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Nguyen T, Mai M, Choudhary A, Gitelman S, Drapkin J, Likourezos A, Kabariti S, Hossain R, Kun K, Gohel A, Niceforo P, Silver M, Motov S. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Ann Emerg Med 2024:S0196-0644(24)00171-9. [PMID: 38703175 DOI: 10.1016/j.annemergmed.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 05/06/2024]
Abstract
STUDY OBJECTIVE We aimed to assess and compare the analgesic efficacy and adverse effects of intravenous subdissociative-dose ketamine to nebulized ketamine in emergency department (ED) patients with acute painful conditions. METHODS We conducted a prospective, randomized, double-blind, double-dummy clinical trial in adult patients (ages 18 and older) with a numerical rating scale pain score of ≥5. We randomized subjects to receive either a single dose of 0.3 mg/kg of intravenous (IV) ketamine or 0.75 mg/kg of nebulized ketamine through a breath-actuated nebulizer. Primary outcome was the difference in pain scores on the numerical rating scale between groups at 30 minutes postmedication administration. The secondary outcomes included the need for rescue analgesia, occurrences of adverse events in each group, and the difference in pain scores at 15, 30, 60, 90, and 120 minutes. We calculated a 95% confidence interval (CI) for a mean difference at 30 minutes, with a minimum clinically important difference set at 1.3 points. RESULTS We enrolled 150 subjects (75 per group). Mean pain scores through numerical rating scale were 8.2 for both groups at baseline, which decreased to 3.6 and 3.8 at 30 minutes, yielding a mean difference of 0.23 (95% CI -1.32 to 0.857). We observed no clinically concerning changes in vital signs. No serious adverse events occurred in any of the groups throughout the study period. CONCLUSION We found no difference between the administration of IV and nebulized ketamine for the short-term treatment of moderate to severe acute pain in the ED, with both treatments providing a clinically meaningful reduction in pain scores at 30 minutes.
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Affiliation(s)
- Tommy Nguyen
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Mo Mai
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Amulya Choudhary
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Slavic Gitelman
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Jefferson Drapkin
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY.
| | | | - Sarah Kabariti
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Rukhsana Hossain
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Karina Kun
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | | | - Michael Silver
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Sergey Motov
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
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Corwell BN, Motov SM, Davis N, Kim HK. Novel uses of ketamine in the emergency department. Expert Opin Drug Saf 2022; 21:1009-1025. [PMID: 35822534 DOI: 10.1080/14740338.2022.2100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Davis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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Davis A, Fassassi C, Dove D, Drapkin J, Likourezos A, Gohel A, Favale P, Hossain R, Butt M, Gerges L, Motov S. Analgesic Efficacy of Oral Aspirin/Ketamine Combination for Management of Acute Musculoskeletal Pain in the Emergency Department - A Proof of Concept Pilot Study. J Emerg Med 2022; 62:750-759. [PMID: 35624056 DOI: 10.1016/j.jemermed.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED). OBJECTIVE We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients. METHODS This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min. RESULTS We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity. CONCLUSION We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.
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Affiliation(s)
- Ashley Davis
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Catsim Fassassi
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Daniel Dove
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Jefferson Drapkin
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Antonios Likourezos
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Patrizia Favale
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Rukhsana Hossain
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Mahlaqa Butt
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Louis Gerges
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
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Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
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Dove D, Fassassi C, Davis A, Drapkin J, Butt M, Hossain R, Kabariti S, Likourezos A, Gohel A, Favale P, Silver M, Marshall J, Motov S. Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med 2021; 78:779-787. [PMID: 34226073 DOI: 10.1016/j.annemergmed.2021.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE We aimed to assess and compare the analgesic efficacies and adverse effects of ketamine administered through a breath-actuated nebulizer at 3 different dosing regimens for emergency department patients presenting with acute and chronic painful conditions. METHODS This was a prospective, randomized, double-blinded trial comparing 3 doses of nebulized ketamine (0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg) administered through breath-actuated nebulizer in adult emergency department patients aged 18 years and older with moderate to severe acute and chronic pain. The primary outcome included the difference in pain scores on an 11-point numeric rating scale between all 3 groups at 30 minutes. Secondary outcomes included the need for rescue analgesia (additional doses of nebulized ketamine or intravenous morphine) and adverse events in each group at 30 and 60 minutes. RESULTS We enrolled 120 subjects (40 per group). The difference in mean pain scores at 30 minutes between the 0.75 mg/kg and 1 mg/kg groups was 0.25 (95% confidence interval [CI] 1.28 to 1.78); between the 1 mg/kg and 1.5 mg/kg groups was -0.225 (95% CI -1.76 to 1.31); and between the 0.75 mg/kg and 1.5 mg/kg groups was 0.025 (95% CI -1.51 to 1.56). No clinically concerning changes in vital signs occurred. No serious adverse events occurred in any of the groups. CONCLUSION We found no difference between all 3 doses of ketamine administered through breath-actuated nebulizer for short-term treatment of moderate to severe pain in the emergency department.
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Affiliation(s)
- Daniel Dove
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Catsim Fassassi
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Ashley Davis
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Jefferson Drapkin
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.
| | - Mahlaqa Butt
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Rukhsana Hossain
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Sarah Kabariti
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | | | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | - Patrizia Favale
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | - Michael Silver
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - John Marshall
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
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Harris EM, Vilk E, Heeney MM, Solodiuk J, Greco C, Archer NM. A systematic review of ketamine for the management of vaso-occlusive pain in sickle cell disease. Pediatr Blood Cancer 2021; 68:e28989. [PMID: 33788404 DOI: 10.1002/pbc.28989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/21/2021] [Accepted: 02/15/2021] [Indexed: 01/13/2023]
Abstract
Vaso-occlusive episodes (VOEs) are a common complication of sickle cell disease (SCD) and a significant cause of morbidity. Managing VOE pain can be difficult and complex. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been used to manage VOE pain. This systematic literature review synthesizes research published from 2010 to 2020 on the use of ketamine infusion to decrease VOE pain. The review demonstrates that ketamine, a safe and effective treatment for VOE pain, could be considered more widely. However, the significant variability among published clinical studies with regard to dosing, timing of initiation, duration of infusion, and timing of discontinuation highlights the need for standardized ketamine infusion protocols for the management of VOE pain. We conclude with a brief discussion of key components of a potential standardized protocol supported by the literature reviewed as well as areas for future investigation.
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Affiliation(s)
- Emily M Harris
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Vilk
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Matthew M Heeney
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Jean Solodiuk
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Christine Greco
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Natasha M Archer
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
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Fisher AD, DesRosiers TT, Drew BG. Prehospital Analgesia and Sedation: a Perspective from the Battlefield. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Introduction: Acute pain from episodic vaso-occlusion (VOC) spans the lifespan of almost everyone with sickle cell disease (SCD), while additional chronic pain develops in susceptible individuals in early adolescences. Frequent acute pain with chronic pain causes significant physical and psychological morbidity, and frequent health-care utilization. Available pharmacologic therapies reduce acute pain frequency but few evidence-based therapies are available for chronic pain. Areas covered: An extensive PubMed literature search was performed with appropriate search criteria. The pathophysiology of acute pain from VOC in SCD is very complex with many events subsequent to sickle polymer formation. Sensitization of pain pathways and alterations of brain networks contributes to the experience of chronic pain. Numerous therapies targeting putative VOC mechanisms are in clinical trials, and show considerable promise. Alternative analgesic treatments for acute and chronic pain have been examined in small patient cohorts, but formal clinical trials are lacking. Expert opinion: Childhood is likely a critical window for prevention of acute and later chronic pain. New multimodal analgesic therapies are needed, particularly for chronic pain, and should be examined in clinical trials. Given the multifactorial nature of both pain and VOC, simultaneously targeting multiple mechanisms may be the optimal approach for effective preventive therapies.
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Affiliation(s)
- Carlton Dampier
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta , Atlanta , GA , USA
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Affiliation(s)
- Robert Goodnough
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California; California Poison Control System, San Francisco Division, San Francisco, California
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Cisewski DH, Motov SM. Essential pharmacologic options for acute pain management in the emergency setting. Turk J Emerg Med 2018; 19:1-11. [PMID: 30793058 PMCID: PMC6370909 DOI: 10.1016/j.tjem.2018.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/19/2022] Open
Abstract
Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A ‘balanced analgesia’ regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options – both opioid and non-opioid – to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.
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Affiliation(s)
- David H Cisewski
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Sergey M Motov
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, NY, USA
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Motov S, Drapkin J, Likourezos A, Doros J, Monfort R, Marshall J. Sub-dissociative dose ketamine administration for managing pain in the emergency department. World J Emerg Med 2018; 9:249-255. [PMID: 30181791 DOI: 10.5847/wjem.j.1920-8642.2018.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We describe our experience of utilizing sub-dissociative dose ketamine (SDK) in managing a variety of acute and chronic painful conditions in the emergency department (ED). METHODS A descriptive study was conducted in our ED over a period of seven years (2010-2016) by retrospectively reviewing charts of patients aged 18 and older presenting to the ED with painful complaints and receiving SDK analgesia. Primary data analyses included type of SDK administration (intravenous push [IVP], short-infusion [SI] or continuous infusion [CI]), dosing, rates of analgesic utilization before and after SDK administration, and adverse effects. RESULTS Three hundred sixty-two patients were enrolled in the study. Mean ketamine doses given by IVP, SI and CI were 26.3 mg, 23.4 mg, and 11.3 mg. The mean duration of CI was 135.87 minutes. The percentage of patients not requiring post-SDK analgesia increased by 16%, 18%, and 37% in IVP, SI and CI groups. Adverse effects were recorded for 13% of patients. CONCLUSION SDK administered by IVP, SI, and CI in the ED for a variety of painful conditions is a feasible analgesic modality in the ED that is associated with a decrease in overall requirements of post-ketamine analgesia and opioid sparing.
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Affiliation(s)
- Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jefferson Drapkin
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Antonios Likourezos
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Joshua Doros
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Ralph Monfort
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - John Marshall
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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