Intranasal Ketamine for Analgesia in the Emergency Department: A Prospective Observational Series

Abstract

Objectives: The objective was to examine the feasibility, effectiveness, and adverse effect profile of intranasal ketamine for analgesia in emergency department (ED) patients.Methods: This was a prospective observational study examining a convenience sample of patients aged older than 6 years experiencing moderate or severe pain, defined as a visual analog scale (VAS) score of 50 mm or greater. Patients received 0.5 to 0.75 mg/kg intranasal ketamine. Pain scores were recorded on a standard 100-mm VAS by trained investigators at baseline, then every 5 minutes for 30 minutes, and then every 10 minutes for an additional 30 minutes. The primary outcome was the number and proportion of patients experiencing clinically significant reductions in VAS pain scores, defined as VAS reductions of 13 mm or more, within 30 minutes. Secondary outcomes included the median reduction in VAS, the median time required to achieve a 13 mm reduction in VAS, vital sign changes, and adverse events. Continuous data are reported with medians and interquartile ranges (IQRs). The Wilcoxon signed-ranks test was used to assess changes in VAS scores. Adverse effects are reported with proportions and 95% confidence intervals (CIs).Results: Forty patients were enrolled with a median age of 47 years (IQR = 36 to 57 years; range = 11 to 79 years) for primarily orthopedic injuries. A reduction in VAS of 13 mm or more within 30 minutes was achieved in 35 patients (88%). The median change in VAS at 30 minutes was 34 mm (44%). Median time required to achieve a 13 mm VAS reduction was 9.5 minutes (IQR = 5 to 13 minutes; range = 5 to 25 minutes). No serious adverse effects occurred. Minor adverse effects included dizziness (21 patients, 53%; 95% CI = 38% to 67%), feeling of unreality (14 patients, 35%; 95% CI = 22% to 50%), nausea (four patients, 10%; 95% CI = 4% to 23%), mood change (three patients, 8%; 95% CI = 3% to 20%), and changes in hearing (one patient, 3%; 95% CI = 0% to 13%). All adverse effects were transient and none required intervention. There were no changes in vital signs requiring clinical intervention.Conclusions: Intranasal ketamine reduced VAS pain scores to a clinically significant degree in 88% of ED patients in this series. Adverse effects were minor and transient. Intranasal ketamine may have a role in the provision of effective, expeditious analgesia to ED patients. ACADEMIC EMERGENCY MEDICINE 2013; 20:1050-1054 © 2013 by the Society for Academic Emergency Medicine T he provision of analgesia is a frequent and integral component of care in the emergency department (ED) setting, yet adequate and timely analgesia is often challenging due to scarcity of available health care providers, stretcher space, and monitoring availability in overcrowded EDs. This study

Intranasal ketamine for the treatment of patients with acute pain in the emergency department

“…[ [5][6][7] The patients received a single dose of 0.3 mg/kg or an additional dose of IN ketamine if the VAS remained 50 mm or higher at 15 minutes after the initial administration of the agent. Dosing was calculated previously for 0.7 mg/kg and 0.3 mg/kg and doses were rounded in the table in five kg weight bands for ease of dose and volume calculation so as to reduce risk of dosing error.…”

“…[4] Because of this analgesic effect at a low dose, patients often remain completely awake and alert and no deleterious or clinically signifi cant hemodynamic or respiratory effects were noted previously, therefore close physiological monitoring of the patients can be avoided in contrast to opioids. [2,[4][5][6][7] IN ketamine in the ED has been explored in recent years internationally; [5][6][7] however, the results are controversial. Recent studies [5,6] have demonstrated adequate analgesia with IN ketamine, whereas one study [7] concluded that IN ketamine had a relatively low response rate.…”

“…[2,[4][5][6][7] IN ketamine in the ED has been explored in recent years internationally; [5][6][7] however, the results are controversial. Recent studies [5,6] have demonstrated adequate analgesia with IN ketamine, whereas one study [7] concluded that IN ketamine had a relatively low response rate. Moreover, there is a paucity of information about this topic in our context using drops rather than mucosal atomizer device for the delivery of IN ketamine.…”

Intranasal Ketamine vs. Intramuscular Pethidine in Labor Pain Analgesia

“…Andolfatto G, et al [15] used Intranasal ketamine for analgesia in the emergency department in a study and have reached a conclusion that intranasal ketamine lowered VAS pain scores to a clinically significant degree in 88% of emergency department (ED) patients Also Roshana S, et al [16] tried intranasal ketamine for the treatment of patients with acute pain in the ED and concluded that intranasal ketamine is an analgesic choice for acute injury patients with moderate to severe pain especially in an overcrowded and resource limited ED.…”

In Children with Limb Injury Pain, Shall We Use Intranasal Fentanyl or Ketamine?

“…Intranasal fentanyl has been widely reported to be an effective tool in pediatric pain relief along with other opiates (4). However, ketamine has only recently been described for the provision of analgesia in pediatric emergency settings (5)(6)(7).…”