Last week’s Morsel discussed patellar dislocations and mentioned the use of nitrous oxide to assist with the reduction. Many of you had great feedback on other pain management options (thank you!). Obviously, the management of pain is one of our primary objectives and the science and art of it does not lend itself to a simple, single option. Fortunately, we have many options that can be appropriately tailored to our patients.
Recently, a colleague and friend, Dr. James Homme, delivered a brilliant presentation on Ketamine for Analgesia at the ACEP/AAP Advanced Pediatric Emergency Medicine Assembly and proclaimed “To know ketamine, is to love ketamine.”
We have covered Ketamine’s use for Delayed Sequence Intubation and for the treatment of Hypercyanotic Spells and the team at Don’tForgetTheBubbles.com just covered it’s use for Conscious / Procedural Sedation. Now, let’s explore the next frontier for Ketamine usage: Analgesia!
The Problem with Brief Painful Procedures…
Many of the procedures that we need to perform in the Emergency Department do not require a prolonged time.
Incision and drainage, uncomplicated joint reductions, wound cleansing / debridement, uncomplicated laceration repair are all great examples of procedures that often do not require more than a few minutes of actual procedure time.
The problem with these procedures is that they are still painful and scarey.
This creates a difficult to solve risk : benefit ratio equation.
Risk of full conscious / procedural sedation
Risk of suboptimal pain and anxiety control
Risk of physical restraint
Unfortunately, the equation is often solved in a manner that inadequately controls the child’s discomfort in favor of being expedient.
There is No Perfect Rx, But Ketamine is Close…
The World Health Organization has characterized Ketamine as a “core medication for basic healthcare systems.”
While those of us in Ivory Towers can debate, it is recommended for systems with far fewer resources.
The US Defense Health Board called Ketamine “a new alternative to conventional battlefield analgesia” in 2012.
Ketamine is ideal for pain management in an austere environment.
Safe and effective.
Rapid onset.
No respiratory depression.
Requires little (if any) monitoring.
Our EDs are like luxury hotels compared to the austere regions it is being used in.
Referred to morphine as “the slipping gold standard.”
The world’s literature (see references) notes Ketamine is effective at reducing pain quickly (usually by 5 minutes).
Dosage Matters
The first publication showing Ketamine as being effective as an analgesic was in 1971.
Ketamine used at subdissociative doses worked better than merperidine for reducing pain response.
Since then we have become very comfortable with it as a medication for conscious / procedural sedation.
It’s association with PCP has likely affected its usage as an analgesic, however.
Analgesic Dosages: 0.1 – 0.3 mg/kg IV; 0.5 – 1 mg/kg IM
Partial Dissociation: 0.4 – 0.8 mg/kg IV
Dissociation Dosages: 1 – 2 mg/kg IV; 2 – 4 mg/kg IM
Barriers to Ketamine’s Use
Institutional labeling
If your hospital has labeled it as a medication to be used for sedation purposes, you will likely met resistance to giving it for analgesia without filling out 1,000 pages of conscious sedation paperwork.
Perhaps you can use the references below to change that.
Certainly we use other medications for various applications (opioids, benzodiazepines, etc).
Myths about head injury
Fear of Emergence Reaction
This is actually a rare event for the group that receives subdissociative doses of Ketamine.
Potential Therapeutic Groups
See reference
The awake patient who needs a brief painful procedure (5-10 min).
The patient with chronic pain on opioids presenting with intractable pain (ex, Sickle Cell Pain Crisis).
The patient in whom pain is associated with emotional distress.
Ketamine not only controls pain, but it also makes people seem to be indifferent to it.
Ketamine is also being looked at for treatment of depression.
So, while you might not be using Ketamine for Analgesia during your next shift for that I+D, maybe in the very near future you will be.
References
Nielsen BN1, Friis SM, Rømsing J, Schmiegelow K, Anderson BJ, Ferreirós N, Labocha S, Henneberg SW. Intranasal sufentanil/ketamine analgesia in children. Paediatr Anaesth. 2014 Feb;24(2):170-80. PMID: 24118506. [PubMed] [Read by QxMD]
The management of procedural pain in children ranges from physical restraint to pharmacological interventions. Pediatric formulations that permit accurate dosing, are accepted by children and a have a rapid onset of analgesia are lacking. [...]
Ahern TL1, Herring AA, Stone MB, Frazee BW. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med. 2013 May;31(5):847-51. PMID: 23602757. [PubMed] [Read by QxMD]
We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain. [...]
Norambuena C1, Yañez J, Flores V, Puentes P, Carrasco P, Villena R. Oral ketamine and midazolam for pediatric burn patients: a prospective, randomized, double-blind study. J Pediatr Surg. 2013 Mar;48(3):629-34. PMID: 23480923. [PubMed] [Read by QxMD]
The aim of this study was to compare the efficacy of oral midazolam and ketamine with oral midazolam, acetaminophen, and codeine in providing sedation and analgesia for wound care procedures in children with burns. [...]
Herring AA, Ahern T, Stone MB, Frazee BW. Emerging applications of low-dose ketamine for pain management in the ED. Am J Emerg Med. 2013 Feb;31(2):416-9. PMID: 23159425. [PubMed] [Read by QxMD]
Richards JR1, Rockford RE. Low-dose ketamine analgesia: patient and physician experience in the ED. Am J Emerg Med. 2013 Feb;31(2):390-4. PMID: 23041484. [PubMed] [Read by QxMD]
Low-dose ketamine (LDK) may be useful for treatment for opioid-tolerant patients. We conducted a survey of patients and their treating clinicians regarding LDK for analgesia. [...]
Niesters M1, Khalili-Mahani N, Martini C, Aarts L, van Gerven J, van Buchem MA, Dahan A, Rombouts S. Effect of subanesthetic ketamine on intrinsic functional brain connectivity: a placebo-controlled functional magnetic resonance imaging study in healthy male volunteers. Anesthesiology. 2012 Oct;117(4):868-77. PMID: 22890117. [PubMed] [Read by QxMD]
The influence of psychoactive drugs on the central nervous system has been investigated with positron emission tomography and task-related functional magnetic resonance imaging. However, it is not known how these drugs affect the intrinsic large-scale interactions of the brain (resting-state functional magnetic resonance imaging connectivity). In this study, the effect of low-dose S(+)-ketamine on intrinsic brain connectivity was investigated. [...]
Arroyo-Novoa CM1, Figueroa-Ramos MI, Miaskowski C, Padilla G, Paul SM, Rodríguez-Ortiz P, Stotts NA, Puntillo KA. Efficacy of small doses of ketamine with morphine to decrease procedural pain responses during open wound care. Clin J Pain. 2011 Sep;27(7):561-6. PMID: 21436683. [PubMed] [Read by QxMD]
The purpose of this study was to evaluate differences in pain intensity, pain quality, physiological measures, and adverse effects when patients received morphine with saline (MS) compared with morphine and a small dose of ketamine (MK) before an open wound care procedure (WCP). [...]
Persson J. Wherefore ketamine? Curr Opin Anaesthesiol. 2010 Aug;23(4):455-60. PMID: 20531172. [PubMed] [Read by QxMD]
Ketamine has been repeatedly reviewed in this journal but novel developments have occurred in the last few years prompting an update. Interesting recent publications will be highlighted against a background of established knowledge. [...]
Zempsky WT1, Loiselle KA, Corsi JM, Hagstrom JN. Use of low-dose ketamine infusion for pediatric patients with sickle cell disease-related pain: a case series. Clin J Pain. 2010 Feb;26(2):163-7. PMID: 20090444. [PubMed] [Read by QxMD]
Sickle cell disease-related pain is difficult to treat adequately. Pain secondary to vasoocclusive episodes (VOE) may be unresponsive to high-dose intravenous opiates. Alternative treatment options for VOE are needed. We sought to review our experience with low-dose ketamine for children hospitalized with VOE. [...]
Black IH1, McManus J. Pain management in current combat operations. Prehosp Emerg Care. 2009 Apr-Jun;13(2):223-7. PMID: 19291561. [PubMed] [Read by QxMD]
Pain management in the U.S. Military, particularly in combat, shares many of the same principles found in civilian heath care organizations and institutions. Pain is one of the most common reasons for which soldiers seek medical attention in the combat environment, which mirrors the civilian experience. However, the combat environment exacerbates the typical challenges found in treating acute pain and has the additional obstacles of a lack of sup [...]
Svenson JE1, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007 Oct;25(8):977-80. PMID: 17920984. [PubMed] [Read by QxMD]
Ketamine has been used extensively for analgesia and anesthesia in many situations, including disaster surgery where extra personnel and advanced monitoring are not available. There are many features of ketamine that seem to make it an ideal drug for prehospital use. The reported use of ketamine in the prehospital environment is limited, however. The purpose of this study is to review the experience in the use of ketamine in a regional air ambula [...]
Kronenberg RH. Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal and intranasal administration. J Pain Palliat Care Pharmacother. 2002;16(3):27-35. PMID: 14640353. [PubMed] [Read by QxMD]
Ketamine is a parenteral anesthetic agent that provides analgesic activity at sub-anesthetic doses. It is an N-methyl-D-aspartate (NMDA) receptor antagonist with opioid receptor activity. Controlled studies and case reports on ketamine demonstrate efficacy in neuropathic and nociceptive pain. Because ketamine is a phencyclidine analogue, it has some of the psychological adverse effects found with that hallucinogen, especially in adults. Therefore [...]
Sadove MS, Shulman M, Hatano S, Fevold N. Analgesic effects of ketamine administered in subdissociative doses. Anesth Analg. 1971 May-Jun;50(3):452-7. PMID: 5103784. [PubMed] [Read by QxMD]
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