The Use of Ketamine for Acute Treatment of Pain

A Randomized, Double-Blind, Placebo-Controlled Trial

Billy Sin, PHARMD, BCPS; Tamara Tatunchak, MD; Mohammad Paryavi, MD; Maria Olivo, MD; Usman Mian, MD; Josel Ruiz, BA, MPH; Bupendra Shah, BSPHARM, MS, PHD; Sylvie de Souza, MD, FACEP

Disclosures

J Emerg Med. 2017;52(5):601-608. 

In This Article

Abstract and Introduction

Abstract

Background: Pain is one of the most common reasons for emergency department (ED) visits in the United States. Ketamine is a sedative with N-methyl-D-aspartate (NMDA) receptor antagonism. Recent literature has suggested that the use of subdissociative dose ketamine (SDDK) may be safe and effective for acute pain.

Objective: The objective of our study was to evaluate ketamine in subdissociative doses as an adjunct for acute pain in the ED.

Methods: This was a single-center, prospective, randomized, double-blind, placebo-controlled trial that evaluated the use of SDDK in adult patients who presented to the ED with acute pain. Patients received ketamine 0.3 mg/kg via intravenous piggyback over 15 min or placebo. Morphine 0.1 mg/kg intravenous push was administered with the study interventions. The primary outcome was the patient's pain score 15 min after initiation of the intervention. Secondary outcomes included adverse events, consumption of rescue analgesia, patient's length of stay, and patient satisfaction with treatment.

Results: Thirty patients were enrolled in each group. Median pain scores in patients who received ketamine were lower than in controls at 15 min (3.5 [interquartile range {IQR} 1.0–7.3 vs. 6.0 [IQR 4.0–9.0], respectively; p = 0.018). No serious adverse events occurred. No difference was detected in the amount of rescue analgesia used or in length of stay. Patients who received ketamine reported a higher mean satisfaction score with their pain management (8.57 [standard deviation {SD} 2.1]) than patients who received placebo (6.05 [SD 2.6]; p = 0.01).

Conclusion: When used as an adjunct, SDDK administered at 0.3 mg/kg over 15 min resulted in safe and effective analgesia for ≤30 min in patients who presented with acute pain in the ED.

Introduction

Pain is one of the most common reasons for emergency department (ED) visits in the United States.[1,2] According to the latest data from the U.S. Centers for Disease Control and Prevention (CDC), there are >136 million patient visits to the ED per year.[1] Of these visits, common principal reasons include: abdominal (8%), headache (3.1%), back (2.8%), and generalized (2.2%) pain.[1] Patient satisfaction has been increasingly used as a measure of performance in the ED.[2] Because the effectiveness of pain management is based on patient feedback, the provision of safe and effective use of analgesics has become a topic of interest in emergency medicine.

Despite continuous efforts in research and the development of practice protocols, the use of opioids for the management of acute pain in the ED continues to be a controversial topic.[3] The use of opioids has been supported by tradition, expert opinion, clinical experience, and case-based observations.[4] Since the start of the millennium, the percentage of ED visits that resulted in the prescribing of opioids has steadily increased from 20.8% to 31%.[5] At the same time, the rate of opioid overdose–related deaths also increased.[6] Because of these factors, there are increasing concerns about and hesitance to use opioids.

Ketamine is a well-known sedative with N-methyl-D-aspartate receptor antagonism. The stimulation of the N-methyl-D-aspartate receptor has been thought to increase impulses responsible for allodynia and hyperalgesia.[7–10] Ketamine's role in pain management has been documented in cancer and palliative care.[8] However, its use is often a topic of controversy because of its ability to cause dissociation and emergence phenomena.[8,9] However, recent evidence from the literature has suggested that the use of subdissociative dose ketamine (SDDK) may be safe and effective for acute pain.[11]

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