Sub-dissociative dose ketamine administration for managing pain in the emergency department

In an Emergency Setting, What Is the Best Intramuscular Pharmacological Treatment to Give to an Agitated Geriatric Patient?

Herein, we describe an agitated geriatric patient who suffered an adverse outcome due to treatment for agitation in an emergency setting. This led to the prompt review of the current literature on best-practice medication to use in this population. After careful review, the authors recommend olanzapine as the first-line medication for agitation due to its lower risk-averse effect profile when compared to other medications used for this patient population.

Paraphimosis Pain Treatment with Nebulized Ketamine in the Emergency Department

BACKGROUND

Paraphimosis is an acute urological emergency occurring in uncircumcised males that can lead to strangulation of the glans and painful vascular compromise. Ketamine has been used in the emergency department (ED) as an anesthetic agent for procedural sedation, and when administrated in a sub-dissociative dose (low dose) at 0.1-0.3 mg/kg, ketamine has been utilized in the ED and prehospital settings for pain control as an adjunct and as an alternative to opioid, as well as for preprocedural sedation. This report details the case of a pediatric patient who presented to our Pediatric ED with paraphimosis and had his procedural pain treated with ketamine administrated via a breath-actuated nebulizer (BAN).

CASE REPORT

This case report illustrates the potential use of ketamine via BAN to effectively achieve minimal sedation for a procedure in pediatric patients in the ED. The patient was a 15-year-old boy admitted to the Pediatric ED complaining of groin pain due to paraphimosis. The patient was given 0.75 mg/kg of nebulized ketamine via BAN, and 15 min after the medication administration the pain score was reduced from 5 to 1 on the numeric pain rating scale. The patient underwent a successful paraphimosis reduction without additional analgesic or sedative agents 20 min after the administration of nebulized ketamine. The patient was subsequently discharged home after 60 min of monitoring, with a pain score of 0. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of nebulized ketamine via BAN might represent a viable, noninvasive way to provide a mild sedative and be an effective analgesic option for managing a variety of acute painful conditions and procedures in the pediatric ED.

Interactions between Ketamine and Magnesium for the Treatment of Pain: Current State of the Art

BACKGROUND

Over the past three decades, NMDA-receptor antagonists have been shown to be efficient drugs for treating pain, particularly pain resistant to conventional analgesics. Emphasis will be on the old-new drugs, ketamine and magnesium, and their combination as a novel approach for treating chronic pain.

METHODS

The MEDLINE database was searched via PubMed for articles that were published up to March 1, 2020, with the keywords 'ketamine', 'magnesium', and 'pain' (in the title/abstract).

RESULTS

Studies in animals, as well as humans, have shown that interactions of ketamine and magnesium can be additive, antagonistic, and synergistic. These discrepancies might be due to differences in magnesium and ketamine dosage, administration times, and the chronological order of drug administration. Different kinds of pain can also be the source of divergent results.

CONCLUSION

This review explains why studies performed with a combination of ketamine and magnesium have given inconsistent results. Because of the lack of efficacy of drugs available for pain, ketamine and magnesium in combination provide a novel therapeutic approach that needs to be standardized with a suitable dosing regimen, including the chronological order of drug administration.

A systematic review of ketamine for the management of vaso-occlusive pain in sickle cell disease

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.

A randomized, noninferiority, controlled trial of two doses of intravenous subdissociative ketamine for analgesia in the emergency department

OBJECTIVE

This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain.

METHODS

This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ₀ , was set to 1.3.

RESULTS

Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group (mean difference = 0.4, 95% CI = -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = -0.8 to ≥1.3 = -δ₀ ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred.

CONCLUSION

Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short-term treatment of acute pain in the ED.

Nebulized ketamine for managing acute pain in the pediatric emergency department: A case series

Administration of sub-dissociative doses of ketamine is used via intranasal (IN) and intravenous routes in the pediatric emergency department for managing acute pain. Due to difficulties in both obtaining intravenous access and compliance with IN medications in children, administration of ketamine via breath-actuated nebulizer can serve as a valuable modality for timely analgesia in children where dosing titration is patient controlled. We describe five pediatric patients who received ketamine via breath-actuated nebulizer at 0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg, with all patients experiencing a decrease in pain score. This case series introduces ketamine inhalation as a modality for managing pain in children.

Ketamine for Pain Management: A Review of Literature and Clinical Application

Ketamine is a dissociative anesthetic used increasingly as analgesia for different manifestations of pain, including acute, chronic, cancer and perioperative pain as well as pain in the critically ill patient population. Its distinctive pharmacologic properties may provide benefits to individuals suffering from pain, including increased pain control and reduction in opioid consumption and tolerance. Despite wide variability in proposed dosing and method of administration when used for analgesia, it is important all clinicians be familiar with the pharmacodynamics of ketamine in order to appropriately anticipate its therapeutic and adverse effects.

The agitated older adult in the emergency department: a narrative review of common causes and management strategies

Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life-threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric-specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non-pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.

Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients

OBJECTIVE

Ketamine is an N-methyl-D-aspartate antagonist with emerging evidence assessing its use as a continuous infusion agent to provide concomitant analgesia and sedation. The role of ketamine as adjunctive therapy in mechanically ventilated patients is unclear. This study sought to investigate the impact of adjunctive continuous infusion ketamine on concomitant analgesic and sedative dosing while providing goal comfort in mechanically ventilated patients.

METHODS

This retrospective two-center intrapatient comparison study included mechanically ventilated adult ICU patients who received continuous infusion ketamine with at least one other analgesic or sedative infusion. The primary outcome assessed percent relative change in concomitant analgesic-sedative doses 24 hours after ketamine initiation. Secondary outcomes included percent of Richmond Agitation and Sedation Score (RASS) assessments at goal, adverse effects, and delirium incidence. Exploratory evaluation of independent factors associated with ketamine responders (50% or more relative reduction in analgesic-sedative dosing requirements at 24 hrs) and nonresponders (less than 50% relative reduction) was performed using multivariate logistic regression.

RESULTS

Overall, 104 patients were included. A total of 160 concomitant analgesic-sedative infusions were used in combination with ketamine, most commonly fentanyl (98 [61.3%]) and propofol (46 [28.8%]). A 20% (interquartile range [IQR] -63.6 to 0.0, p<0.001) relative reduction in total analgesic-sedative infusion pharmacotherapy was achieved at 24 hours after ketamine initiation. Analgesic and sedative infusion doses decreased at 24 hours (fentanyl: pre, 175 μg/hr [IQR 100-200 μg/hr] vs post, 125 μg/hr [IQR 50-200 μg/hr], p<0.001; propofol: pre, 42.5 μg/kg/min [IQR 20.0-60.0 μg/kg/min] vs post, 20.0 μg/kg/min [IQR 3.8-31.3 μg/kg/min], p<0.001). Median percent time within goal RASS improved after ketamine initiation (pre, 7.1% [0-40%] vs post, 25% [0-66.7%], p=0.005). No differences were observed in secondary outcomes between responders and nonresponders, except a longer non-ICU hospital length of stay in responders. Independent factors associated with ketamine response included a lower body mass index, higher starting dose of ketamine, lower severity of illness, and need for multiple concomitant analgesic-sedative infusions before initiation of ketamine.

CONCLUSIONS

Adjunctive continuous infusion ketamine promotes analgesic and sedative dose-sparing effects in mechanically ventilated patients while improving time spent within goal sedation range. Further prospective research is warranted.

Administration of Nebulized Ketamine for Managing Acute Pain in the Emergency Department: A Case Series

Ketamine administration in sub-dissociative doses in the emergency department (ED) results in effective pain relief in patients with acute traumatic and non-traumatic pain, chronic pain, and opioid-tolerant pain. This case series describes five adult ED patients who received nebulized ketamine for predominantly acute traumatic pain. Three patients received nebulized ketamine at 1.5 milligrams per kilogram (mg/kg) dose, one patient at 0.75 mg/kg, and one patient at 1 mg/kg. All five patients experienced a decrease in pain from the baseline up to 120 minutes. The inhalation route of ketamine delivery via breath-actuated nebulizer may have utility for managing pain in the ED.