IntroductionPatients frequently present to the emergency department (ED) with migraine headaches. Although low-dose ketamine demonstrates analgesic efficacy for acute pain complaints in the ED, headaches have historically been excluded from these trials. This study evaluates the efficacy and safety of low-dose ketamine for treatment of acute migraine in the ED.MethodsThis randomized, double-blinded, placebo-controlled trial evaluated adults 18 to 65 years of age with acute migraine at a single academic ED. Subjects were randomized to receive 0.2 milligrams per kilogram of intravenous (IV) ketamine or an equivalent volume of normal saline. Numeric Rating Scale (NRS-11) pain scores, categorical pain scores, functional disability scores, side effects, and adverse events were assessed at baseline (T0) and 30 minutes post-treatment (T30). The primary outcome was between-group difference in NRS score reduction at 30 minutes.ResultsWe enrolled 34 subjects (ketamine=16, placebo=18). Demographics were similar between treatment groups. There was no statistically significant difference in NRS score reductions between ketamine and placebo-treated groups after 30 minutes. Median NRS score reductions at 30 minutes were 1.0 (interquartile range [IQR] 0 to 2.25) for the ketamine group and 2.0 (IQR 0 to 3.75) for the placebo group. Between-group median difference at 30 minutes was −1.0 (IQR −2 to 1, p=0.5035). No significant differences between treatment groups occurred in categorical pain scores, functional disability scores, rescue medication request rate, and treatment satisfaction. Side Effect Rating Scale for Dissociative Anesthetics scores in the ketamine group were significantly greater for generalized discomfort at 30 minutes (p=0.008) and fatigue at 60 minutes (p=0.0216). No serious adverse events occurred in this study.ConclusionWe found that 0.2mg/kg IV ketamine did not produce a greater reduction in NRS score compared to placebo for treatment of acute migraine in the ED. Generalized discomfort at 30 minutes was significantly greater in the ketamine group. Overall, ketamine was well tolerated by migraine-suffering subjects. To optimize low-dose ketamine as an acute migraine treatment, future studies should investigate more effective dosing and routes of administration.
Ketamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs. 19%), but the side effect profile appears tolerable.
IntroductionPatients are often discharged from the emergency department (ED) prior to final culture results, leading to the development of post‐ED discharge urine culture review programs (UCRPs) to ensure appropriate management. The purpose of this study was to evaluate the impact ED pharmacists have on antibiotic management and determine areas for improved antimicrobial stewardship efforts.MethodsThis was a single‐system, retrospective, quasi‐experimental study of patients who visited the ED for evaluation of a urinary tract infection comparing no pharmacist involvement in a culture review to a process when ED pharmacists were involved. Patients included those discharged from the ED requiring review under a UCRP. Incarcerated patients and those admitted to an inpatient service from the ED were excluded. The primary outcome was the receipt of guideline‐appropriate management. Secondary outcomes included unplanned admission or ED revisit within 14 and 30 days related to the initial ED visit, all‐cause hospital admission or ED revisit within 14 and 30 days, and acceptance rate of pharmacist recommendations.ResultsA total of 142 patients were included (before pharmacist integration = 70, after pharmacist integration = 72). Receipt of guideline‐appropriate management occurred at 33% without pharmacist integration and 85% in the arm with pharmacist integration, p < 0.001. Pharmacist recommendations were accepted in 97% of cases. No difference was noted between ED revisit within 14 and 30 days with a chief complaint directly related to the initial ED visit, 14 and 30 day admission related to the initial encounter, and all‐cause hospital admission or ED revisit within 14 and 30 days. In patients with asymptomatic bacteriuria, there was a higher receipt of inappropriate management 67% (20/30) in the time before pharmacist integration versus 19% (9/48) after pharmacist integration (p < 0.001).ConclusionThere was a significantly higher number of patients with appropriate antimicrobial management after pharmacist involvement in UCRP review.
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