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

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.

Paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN): a randomised, double-blind, phase 3 trial

Background

Paramedics frequently administer analgesic medications for pain following trauma. Morphine is the most commonly administered strong analgesic. However, it may not be the best option as it may lower blood pressure, depress respiration and there is a risk of dependency. Ketamine might be a better option due to speed of onset and favourable side-effect profile. We sought to compare clinical effectiveness of paramedic administered ketamine and morphine in patients with severe pain following trauma.

Methods

PACKMaN was a double-blinded, randomised controlled, superiority trial, conducted in two regional ambulance services in the UK. Eligible patients were 16 years of age or over, had an acute injury, and articulated a pain score of 7 or greater on a 0-10 numeric rating score (NRS). We excluded pregnant patients, prisoners, those unable to articulate a pain score and anyone lacking capacity. The randomisation list prepared by the study programmer, utilised a permuted, unstratified, block randomisation system (variable size blocks) to achieve an overall ratio of 1:1 control (morphine): intervention (ketamine). Treatment packs were identical in appearance, apart from their unique sequential number. Individual participant randomisation occurred when the attending paramedic opened the treatment pack. The maximum available dose of morphine was 20 mg while the maximum available dose of ketamine was 30 mg. The treating paramedic administered the trial drug slowly, in regular small aliquots, via the intravenous (or intraosseous) route, titrating treatment until the patient reported adequate analgesia or requested that treatment stop due to undesired side effects. Timing of drug administration was not prespecified. The primary outcome was the Sum of Pain Intensity Difference (SPID) score on arrival to the hospital, calculated using patient reported NRS scores. Analysis was performed on an intention to treat basis. PACKMaN is registered with the International Clinical Trials Registry (ISRCTN14124474).

Findings

PACKMaN recruited its first patient on 10/11/2021 and achieved its recruitment target on 16/05/2023. We randomised 449 participants: 219 (49%) received ketamine and 230 (51%) received morphine. The SPID score was 3.5 (SD 2.8) for ketamine and 3.4 (SD 3.0) for morphine. We found no significant difference in efficacy between drugs (adjusted mean difference 0.1, 95%CI -0.4 to 0.6, p = 0.74). There was no significant difference in the incidence of serious adverse events [4 (2%) ketamine; 8 (3%) morphine]. There were no treatment related deaths.

Interpretation

Ketamine did not provide superior analgesia than morphine when used by paramedics to treat acute severe trauma pain. Unexpected adverse events occurred infrequently. Despite analgesia, many patients still experienced pain on arrival at hospital, highlighting the need for further research.

Funding

PACKMaN was funded by the National Institute for Health and Care Research.

Comparison of analgesic efficacy of ibuprofen and dexketoprofen in pain management of long bone fractures: a prospective, randomized, double-blind study

INTRODUCTION

Long bone fractures (LBF) often cause severe pain, impacting patients' quality of life. This prospective, randomized, double-blind study aimed to compare the analgesic efficacy of dexketoprofen (Dex) and ibuprofen (Ibu) in LBF patients in the emergency department.

METHODS

Conducted between August 10, 2023, and January 17, 2024, the study included 100 eligible patients randomized into Dex and Ibu groups. Visual analog scale (VAS) scores were measured at baseline and at 30, 60, and 120 min. DeltaVAS (ΔVAS) values and ΔVAS percentages (ΔVAS%) were calculated. Primary endpoints were ΔVAS scores (ΔVAS 30-60-120) and ΔVAS% for comparative analysis.

RESULTS

Statistical analysis showed no significant difference in ΔVAS30 (p = 0.359). However, ΔVAS60 exhibited a significant difference (p = 0.027), as did ΔVAS120 (p = < 0.001). ΔVAS%30 showed no significance (p = 0.224), but ΔVAS%60 and ΔVAS%120 were clinically and statistically significant (p = 0.017 and p = < 0.001, respectively).

CONCLUSION

Ibuprofen 800 mg demonstrated superior analgesic efficacy at 60 and 120 min compared to Dex in long bone fractures. These findings suggest ibuprofen's potential as an effective pain management option in emergency departments.

Am I Sedated or in Pain? Please Monitor by Brain

How to cite this article: Gupta A, Tomar DS. Am I Sedated or in Pain? Please Monitor by Brain. Indian J Crit Care Med 2024;28(6):531-532.

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.

Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge.

METHODS

Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge.

CONCLUSIONS

Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days.

PROTOCOL REGISTRATION

10.31219/osf.io/w4z3u.

Comparison of the Analgesic Effects of Low-Dose Ketamine Versus Fentanyl in Patients With Long Bone Fractures in the Emergency Department: A Prospective Observational Study

Aim and background In most emergency departments (ED), opioids are the primary analgesic agents for trauma patients. However, safe alternative drugs are required because of possible adverse effects. Ketamine, an anesthetic agent, provides satisfactory analgesia at low doses and is an alternative drug that has begun to be used in numerous areas with fewer side effects. This study aimed to compare low-dose ketamine and fentanyl infusions in terms of their pain-relieving effects and observed adverse effects in patients presenting to the ED with isolated long bone fractures. Materials and methods This single-center observational study was conducted in the ED of the Marmara University Pendik Training and Research Hospital between August 2018 and December 2019. Patients diagnosed with isolated long bone fractures who were administered low-dose ketamine or fentanyl rapid infusions for pain relief were included in the study. Patient pain scores were evaluated using the visual analog scale (VAS) with a standard horizontal 10-centimeter line. The primary outcome of the study was to compare the changes in pain at 30 and 60 min after medication administration for each group. Results A total of 100 patients were included in the study. Ketamine infusion was administered to 48% (n=48) of the patients as a pain reliever. After 60 min of observation, pain was significantly reduced in both study groups. However, the pain scores at baseline (p=0.319), 30 min (p=0.631), and 60 min (p=0.347) after treatment were similar in both groups. In terms of the observed adverse effects, dizziness was more common in the ketamine group (p=0.010). Conclusion The results of this study showed that low-dose ketamine infusion (0.3 mg/kg/h) had a similar effect to fentanyl infusion (1 mcg/kg/h) as a pain reliever in patients with isolated long bone fractures in the ED.

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).

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis

OBJECTIVE

There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED.

METHODS

Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence.

RESULTS

Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence.

CONCLUSION

Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.

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.