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

AbstractObjectivesThe 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).MethodsWe 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.ResultsOur 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).ConclusionThere 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.

Download Full-text

LO048: Systematic review of the use of low-dose ketamine for analgesia in the emergency department

CJEM ◽

10.1017/cem.2016.85 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S46-S47

Author(s):

G. Ghate ◽

E. Clark ◽

C. Vaillancourt

Keyword(s):

Emergency Department ◽

Pain Management ◽

Adverse Events ◽

Acute Pain ◽

Analgesic Effect ◽

Low Dose ◽

Risk Of Bias ◽

Quality Data ◽

Acute Pain Management ◽

Rescue Analgesia

Introduction: Ketamine is a popular sedative agent for painful procedures. It is not widely used at sub-dissociative analgesic doses in the emergency department (ED). We sought to determine the performance of low-dose ketamine (LDK) as an analgesic for acute pain management in adult patients in the ED. Methods: We systematically reviewed electronic databases (MEDLINE, EMBASE, AMED, CINAHL, PubMed and Cochrane database of systematic reviews), grey literature, conference proceedings and clinical trials registries. Two independent reviewers identified eligible studies using pre-determined criteria. We included peer-reviewed studies that used LDK (<1 mg/kg IV or <2mg/kg IM) in adult patients (>18 yo) requiring acute pain management for any condition in the ED. Our outcome measures included analgesic effect of LDK compared to any opioids, need for rescue analgesia, and neuropsychological adverse events. We assessed inter-rater agreement using kappa statistics, risk of bias using the Cochrane Collaboration’s Tool, and propose a treatment recommendation using GRADE. Heterogeneity among studies precluded meta-analysis. Results: We reviewed 1,408 studies and selected 44 for full review (kappa = 0.70). Thirty-three were excluded due to wrong patient population and non-analgesic use of ketamine. Eleven studies with 1,249 participants were included - six randomized control trials (RCTs) and five observational studies. All of which 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. There is a lack of high quality data regarding the use of LDK as an analgesic agent in the ED. However, the current moderate quality data demonstrates a significant analgesic effect of LDK with occasional need for rescue analgesia and neuropsychological adverse events. Commonly reported neuropsychological adverse events included dizziness, dysphoria, and confusion, rarely agitation or hallucinations. All adverse events were self-limited or occasionally required benzodiazepines for resolution. Conclusion: Our GRADE evidence table identified moderate quality evidence from six RCTs supporting the analgesic effect of LDK for acute pain management in the ED when compared to using opioids alone.

Download Full-text

Adverse Events Costs Associated With Pain Management In Adult Patients With Osteoarthritis And Rheumatoid Arthritis In Five Latin American Countries

Value in Health ◽

10.1016/j.jval.2013.03.1120 ◽

2013 ◽

Vol 16 (3) ◽

pp. A221 ◽

Cited By ~ 1

Author(s):

J. Mould-Quevedo ◽

G. Luna-Casas ◽

L. Garcia-Mollinedo ◽

A. Rosado-Buzzo

Keyword(s):

Rheumatoid Arthritis ◽

Pain Management ◽

Adverse Events ◽

Latin American ◽

Adult Patients ◽

Latin American Countries

Download Full-text

Low dose ketamine use in the emergency department, a new direction in pain management

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2017.03.005 ◽

2017 ◽

Vol 35 (6) ◽

pp. 918-921 ◽

Cited By ~ 22

Author(s):

A Pourmand ◽

M Mazer-Amirshahi ◽

C Royall ◽

R Alhawas ◽

R Shesser

Keyword(s):

Emergency Department ◽

Pain Management ◽

Low Dose

Download Full-text

Low dose long-acting factor VIII prophylaxis in pediatric and young adult patients with hemophilia A: Short-term single-center experience from a developing country

10.25259/jhas_13_2021 ◽

2021 ◽

Vol 0 ◽

pp. 1-6

Author(s):

Shailendra Prasad Verma ◽

Anil Kumar Tripathi ◽

Geeta Suri Sharma ◽

Nidhish Kumar ◽

Rashmi Kushwaha

Keyword(s):

Young Adult ◽

Adverse Events ◽

Factor Viii ◽

Low Dose ◽

Hemophilia A ◽

Adult Patients ◽

Severe Hemophilia ◽

Emergency Visits ◽

Episodic Treatment ◽

Long Acting

Objectives: High dose factor prophylaxis in hemophilia has been proven to prevent joint bleeds in the western world effectively. We look for a cost-effective and feasible way for Indian patients to reduce the dose and frequency of factor infusion. Data on prophylaxis with a low dose, long-acting factor infusion twice a week dosing schedule is limited. The purpose was to study the efficacy and safety of long-acting factor VIII (Eloctate) for secondary/ tertiary prophylaxis in pediatric and young adult patients with moderate and severe hemophilia A. Materials and Methods: Thirty-eight patients with moderate and severe hemophilia A with an age range from 1 to 25 years were included in the study. During the initial 4 months, they received therapeutic doses of ELOCTATE (Factor VIII with Fc Fusion Protein) on an episodic basis after a clinical bleed. In the next 4 months, they received prophylactic intravenous ELOCTATE at the dose of 20 units/kg body weight twice a week. Annual bleeding rates (ABR), school absenteeism, emergency visits, joint scores, and adverse events were compared during both periods. Results: The total number of joint bleeds during the episodic treatment and prophylaxis period was 608 and 67, respectively. ABR was 47.9 during the episodic treatment period and 5.3 during prophylaxis showing an 88.9% reduction in joint bleeds. School/college absenteeism and emergency visits were significantly reduced during prophylaxis. No significant adverse events were noted during prophylaxis. Conclusion: Low dose, twice a week, and long-acting recombinant factor VIII-Fc (Eloctate) prophylaxis can be a reasonable options for patients with hemophilia A in developing countries.

Download Full-text

Preoperative low-dose ketamine has no preemptive analgesic effect in opioid-naïve patients undergoing colon surgery when nitrous oxide is used - a randomized study

F1000Research ◽

10.12688/f1000research.5258.1 ◽

2014 ◽

Vol 3 ◽

pp. 226 ◽

Cited By ~ 3

Author(s):

Beatriz Nistal-Nuño ◽

Enrique Freire-Vila ◽

Francisco Castro-Seoane ◽

Manuel Camba-Rodriguez

Keyword(s):

Patient Satisfaction ◽

Postoperative Pain ◽

Analgesic Effect ◽

Low Dose ◽

Randomized Study ◽

Colon Surgery ◽

Morphine Consumption ◽

Control Group ◽

Hemodynamic Parameters ◽

Rescue Analgesia

Background: The analgesic properties of ketamine are associated with its non-competitive antagonism of the N-methyl-D-aspartate receptor; these receptors exhibit an excitatory function on pain transmission and this binding seems to inhibit or reverse the central sensitization of pain. In the literature, the value of this anesthetic for preemptive analgesia in the control of postoperative pain is uncertain. The objective of this study was to ascertain whether preoperative low-dose ketamine reduces postoperative pain and morphine consumption in adults undergoing colon surgery.Methods: In a double-blind, randomized trial, 48 patients were studied. Patients in the ketamine group received 0.5 mg/kg intravenous ketamine before surgical incision, while the control group received normal saline. The postoperative analgesia was achieved with a continuous infusion of morphine at 0.015 mg∙kgˉ¹∙hˉ¹ with the possibility of 0.02 mg/kg bolus every 10 min. Pain was assessed using the Visual Analog Scale (VAS), morphine consumption, and hemodynamic parameters at 0, 1, 2, 4, 8, 12, 16, and 24 hours postoperatively. We quantified times to rescue analgesic (Paracetamol), adverse effects and patient satisfaction.Results: No significant differences were observed in VAS scores between groups (P>0.05), except at 4 hours postoperatively (P=0.040). There were no differences in cumulative consumption of morphine at any time point (P>0.05). We found no significant differences in incremental postoperative doses of morphine consumption in bolus, except at 12 h (P =0.013) and 24 h (P =0.002). The time to first required rescue analgesia was 70 ± 15.491 min in the ketamine group and 44 ± 19.494 min in the control (P>0.05). There were no differences in hemodynamic parameters or patient satisfaction (P>0.05).Conclusions: Preoperative low-dose-ketamine did not show a preemptive analgesic effect or efficacy as an adjuvant for decreasing opioid requirements for postoperative pain in patients receiving intravenous analgesia with morphine after colon surgery.

Download Full-text

Efficacy of low-dose methoxyflurane analgesia in adult patients presenting to the emergency department with acute pain due to contusions and lacerations: a sub-analysis of a Phase III, randomised, double-blind, placebo controlled UK study (STOP!)

10.26226/morressier.58f5b030d462b80296c9e4f9 ◽

2017 ◽

Author(s):

Frank Coffey

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Low Dose ◽

Adult Patients ◽

Phase Iii ◽

Double Blind ◽

Double Blind Placebo

Download Full-text

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Anesthesiology ◽

10.1097/aln.0000000000003428 ◽

2020 ◽

Vol 133 (2) ◽

pp. 265-279 ◽

Cited By ~ 11

Author(s):

Michael Verret ◽

François Lauzier ◽

Ryan Zarychanski ◽

Caroline Perron ◽

Xavier Savard ◽

...

Keyword(s):

Chronic Pain ◽

Postoperative Pain ◽

Adverse Events ◽

Pain Intensity ◽

Acute Pain ◽

Analgesic Effect ◽

Mean Difference ◽

Adult Patients ◽

Opioid Use ◽

Clinically Significant

Background Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients. Methods Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences. Results In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance. Conclusions No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Download Full-text