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Systematic review of the use of low-dose ketamine for analgesia in the emergency department

  • Gauri Ghate (a1), Eric Clark (a1) and Christian Vaillancourt (a1) (a2)

Abstract

Objectives

The aim of the study is to determine the performance of low-dose ketamine (LDK) as an analgesic for acute pain management in adult patients in the emergency department (ED).

Methods

We systematically reviewed electronic databases, grey literature, conference abstracts, and clinical trial registries. Two independent reviewers identified eligible studies. These selections were subsequently reviewed by one reviewer who identified the final eligible studies, using refined inclusion and exclusion criteria. Our outcome measures included the analgesic effect of LDK, need for rescue analgesia, and neuropsychological adverse events secondary to LDK use. We assessed inter-rater agreement using kappa statistics and proposed a treatment recommendation using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) software. Heterogeneity among studies precluded meta-analysis.

Results

Our electronic search identified 1,408 records; 44 were selected for full evaluation (kappa=0.70), and 8 were included after the final review. All six randomized controlled trials and two observational studies were set in the ED where LDK was administered to adult patients ( >18 years old) exclusively for pain management. All studies had an overall low risk of bias. There was extensive variation in the dose and route of LDK used (0.1-0.7 mg/kg SC/IV/IM), administration protocols, and use of adjunct analgesia. Overall, most studies reported a significant analgesic effect of LDK with occasional need for rescue analgesia and mild-to-moderate adverse events (dizziness, dysphoria, and confusion).

Conclusion

There are moderate to low quality data supporting LDK as an alternative analgesic in the ED with the potential for minimal requirement of rescue analgesia and self-limited neuropsychological adverse events.

Objectif

L’étude visait à déterminer l’efficacité de la kétamine à faible dose (KFD) comme analgésique dans le soulagement de la douleur aiguë chez les adultes au service des urgences (SU).

Méthode

Nous avons procédé à une revue systématique des bases de données, de la documentation parallèle, des résumés de congrès et des registres d’essais cliniques. Deux examinateurs indépendants ont repéré les études susceptibles d’être retenues, puis un examinateur les a passées en revue pour ne sélectionner finalement que les plus pertinentes après raffinement des critères d’inclusion et d’exclusion. Les critères d’évaluation comprenaient l’effet analgésique de la KFD, la nécessité d’une analgésie d’appoint et les événements neuropsychologiques indésirables du médicament. Nous avons évalué la fidélité interjuges à l’aide du test de concordance kappa, et présentons une recommandation sur le traitement qui repose sur le logiciel GRADE (Grading of Recommendations Assessment, Development and Evaluation). Il n’a pas été possible de procéder à une méta-analyse en raison de l’hétérogénéité des études.

Résultats

La recherche électronique a permis de relever 1408 études possibles, dont 44 ont été retenues en vue d’une évaluation complète (kappa=0,70); sur ce dernier nombre, 8 finalement ont été sélectionnées après examen. Il s’agissait de six essais comparatifs, à répartition aléatoire, et de deux études d’observation menés dans des SU où la KFD avait été administrée à des adultes (>18 ans) uniquement à des fins de soulagement de la douleur. Le risque de biais était généralement faible dans toutes les études. Toutefois, il y avait des différences importantes en ce qui concerne les voies d’administration et les doses de kétamine (0,1-0,7 mg/kg, s.c./i.v./i.m.), les protocoles d’administration et la nécessité d’une analgésie d’appoint. Les études ont fait état, dans l’ensemble, d’un bon effet analgésique, nécessitant parfois une analgésie d’appoint et accompagné d’événements indésirables légers ou modérés (étourdissements, dysphorie et confusion).

Conclusions

Des données de qualité médiocre ou moyenne étayent l’utilisation de la KFD comme analgésique de rechange au SU, nécessitant dans peu de cas une analgésie d’appoint et accompagné d’événements neuropsychologiques indésirables qui disparaissent spontanément.

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Copyright

Corresponding author

Correspondence to: Dr. Gauri Ghate, Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital – Civic Campus, 1053 Carling Ave., E-Main, Room EM-206, Box 227, Ottawa, ON K1Y 4E9; Email: gauri.ghate@gmail.com

References

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1. Thomas, SH. Management of pain in the emergency department. ISRN Emerg Med 2013;2013:583132.
2. Green, L. Ketamine in adults: what emergency physicians need to know about patient selection and emergence reactions. Acad Emerg Med 2000;7(3):278-281.
3. Chudnofsky, CR, Weber, JE, Stoyanoff, PJ, et al. A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients. Acad Emerg Med 2000;7(3):228-235.
4. Messenger, DW, Murray, HE, Dungey, PE, et al. Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomized clinical trial. Acad Emerg Med 2008;10:877-886.
5. Richards, J, Rockford, R. Low-dose ketamine analgesia: patient and physician experience in the ED. Am Emerg Med 2013;31(2):390-394.
6. Willman, EV, Andolfatto, G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med 2007;49(1):23-30.
7. Green, SM, Roback, MG, Kennedy, RM, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med 2011;57(5):449-461.
8. Bell, RF, Dahl, JB, Moore, RA, Kalso, E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005;49:1405-1428.
9. Kochs, E, Scharein, E, Möllenberg, O, Bromm, B, Schulte am Esch, J. Analgesic efficacy of low-dose ketamine. Anesthesiology 1996;85:304-314.
10. Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, the PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med 2009;151(4):264-269.
11. Higgins, JP, Altman, DG, Gøtzsche, PC, Jüni, P, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.
12. Ahmadi, O, Isfahani, MN, Feizi, A. Comparing low-dose intravenous ketamine-midazolam with intravenous morphine with respect to pain control in patients with closed limb fracture. J Res Med Sci 2014;19:502-508.
13. Beaudoin, FL, Lin, C, Guan, W, et al. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial. Acad Emerg Med 2014;11:1194-1202.
14. Galinski, M, Dolveck, F, Combes, X, et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J Emerg Med 2007;25:385-390.
15. Gurnani, A, Sharma, PK, Rautela, RS, et al. Analgesia for acute musculoskeletal trauma: low-dose subcutaneous infusion of ketamine. Anaesth Int Care 1996;24:32-36.
16. Miller, JP, Schauer, SG, Ganem, VJ, et al. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J Emerg Med 2015;33(3):402-408.
17. Motov, S, Rockoff, B, Cohen, V, et al. Intravenous sub-dissociative dose ketamine versus morphine for analgesia in the emergency department: a prospective, randomized, double-blind study. Ann Emerg Med 2014;5(Suppl 1):S20-S21.
18. Ahern, T, Herring, A, Stone, M, et al. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med 2013;31(5):847-851.
19. Ahern, TL, Herring, AA, Miller, S, Frazee, BW. Low-dose ketamine infusion for the emergency department patients with severe pain. Pain Med 2015;16(7):1402-1409.
20. Ahern, TL, Herring, AA, Anderson, ES, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med 2015;33(2):197-201.
21. Lester, L, Braude, DA, Niles, C, et al. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J Emerg Med 2010;28(7):820-827.
22. Yeaman, F, Meek, R, Egerton-Warburton, D, et al. Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients. Emerg Med Australas 2014;26(3):237-242.
23. Lee, EN, Lee, JH. The effects of low-dose ketamine on acute pain in an emergency setting: a systematic review and meta-analysis. PLoS ONE 2016;11(10):e0165461.
24. Jennings, PA, Cameron, P, Bernard, S, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med 2012;59(6):497-503.
25. Sin, B, Ternas, T, Motov, SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med 2015;22(3):251-257.
26. Kennedy, RM, Porter, FL, Miller, JP, et al. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics 1998;102(4 Pt 1):956-963.

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