Low Dose Ketamine for

Analgesia in the ED

Dr. Bruce Mohr MD CCFP(EM) Dip. Sport Med, FRRMS

Faculty/Presenter Disclosure

Faculty: Bruce Mohr MD

No relationships with commercial interests

No financial support

No honorarium from CAEP

No “in-kind” support

LDK is Off-Label use of Ketamine (sub-anesthetic

dosing)

• summarize ED LDK research

• suggest when it might be most useful

• suggest when to avoid it

• how to use it

• provide some case examples

3

Objectives

PAINTodd KH, Ducharme J, et al. Pain in the Emergency Department: results of the pain and emergency medicine

initiative (PEMI) multi centre study J. Pain 2007;8460-6.

• Opioids most commonly used, Morphine especially

• Many different kinds of pain

• Many different kinds of patients

• Complex interplay of receptors - peripheral and central

• ED Docs are THE ACUTE PAIN SPECIALISTS

• “A Little Bit of This and a Little Bit of That”

• LDK is just another potential tool

Ketamine dosing

• Ketamine as induction agent 1-2 mg/kg

• Ketamine dissociative dose = >0.7 mg/kg

• Ketamine partially dissociative dose = 0.3-0.7 mg/kg

• Ketamine Recreational = 0.2-0.5 mg/kg

• Ketamine Subdissociative dose = 0.3 mg/kg

• Low-Dose Ketamine = 0.1 - 0.3 mg/kg

PSA

LDK (0.1-0.3 mg/kg) - Mechanism of Action as an Analgesic

• blockade of CNS N-methyl-D-aspartic acid (NMDA) postsynaptic receptors

• sensory association areas in cortex, limbic system and thalamus are

depressed (CNS effect)

• reduces neuronal hyperexcitability of spinal nociceptive neurons leading to

central sensitization and chronic pain states

• LDK augments the opioid presynaptic reduction in transmitter release from

afferent C fibres (pain-carrying fibres)

• blockade of PNS Na+ channels

• inhibits nitric oxide synthase (reduces NO levels which are involved in pain

perception in CNS and PNS)

•NMDAPNS

CNS

LDK - Pre-hospital and ED research

• less narcotics required when combined with LDK (5)

• ketamine 0.1-0.3 mg/kg safe and feasible in a diverse ED

population (6)

• sub-dissociative dose (0.3 mg/kg) comparable to morphine

0.1mg/kg in safety and effectiveness (7,8)

• useful in ED patients with high tolerance to narcotics (9)

• more rapid onset of pain control using LDK plus reduced dose IV

Hydromorphone (3)

• LDK has a morphine-sparing effect (11)

• better pain relief for LDK plus IV Morphine at 30, 60, 120 min (12)

LDK - (I used it as an adjunct to opiates,

propofol, benzodiazepines…”this and that”)

• Multi-traumas

• fractures/discos - ski boot removal,

“unpackaging”, reduction and

splinting/casting

• nasal fracture reduction

• severe sciatica/nerve pain

• flank/abdominal pain

LDK - suggested indications

• when more rapid relief of pain desired

• when opioids suboptimal or ineffective

• when want to minimize opioid use because of concerns

re: respiratory/CV depression

• Complex Regional Pain Syndrome, peripheral

neuropathic pain, spinal chord injury pain, lower limb

ischemic rest pain, chronic phantom limb pain (14)

LDK - mitigating side effects

• “LLD” 0.1 - 0.15 mg/kg

• kids are kool, with adults be kareful

• slow push or short infusion(13)

• the Art of patient suggestion

• adjunctive midazolam/ondansetron prn

• Caution!! Preparations: 10 mg/ml, 50 mg/ml, 100 mg/ml

• bedside monitoring (optional)

• precautions (exclusion criteria in some studies) with: elderly, active

coronary disease, unstable psychiatric disease*, serious co-morbidities

(liver, kidney)

References1.Todd KH, Ducharme J, et al. Pain in the Emergency Department: results of the pain and emergency medicine initiative (PEMI) multi

centre study J. Pain 2007;8460-6.

2.Galinski,M et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J Emerg

Med (2007) 25,385-390

3.Ahern,TL et al. Affective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J

Emerg Med (2013) 31 847-851

4.Aroni, Filippia et al. Pharmacolgical Aspects and Potential new Clinical Applications of 5.Ketamine: Reevaluation of an Old Drug. J

Clin Pharmacol 2009;49:957-964

5.Johansson et al. The effect of combined treatment with morphine sulphate and low-dose ketamine in a prehospital setting.

Scandinavian J of trauma, Resus and Emerg Medicine 2009, 17:61 doc:10.1 186/1757-7241-17-61

6.Terence L. et al, The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED.

Am J of Emerg Med 33 (2015) 197-201

7. Motov,S et al. Intravenous Subdissociative-dose Ketamine versus Morphine for analgesia in the ED: A randomized Controlled trial.

Annals of Emergency medicine volume 66, no 3: sep 2015 pp 222-229

8. Miller, J. et al. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J of Emerg Med 33

(2015) 402-408

9. Laeben L. et al. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J of Emerg med (2010) 28, 820-827

10. Chauny, JM the Simple Query “do you want more pain medication ?” is not a reliable way to assess acute pain relief in patients in

the ED. CJEM 2018;20(1):21-27 DOI 10.1017/cem.2017.2

11. Galinski,M et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J of

Emerg med (2007) 25, 385-390

12. Beaudoin, FL et al. Low-dose ketamine improves pain relief in patients receiving IV opioids for acute pain in the ED: results of a

randomized double-blind clinical trial. Acad Emerg Med 2014;21:1194-1202

13. Motov S. et al. A prospective randomized double-dummy trial comparing IV push LDK to short infusion ketamine for treatment of

pain in the ED

14. Visser, E. The role of ketamine in pain management. Biomed Pharmacother. 2996;60:341-348

LDK