Ketamine for Analgesia

Ketamine for analgesia

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…

  1. Many of the procedures that we need to perform in the Emergency Department do not require a prolonged time.
    1. 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.
  2. The problem with these procedures is that they are still painful and scarey.
  3. This creates a difficult to solve risk : benefit ratio equation.
    1. Risk of full conscious / procedural sedation
    2. Risk of suboptimal pain and anxiety control
    3. Risk of physical restraint
  4. 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]

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]

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]

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]

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]

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]

Persson J. Wherefore ketamine? Curr Opin Anaesthesiol. 2010 Aug;23(4):455-60. PMID: 20531172. [PubMed] [Read by QxMD]

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]

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]

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]

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]

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]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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8 Responses

  1. Simon Craig says:

    Dear Sean,

    Here are a couple of articles regarding intranasal ketamine for analgesia
    http://www.ncbi.nlm.nih.gov/pubmed/23560967

    http://www.ncbi.nlm.nih.gov/pubmed/24712757

    The authors have just finished a study on intranasal fentanyl vs intranasal ketamine… Looking forward to hearing about the findings.

    Kind regards,

    Simon

  2. Andrés says:

    I,ve had excellent professional experiences with Ketamine! Just two questions.

    1. When considering ketamine’s use in the ER, how many fasting hours do you consider safe enough?

    2. Any relevant side effects we should be prepared for? I have never seen any bronchorrea.

    • Sean Fox says:

      Thank you for your comment!
      Ketamine does have many excellent benefits and a great safety profile. It is, however, important, to always anticipate side effects. Bronchorrhea can occur, but I do not typically administer medicines empirically to counteract this possibility. Other commonly considered issues to ponder: laryngospasm, respiratory depression, emesis.

      As for “fasting” times… there is NO evidence that a specific amount of fasting time is beneficially for procedural sedation in the Emergency Department. BUT… you should always follow your hospital’s protocols.
      Thank you,
      sean

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