Dose Finding Ketamine ED pain

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Lovett S, et al. "A randomized, noninferiority, controlled trial of two doses of intravenous subdissociative ketamine for analgesia in the emergency department". Acad Emerg Med. 2020. Online ahead of print:.
PubMedFull text

Clinical Question

In adult patients with moderate to severe pain in the ED that receive a sub-dissociative dose of ketamine, is a lower dose of 0.15 mg/kg non-inferior to 0.30 mg/kg?

Bottom Line

The lower dose of 0.15 mg/kg was non-inferior to the higher dose of 0.30 mg/kg

Major Points

Guidelines

American Academy of Emergency Medicine White Paper on Acute Pain Management in the Emergency Department (adapted, 2017): [1]

Non-opioid Pharmacological Management:

  • Non-steroidal anti-inflammatory drugs (NSIAD) at lowest effective doses
    • Topical NSAIDs or other topical analgesics (eg. lidocaine patches) if systemic NSAID contraindicated
  • Oral/rectal acetaminophen
  • Sub-dissociative dose ketamine (SDK) used alone or as part of a multimodal analgesic approach
  • consider intravenous lidocaine for specific conditions (renal colic, herpetic/post-herpetic neuralgia) in patients without contraindications
  • trigger point injections with local anesthetics
  • nitrous oxide, alone or as an adjunct

Design

  • Randomized, prospective, double-blinded, noninferiority trial
  • N=98
    • Low dose ketamine 0.15 mg/kg (n=49)
    • High dose ketamine 0.30 mg/kg (n=49)
  • Setting:
  • Enrollment:
  • Mean follow-up:
  • Analysis:
  • Primary Outcome: Change in 11-point numeric rating scale (NRS) pain score at 30 minutes

Population

Inclusion Criteria

  • age 18 to 59 years
  • presenting to the ED
  • acute moderate to severe pain

Exclusion Criteria

Baseline Characteristics

BLANK Group displayed

  • Demographics:
  • Physiologic parameters:
  • Anthropomorphics: Weight
  • Labs:
  • Site of infection

Interventions

  • "Low" dose ketamine of 0.15 mg/kg IV over 15 minutes
  • "High" dose ketamine of 0.30 mg/kg IV over 15 minutes

Outcomes

Comparisons are 0.15 mg/kg ketamine vs. 0.30 mg/kg ketamine.

Primary Outcomes

mean NRS at 30 minutes
4.7 vs. 5 (mean difference = 0.4, 95% CI = -0.8 to 1.5)

Secondary Outcomes

Subgroup Analysis

Adverse Events

Criticisms

Funding

Further Reading

  1. [1] " AAEM White Paper on Acute Pain Management in the Emergency Department”

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