Comparing the analgesic effect of intranasal with intravenous ketamine in isolated orthopedic trauma: A randomized clinical trial

Abstract

ObjectivesKetamine is commonly used in anesthetic and sedation before surgical procedures and acts as an analgesic in smaller doses. The aim of this study was to assess the effects of intranasal (IN) ketamine in patients with moderate to severe limb trauma (visual analog scale (VAS) > 60 mm).MethodsIn a triple-blind randomized controlled clinical trial; 154 patients with isolated orthopedic trauma and visual analog scale (VAS) ≥60 mm were included on the basis of inclusion and exclusion criteria. Patients were divided into two groups of ketamine-IN (0.4 mg/kg IN ketamine and an equal volume of placebo saline intravenously (IV)) and ketamine-IV (0.2 mg/kg ketamine IV with 0.5 ml saline IN) on the basis of balanced block randomization method. At 5, 10, 20, and 30 min, patients were assessed for VAS measurement and adverse events. Repeated measure ANOVA, independent t-test and chi square test were employed. The level of statistical significance was considered to be less than 0.05.ResultsMean VAS in IN ketamine and IV group at minute 30 was 31.50 ± 13.40 and 29.35 ± 11.73, respectively. At minute 30, 31 patients (20.39%) required a low-dose of morphine as rescue analgesia (P = 0.427). The results showed that mean change score of VAS (difference of time 0 and time 30) in IN ketamine and IV ketamine VAS were 43.8 (95% confidence interval: 41.1–46.5) and 46.4 (95% confidence interval: 42.8–50.1) and there is no difference between two groups in case of score change of VAS (P = 0.245). Adverse events in nasal and intravenous ketamine in both groups were mild and transient.ConclusionIN ketamine is associated with few side effects and appropriate analgesic effects in isolated orthopedic trauma patients, and it may be used in cases where there is no need for venipuncture of peripheral vessels, especially in crowded EDs.

Efficacy and Safety of Intranasal Ketamine for Acute Pain Management in the Emergency Setting: A Systematic Review and Meta-Analysis

“…After removing 269 studies (non-human studies (n = 4), review articles (n = 42), case reports (n = 16), duplicate studies (n = 207)), another 512 studies were excluded based on their abstracts as they did not comply with the objective and inclusion criteria of this study. Finally, seven RCTs [20,22,[31][32][33][34][35] with a total of 1760 participants were included in this SRMA (Figure 1).…”

“…All trials were doubleblinded RCTs with mean ages ranging from 30.4 to 40.3 years. Five trials were conducted in Iran [20,[31][32][33][34], and another two trials were conducted in Tunisia [22] and Israel [35]. Causes of acute pain included acute traumatic pain [20,22,34,35] and renal colic [31][32][33].…”

“…IN ketamine is a quick and non-invasive method of drug administration and provides an analgesic effect in acute pain. It might be used in overcrowded EDs and prehospital situations where IV cannulation is not required or difficult [20]. Moreover, a systematic review of ketamine's analgesic effect on burn injuries in adults found its effectiveness in pain relief and reduced secondary hyperalgesia compared to opioids.…”

Novas utilizações da cetamina para tratamento da dor somática e seus mecanismos de ação

“…Já Andolfatto et al (2013), também em humanos, referiam que o uso de morfina intravenosa ou fentanil intranasal podem resultar em depressão respiratória, a passo que a cetamina intranasal não apresentou nenhum efeito adverso grave, e foi capaz de oferecer controle da dor em 88% dos pacientes. Ademais, Parvizrad et al (2017) concluíram em seu estudo que a cetamina intranasal foi capaz de suprir um bom controle analgésico em pacientes humanos com traumas ortopédicos moderados à grave, além de apresentar poucos efeitos adversos.…”

“…Apesar da condecoração da cetamina como anestésico dissociativo, suas características antálgicas possibilitaram um reconhecimento maior desse fármaco como analgésico, quando o mesmo é utilizado em doses baixas ou doses subanestésicas. Sendo que o efeito analgésico destas é tão eficaz quanto das doses anestésicas, porém sem apresentar os efeitos adversos (Rascón-Martínez et al, 2016;Allen e Ivester, 2017;Motov et al, 2017;Parvizrad et al, 2017;Pourmand et al, 2017). O efeito analgésico é proveniente do antagonismo não competitivo pelos receptores do tipo N-metil-D-aspartato (NMDA), importantes sítios de ligação para anestésicos presentes no sistema nervoso central, sendo o glutamato o principal neurotransmissor excitatório que age nestes receptores.…”