₀ similar to ketamine for loss of righting reflex following bolus intravenous injection (KEA-1010 11.4 mg/kg [95% CI 10.6 to 12.3]; ketamine (racemic) 9.6 mg/kg [95% CI 8.5–10.9]). Duration of hypnosis was four-fold shorter in KEA-1010 treated animals. KEA-1010 prolonged thermal tail flick responses comparably with ketamine when administered de novo, and augmented morphine-induced prolongation of tail flick when administered acutely. The analgesic effect of KEA-1010 on thermal tail flick was preserved in opioid tolerant rats. KEA-1010 resulted in increased paw-withdrawal thresholds in a rat paw incision model, similar in magnitude yet more persistent than that seen with fentanyl injection, and additive when co-administered with fentanyl. In contrast to ketamine, behavioural aberration following KEA-1010 injection was largely absent and no pre-pulse inhibition to acoustic startle was observed following KEA-1010 administration in rats.

Conclusions

KEA-1010 provides antinociceptive efficacy in acute thermal and mechanical pain models that augments standard opioid analgesia and is preserved in opioid tolerant rodents. The NMDA channel affinity and psychomimetic signature of the parent compound ketamine is largely absent for KEA-1010.

An Update on the Basic and Clinical Science of Ketamine Analgesia

OBJECTIVE

In the context of the current opioid epidemic, there has been a renewed interest in the use of ketamine as an analgesic agent.

METHODS

We reviewed ketamine analgesia.

RESULTS

Ketamine is well-known as an antagonist for N-methyl-D-aspartate receptors. In addition, it can regulate the function of opioid receptors and sodium channels. Ketamine also increases signaling through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors. These myriad of molecular and cellular mechanisms are responsible for a number of pharmacological functions including pain relief and mood regulation. Clinically, a number of studies have investigated the role of ketamine in the setting of acute and chronic pain, and there is evidence that ketamine can provide analgesia in a variety of pain syndromes.

DISCUSSION

In this review, we examined basic mechanisms of ketamine and its current clinical use and potential novel use in pain management.

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Objectives: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. Methods: We searched MEDLINE^®, Embase^®, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). Results: We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV. Conclusions: As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed.

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.

The Intranasal Route as an Alternative Method of Medication Administration

Intranasal drug administration is a less invasive method of drug delivery that is easily accessible for adult and pediatric patients. Medications administered by the intranasal route have efficacy comparable to intravenous administration and typically have superior efficacy to subcutaneous or intramuscular routes. The intranasal route is beneficial in emergent situations when the intravenous route is not available. The intranasal route is safe and effective in various indications, and therapeutic systemic concentrations of medication can be attained via this route. As the evidence for and comfort with intranasal administration continue to grow, guidance on correct technique, medications, and dosing is vital for appropriate use. This article reviews the process and practices of appropriate intranasal medication administration.

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

BACKGROUND

Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines.

METHODS

The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls.

RESULTS

Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions.

CONCLUSIONS

Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.

Intranasal Ketamine Administration for Narcotic Dose Decrement in Patients Suffering from Acute Limb Trauma in Emergency Department: a Double-Blind Randomized Placebo-Controlled Trial

Introduction:

pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases.

Objective:

This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury.

Method:

This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patients' narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes.

Results:

Ninety-one patients with mean age of 31.59 ± 11.33 years were enrolled (38.8% female). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001).

Conclusion:

It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma.

A Survey of Wilderness Medicine Analgesia Practice Patterns

INTRODUCTION

In 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices.

METHODS

We conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included.

RESULTS

During the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42±12 (24-79) years (mean±SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine.

CONCLUSIONS

Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.

Intranasal Ketamine and Its Potential Role in Cancer-Related Pain

Cancer-related pain continues to be a significant therapeutic challenge, made more difficult by contemporary opioid use and diversion concerns. Conventional treatment using a tiered approach of nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and adjuvant agents is limited; and alternatives are needed for patients with rapidly progressing pain and those who develop hyperalgesia and tolerance to opioids. Ketamine, an N-methyl-d-aspartate (NMDA) selective antagonist, has historically been used for anesthesia in adult and pediatric populations but has also been investigated for depression, bipolar disorder, and general and postoperative pain management. As an analgesic, low-dose ketamine decreases morphine requirements and rates of nausea and vomiting, suggesting a potentially beneficial role in cancer-related pain. Ketamine is typically administered intravenously and has a rapid onset of action with a relatively short half-life (2-3 hours) but is inconvenient for use in an ambulatory setting. Oral bioavailability is low and erratic, limiting application of this route for chronic use. Intranasal administration has a number of potential advantages, including avoidance of first-pass hepatic metabolism, no need for venous access, ability to repeat doses quickly, and rapid absorption. Although early studies of intranasal ketamine are promising in a number of indications, information is more limited in its use as an adjunct in cancer-related pain. We review the background, rationale, pharmacokinetics, and clinical and safety data using intranasal ketamine as an adjunctive agent and its potential in cancer-related pain.

Efficacy and Safety of Morphine and Low Dose Ketamine for Pain Control of Patients with Long Bone Fractures: A Randomized, Double-Blind, Clinical Trial

Objective

To compare the effects of intravenous morphine and a low dose of ketamine on pain intensity of patients with traumatic fractures of the long bones.

Methods

This randomized, controlled, double-blinded, clinical trial was conducted in the adult emergency department (ED) of Emam Khomeini hospital, a tertiary general hospital affiliated with Mazandaran University of Medical Sciences, in Northern Iran, during a 6-month period. Patients were randomly assigned to receive intravenous morphine (0.1 mg/kg) or low dose ketamine (0.5 mg/kg) for control of the pain in the emergency room. The pain intensity was checked by a nurse using the visual analogue scale (VAS) at 30, 60, 90, 120, 180 and 240, minutes after the intervention.

Results

Overall we included a total number of 156 patients with mean age of 35.87±3.38 years. There were 111 (71.2%) men and 4 (28.8%) women among the patients. Patients were randomly assigned to receive intravenous morphine (n=78) or low dose ketamine (n=78). The pain intensity decreased significantly in both study groups after 240 minutes of intervention. However, there was no significant difference between the two study groups regarding the pain intensity at 30 (p=0.378), 60 (p=0.927), 90 (p=0.434), 120 (p=0.557), 180 (p=0.991) and 240 (p=0.829) minutes. The side effects were comparable while low dose ketamine was associated with higher need for rescue analgesic (p=0.036).

Conclusion

The results of the current study demonstrates that the intravenous low dose ketamine leads to successful pain control in patients with long bone fractures and the effects are comparable with intravenous morphine.