Effect on Opioids Requirement of Early Administration of Intranasal Ketamine for Acute Traumatic Pain

Abstract

Objectives: To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine on reducing the need for opioid and nonopioid analgesic agents in emergency department (ED) patients with acute moderate to severe acute limbs’ trauma pain. Patients and Methods: This is a double-blind, randomized, prospective, controlled study conducted in the ED. The included patients were randomly assigned to intranasal pulverization of ketamine or placebo. Protocol treatment was given at the triage. The primary outcome is the need for opioids during ED stay. Secondary outcome included the requirement of nonopioid analgesic agents and the percentage of patients discharged from the ED with a visual analog scale (VAS) <30. A combined outcome score including the 3 outcome items was constructed. Results: The authors included 1102 patients, 550 patients in the placebo group, and 552 in the intranasal ketamine group. The groups were similar regarding demographics, clinical characteristics, and baseline VAS. The need for opioids was decreased in the intranasal ketamine group compared with the placebo group (17.2% vs. 26.5%; P<0.001). The need for nonopioid analgesics was significantly lower in the intranasal ketamine group compared with the placebo group (31.1% vs. 39.6%; P=0.003). The percentage of patients discharged with a VAS score <30 was significantly higher in the intranasal ketamine group (P<0.001). The mean combined outcome score was 0.97 in the placebo group and 0.67 in the intranasal ketamine group (P<0.001). Conclusion: Intranasal ketamine administered early in the triage was associated with a decrease in opioids and nonopioid analgesics need in patients with acute limb trauma-related pain.

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].…”

“…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 six trials [20,22,[32][33][34][35], researchers used the VAS as a pain scale, whereas only a single trial used the NRS [31].…”

“…Ketamine is extensively utilised in adult populations as an adjuvant to opioid pain therapy to reduce opioid use. In addition, ketamine is being studied as a first-line analgesic treatment for acute pain to minimise opioid consumption [22]. Recent randomised controlled trials (RCTs) have evaluated IN ketamine's analgesic effectiveness and safety in the adult population.…”

Transmucosal drug administration as an alternative route in palliative and end-of-life care during the COVID-19 pandemic

“…Because of the relatively large surface area of the nasal cavity and the extensive vascularisation of the nasal mucosa, this route of administration has received increasing attention for systemic drug delivery. The fast onset of action and non-invasive administration also make the intranasal route particularly attractive for the management of acute pain and breakthrough pain in cancer patients [ [52] , [53] , [54] , [55] ]. It has great potential to be used as an alternative route of drug administration in palliative care.…”