Ketamine for Acute Pain

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Ketamine Can it tame the pain? Casey Glass, MD Douglas Brtalik, MD Christ Post, MD

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  • KetamineCan it tame the pain?

    Casey Glass, MD Douglas Brtalik, MDChrist Post, MD

  • KetamineAn illustrated History

    and Pharmacology

  • PCP

  • PCP accomplished general anesthesia levels of sedation but has effects that are too long lasting

  • KetamineKetamine was one of many derivatives of PCP and selected

    for use due to more rapid resolution of effect. It was first given to a human in clinical trials in 1964.

  • 4-5 minutes

    Redistributes back to the body over 5 minutes

  • Ketamine is highly water soluble and not very lipophilic so has small volume of distribution

  • Ketamine has a high affinity for the NMDA receptors in the CNS and a lesser affinity for opioid receptors

  • Ketamine has a remarkable ability to reduce the central

    perception of pain, especially in chronic pain conditions that wind

    up the CNS response.

  • The Literature

  • Design: RCT

    Single agent IV ketamine vs IV morphine

    Outcome measures

    Self reported pain score at various intervals

    Need for rescue pain medication for uncontrolled pain

    Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department:

    A Randomized Controlled Trial Sergey Motov, MD*; Bradley Rockoff, MD; Victor Cohen, PharmD; Illya Pushkar, MPH;

    Antonios Likourezos, MA, MPH; Courtney McKay, PharmD; Emil Soleyman-Zomalan, MD; Peter Homel, PhD; Victoria Terentiev, BA; Christian Fromm, MD

    Motov 2015, PMID: 25817884

  • Motov 2015, PMID: 25817884

  • Motov 2015, PMID: 25817884

  • Study Conclusion Ketamine as effective as Morphine as single agent

    Higher proportion of patients who reported pain level of zero without need of rescue opiate medication.

    Overall similar incidence of side effects but with statistically significant increase in side effects reported at time of injection with ketamine

    Motov 2015, PMID: 25817884

  • The Use of Subdissociative-dose Ketamine for Acute Pain in the Emergency Department Billy Sin, PharmD, Theologia Ternas, PharmD, and Sergey M. Motov, MD

    Sin 2015, PMID: 25716117

    Design: Structured Review

    4 studies from 1998 to 2008 totaling 428 patients of which 260 are pediatric patients

  • Sin 2015, PMID: 25716117

  • Messenger et al, 2008; Galinski et al, 2007

    Messenger et al Compared IV Fentanyl 1.5 mcg/kg vs .3 mg/kg Ketamine Primary outcome adverse events and pain levels

    Galinski et al compared .2 mg/kg IV Ketamine over 10 min + .1mg/kg Morphine

    over 10 min vs .1mg/kg morphine alone

    Both showed no significant difference in patient pain or adverse outcomes.

    Sin 2015, PMID: 25716117

  • Gurnani et al, 2007 Ketamine infusion vs IV opioid prn (standard of care) Patients receiving ketamine had significantly lower

    pain scores Patients receiving ketamine consumed less morphine Interesting other observations noted

    No rescue pain meds needed with ketamine infusion group (vs 90% in standard group)

    No side effects noted in this group

    Sin 2015, PMID: 25716117

  • Conclusion

    Officially: failed to provide enough evidence to support or refute use of SDDK

    Appears not inferior to IV narcotic alone

    Infusion ketamine as an option in ED??

    Sin 2015, PMID: 25716117

  • Design: RCT

    Infusion ketamine rather than boluses for acute pain

    NOT comparing to IV opioids

    Allowed use of IV morphine in small doses q20 prn

    Followed pain scoring for 120 min

    Infusion for one hour then cut off for one hour

    Brief Research Report: Low-Dose Ketamine Infusion for Emergency Department Patients with Severe Pain

    Terence L. Ahern MD,* Andrew A. Herring MD, Steve Miller MD, and Bradley W. Frazee MD

    Ahern 2015, PMID: 25643741

  • Ahern 2015, PMID: 25643741

  • Conclusion Pain scores at various intervals all decreased Rescue pain meds used in 58% Those that did not require other pain meds had much

    better pain reduction than others Reports complete pain control at 10/60/120 mins were 75%;

    100%; 83% vs those who got additional pain meds who reported 36%; 53%; 61%

    Ketamine responders? Pt satisfaction 84%

    Ahern 2015, PMID: 25643741

  • Design: RCT

    Superiority trial, ketamine compared to IV morphine

    Outcome measure was change in pt pain reported at given time intervals

    Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial.

    Miller JP, Schauer SG, Ganem VJ, Bebarta VS

    Miller 2015, PMID: 25624076

  • Miller 2015, PMID: 25624076

  • Miller 2015, PMID: 25624076

  • Conclusion Similar pain management with ketamine and morphine

    No superiority

    DID note faster reported pain relief with ketamine

    Side effect reported similar

    Pt satisfaction similar

    Miller 2015, PMID: 25624076

  • My take Ketamine well studied as adjunct to IV narcotics for acute

    pain control

    Ketamine looks to work about as well as IV narcotics when used in isolation

    Infusion ketamine

    No study found significant adverse events with use of Ketamine

  • Ketamine in Practice

  • When to use Ketamine

    Opioid Tolerance/Abuse

    TraumaNeuropathic

    PainIntractable

    Pain

  • Dosing for Acute PainIntravenous 0.15 - 0.3 mg/kg slow push(some recommend repeating dose over an hour after a load)

    Intranasal: 0.7 - 1 mg/kg

  • Dose Adjustment for Size

    Dose based on Ideal Body Weight, not Actual weight!

  • K Hole!

    Give the loading dose slow Total dose based on IBW

  • ContraindicationsAllergy (only true absolute)

    Severe hypertension

    Chronic Liver Disease

    Head Trauma?

    Glaucoma?

    Active Schizophrenia

    Younger than 3 months

  • Adverse Reactions

    Composite: Molotov 2015, Miller 2015, Ahern 2015Aggregate 58% of patients

  • Adverse ReactionsDisorientation/Mood: 36%

    Dizziness/Sensory: 32%

    Nausea/Vomiting: 14%

    Composite: Molotov 2015, Miller 2015, Ahern 2015

  • The Elephant in the room... Emergence Reactions!

    this likely represents partial dissociation

    Mild in ~6%, clinically significant in 1-2%

    Multifactorial related to dosage, patient selection, age

    Not well studied in sub-dissociative dosage

    Possibly related to improper dosing

  • For Debate

    Is Ketamine analgesia a safe

    and effective therapy?

  • For Debate

    Is it appropriate to offer ketamine as a first line pain medication?

  • For Debate

    What should patients be told when ketamine is offered for analgesia?

  • References

    Available via Pubmed at http://1.usa.gov/1Y0Hqmr

    Articles available for Wake residents and staff athttp://bit.ly/1mas1V2

    http://1.usa.gov/1Y0Hqmrhttp://bit.ly/1mas1V2