Comparing intranasal ketamine with intravenous fentanyl in reducing pain in patients with renal colic: A double-blind randomized clinical trial

Exploring the Efficacy and Safety of Ketamine for Managing Acute Renal Colic in Emergency Departments: A Systematic Review of Recent Clinical Trials

Kidney stones typically present as renal colic in emergency departments (EDs), where patients experience severe pain and often require parenteral therapy for symptom management. The economic burden associated with managing kidney stones exceeds USD 5 billion annually in the US and accounts for more than a million visits to EDs each year. There is clear evidence emphasizing the need for innovative and alternative pain control options for patients with renal colic. Recent randomized controlled trials suggest that intranasal (IN) and intravenous (IV) ketamine are as effective as parenteral NSAIDs and opioids in treating renal colic. However, the limited studies available show inconsistent results regarding the analgesic effects of ketamine. In this study, we reviewed the mechanism of action of ketamine for kidney stones, its efficacy in treating acute renal colic, and the potential adverse side effects of ketamine treatment. A population, intervention, comparison, and outcome (PICO)-related question was formulated to guide our research inquiry: "What are the effects of IV or IN ketamine, as a single agent or as an adjuvant (I), in adult patients diagnosed with acute renal colic (P) on pain scale scores and adverse side effects (O) compared to NSAIDs and/or opioids (C)?"

Clinical and pharmacokinetics overview of intranasal administration of fentanyl

Due to the presence of large surfaces and high blood supply, drug delivery through the nasal route of administration is the appropriate route to administrate drugs with rapid onsets of action. Bypassing first-pass metabolism can increase drug bioavailability. The physicochemical properties of fentanyl led to a need to develop formulations for delivery by multiple routes. Several approved inter-nasal fentanyl products in Europe and the USA have been used in prehospital and emergency departments to treat chronic cancer pain and used to treat severe acute abdominal and flank pain. Analgesia durations and onsets were not significantly different between intranasal and intravenous fentanyl in patients with cancer breakthrough pain and were well-tolerated in the long term. Intranasal Fentanyl (INF) at a 50 μg/ml concentration decreased renal colic pain to the lowest level in 30 min. Possible adverse effects specific to INF are epistaxis, nasal wall ulcer, rhinorrhea, throat irritation, dysgeusia, nausea, and vomiting. However, there is limited available literature about the serious adverse effects of INF in adults and children. Intranasal Fentanyl Spray (INFS) results in significantly higher plasma concentrations and has a lower Tmax than oral transmucosal formulation, and the bioavailability of fentanyl in intranasal formulations is very high (89 %), particularly in pectin-containing formulations such as PecFent and Lazanda.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

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.

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.

Intranasal Ketamine for Acute Pain

OBJECTIVES

The aim was to review current evidence regarding the off-label use of intranasal ketamine for acute pain presenting in the setting of the emergency department, and secondary to pediatric limb injuries, renal colic, digital nerve block, and migraines.

RESULTS

In all 5 indications reviewed, ketamine demonstrated efficacy in reducing pain. However, when compared with other agents, ketamine did not demonstrate superiority over opioids in pediatric limb injuries or renal colic and was not as efficacious as standard therapy for migraine relief. Ketamine was also associated with a greater incidence of transient adverse reactions, such as dizziness, bitter aftertaste, fatigue, and vomiting than opioid therapies.

DISCUSSION

The current body of evidence is insufficient to support the use of intranasal ketamine over other standard therapies for acute pain. However, current evidence can be used when developing dosing strategies, preparing for adverse reactions, and generating hypotheses for future, more robust research.

Erector spinae plane block vs non-steroidal anti-inflammatory drugs for severe renal colic pain: A pilot clinical feasibility study

AIM

Ultrasound-guided plane blocks are increasingly used in the multi-modal analgesic concept for reducing opioid consumption. The present study was conducted to compare the analgesic effect of intravenous non-steroidal anti-inflammatory drugs (NSAIDs) and erector spinae plane (ESP) block in renal colic patients.

METHODS

In this prospective randomised study, 40 patients with renal colic pain were randomly assigned into two groups: Group NSAID (n = 20) received an intravenous infusion of 50 mg of dexketoprofen trometamol and Group ESP (n = 20) received ultrasound-guided ESP block with 30 ml 0.25% bupivacaine at the T8 level. The pain severity of patients was assessed using the visual analogue scale (VAS) at baseline, 5, 15, 30, 45 and 60 minutes after intervention. Opioid consumption, patient satisfaction and side effects were recorded.

RESULTS

In the ESP group, the VAS scores were significantly lower than the NSAID group at 5, 15, 30, 45 and 60 minutes after the procedure (P < .001). Opioid consumption was significantly higher in the NSAID group compared with the ESP group (10/20 vs 0/20, respectively; P < .001). Patient satisfaction was significantly higher in the ESP group (P < .001).

CONCLUSIONS

ESP block can be an alternative, efficient and safe method for the relief of acute renal colic pain.

Comparing Intradermal Sterile Water with Intravenous Morphine in Reducing Pain in Patients with Renal Colic: A Double-Blind Randomized Clinical Trial

OBJECTIVE

The present study was conducted to investigate the effect of intradermal administration of sterile water compared to intravenous morphine on patients with renal colic.

METHODS

This double-blind, randomized clinical trial study was conducted in 2017 to compare the therapeutic effects of intradermal sterile water with those of intravenous morphine on patients with renal colic presenting to the emergency departments (ED) of Imam Khomeini and Golestan Hospitals in Ahvaz, Iran. The first group received 0.5 ml of intradermal sterile water, and the second group 0.1mg/kg of intravenous morphine plus 0.5 ml of intradermal sterile water in the most painful area or the center of the painful area in the flank. The pain severity was measured using a visual analogue scale (VAS), and the medication side-effects were recorded at the beginning of the study and minutes 15, 30,45 and 60.

RESULTS

A total of 94 patients were studied in two groups. The mean severity of pain was 2.97 ± 1.51 in the sterile water group and 2.34 ± 1.89 in the morphine group at minute 30 (P=0.042), 2.58 ± 1.43 in the sterile water group and 1 ± 1.23 in the morphine group at minute 45 (P<0.001), and 1.89 ± 1.7 in the sterile water group and 0.52 ± 0.79 in the morphine group at minute 60 (P<0.001).

CONCLUSION

Morphine reduces pain faster and more effectively than intradermal sterile water; nevertheless, treatment with intradermal sterile water can be used as an appropriate surrogate or adjunct therapy for pain control, particularly in special patients or in case of medication scarcity.