Ketamine administration for acute painful sickle cell crisis: A randomized controlled trial

Alshahrani, Mohammed; AlSulaibikh, Amal; El-Tahan, Mohamed R.; Alfaraj, Sukayna; Asonto, Laila Perlas; Almulhim, Abdullah; Alabbad, Murad F.; Almaghraby, Nisreen; Jumaan, Mohammed Al; AlJunaid, Thamir O.; Darweesh, Moath N.; Al-Hawaj, Faisal; Mahmoud, Alaa M.; Alossaimi, Bader; Alotaibi, S.; AlMutairi, Talal M.; Alsulaiman, Duaa; Alfaraj, Dunya; Alhawwas, Reem; Mbuagbaw, Lawrence; Lewis, Kim; Verhovsek, Madeleine; Crowther, Mark; Guyatt, Gordon; Alhazzani, Waleed

doi:10.1111/acem.14382

Cited by 21 publications

(23 citation statements)

References 48 publications

(68 reference statements)

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“…10,16 Of the studies identified, two were conducted in the ED, 17,18 six were conducted on general inpatient floors, 5,[10][11][12]14,15 and two were conducted in the intensive care unit (ICU). 13,16 Six studies were stratified as adult studies (Table 1) [11][12][13][14]16,17 and four as pediatric studies (Table 2). 5,10,15,18 Use of ketamine alone versus as an adjunct to opioids, method of ketamine delivery, use of a bolus versus infusion without a bolus, starting doses, and infusion times differed among the studies.…”

Section: Resultsmentioning

confidence: 99%

“…Though no significant difference was found in mean pain scores or hospitalization rates at the end of the trial, the ketamine group had lower mean opioid use than the morphine group. 17 Among the adult studies, two documented adverse effects led to treatment cessation in affected participants. In one of these studies, one patient (of nine) developed psychotomimetic symptoms after ketamine was first given as a bolus at 0.25 mg/kg and Mohammad H. Bawany, et al…”

Section: Resultsmentioning

confidence: 99%

“…9 However, studies on the use of ketamine in VOC are sparse though increasing. 5,[10][11][12][13][14][15][16][17] There is variation among these studies in terms of ketamine dose, treatment duration, and concurrent opioid use.…”

Section: Introductionmentioning

confidence: 99%

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Subdissociative-dose ketamine for sickle cell vaso-occlusive crisis: a narrative review for the emergency physician

Bawany

Motov

2022

Clin Exp Emerg Med

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Vaso-occlusive crisis (VOC) in sickle cell disease can cause severe pain and requires a thoughtful approach to analgesia. Considering the heightened awareness of the harm associated with opioids, an exploration of safer and more effective alternatives is overdue. Ketamine may play a role in supplementing or replacing opioid analgesia for patients in VOC. Studies on the use of ketamine for VOC are sparse, though increasing. In this review, we summarize the literature on subdissociative ketamine use for VOC to offer providers insight into the most effective and safe dosing regimens for sickle cell disease patients. Overall, the studies discussed in this review show decreased opioid use when subdissociative ketamine is provided as an adjunct and resolution of pain for most patients when subdissociative ketamine is used as the sole form of analgesia in VOC. Most studies examined intravenous delivery, and successful outcomes were established for both adult and pediatric patients in multiple clinical settings, including in the emergency department. Although more research is needed, it is clear from the published data that subdissociative ketamine may provide an efficacious addition to the clinician’s toolbox for managing VOC.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Subdissociative-dose ketamine for sickle cell vaso-occlusive crisis: a narrative review for the emergency physician

Bawany

Motov

2022

Clin Exp Emerg Med

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“…It is encouraging that, since the completion of our literature search, several studies assessing the efficacy of these adjuncts for sickle cell pain have been published. 133–136 These analgesics have the potential to expand treatment for VOCs to a true multimodal approach, and as a result, attenuate some of the possible adverse effects of the opioid analgesics. Our explanatory pain model for SCD captures the multidimensional nature of the pain experience and suggests new SCD pain targets as well as new measures of efficacy.…”

Section: Discussionmentioning

confidence: 99%

Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review

Kenney¹,

Smith²

2022

JPR

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Purpose of Review Sickle cell disease (SCD) is an inherited hemoglobinopathy with potential life-threatening complications that affect millions of people worldwide. Severe and disabling acute pain, referred to as a vaso-occlusive crisis (VOC), is a fundamental symptom of the disease and the primary driver for acute care visits and hospitalizations. Despite the publication of guidelines for VOC management over the past decade, management of VOCs remains unsatisfactory for patients and providers. Recent Findings Acute SCD pain includes pain secondary to VOCs and other forms of acute pain. Distinguishing VOC from non-VOC pain may be challenging for both patients and clinicians. Further, although opioids have been the gold-standard for VOC pain management for decades, the current highest standard of care for all acute pain is a multimodal approach that is less dependent on opioids, and, instead incorporates analgesics and adjuvants from different mechanistic pathways. In this narrative review, we focus on a multimodal pharmacologic approach for acute SCD pain management and explore the evidence for existing non-opioid pharmacological adjuncts. Moreover, we present an explanatory model of pain, which is not only novel in its application to SCD pain but also captures the multidimensional nature of the SCD pain experience and supports the need for such a multimodal approach. This model also highlights opportunities for new investigative and therapeutic targets – both pharmacological and non-pharmacological. Summary Multimodal pain regimens that are less dependent on opioids are urgently needed to improve acute pain outcomes for individuals with SCD. The proposed explanatory model for SCD pain offers novel opportunities to improve acute pain management for SCD patients.

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“…In parallel‐group trials, participants are randomized to different study arms and stay within their assigned group for the duration of the study. Parallel‐group trials in the ED have studied pediatric septic shock treatment, 62 computerized clinical decision support to streamline the workflow for ED‐initiated buprenorphine/naloxone and referral, 63 ketamine infusion for acute sickle vaso‐occlusive crisis, 64 and shared decision making in low‐risk chest pain 65 …”

Section: Pct Study Design Types and Examplesmentioning

confidence: 99%

Pragmatic clinical trial design in emergency medicine: Study considerations and design types

Gettel

Yiadom

Bernstein

et al. 2022

Academic Emergency Medicine

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Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record.The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.

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Ketamine administration for acute painful sickle cell crisis: A randomized controlled trial

Abstract: This is an open access article under the terms of the Creat ive Commo ns Attri butio n-NonCo mmerc ial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Cited by 21 publications

References 48 publications

Subdissociative-dose ketamine for sickle cell vaso-occlusive crisis: a narrative review for the emergency physician

Subdissociative-dose ketamine for sickle cell vaso-occlusive crisis: a narrative review for the emergency physician

Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review

Pragmatic clinical trial design in emergency medicine: Study considerations and design types

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