Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department.

Autor: Beaudrie-Nunn AN; Department of Pharmacy Services, Mayo Clinic, Rochester, MN, United States of America., Wieruszewski ED; Department of Pharmacy Services, Mayo Clinic, Rochester, MN, United States of America. Electronic address: Wieruszewski.Erin@mayo.edu., Woods EJ; Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America., Bellolio F; Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America. Electronic address: Bellolio.Fernanda@mayo.edu., Mara KC; Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States of America. Electronic address: Mara.Kristin@mayo.edu., Canterbury EA; Department of Pharmacy Services, Mayo Clinic, Rochester, MN, United States of America.
Jazyk: angličtina
Zdroj: The American journal of emergency medicine [Am J Emerg Med] 2023 Aug; Vol. 70, pp. 133-139. Date of Electronic Publication: 2023 May 26.
DOI: 10.1016/j.ajem.2023.05.026
Abstrakt: Background: Acute pain accounts for over 70% of Emergency Department (ED) visits. Sub-dissociative dose ketamine (0.1-0.6 mg/kg) is safe and effective for the management of acute pain in the ED. However, the optimal dose of intravenous ketamine that provides effective analgesia and minimizes the risk of adverse effects has yet to be identified. The objective of this study was to describe an effective analgesia dose range of IV ketamine for acute pain in the ED.
Methods: This multi-center, retrospective cohort study evaluated adult patients who received analgesic and sub-dissociative dose ketamine for the management of acute pain between May 5, 2018, and August 30, 2021, in 21 emergency departments at academic, community, and critical access hospitals across four states. Patients were excluded if they received ketamine for an indication other than pain, such as procedural sedation or intubation, or for whom there was incomplete documentation for the primary outcome. Patients who received a ketamine dose <0.3 mg/kg were stratified into the low-dose group, and those who received a dose of 0.3 mg/kg or higher to the high-dose group. The primary outcome was change in pain scores within 60 min using a standard 11-point numeric rating scale (NRS). Secondary outcomes included incidence of adverse effects and use of rescue analgesics. Continuous variables were compared between dose groups using student t-test or Wilcoxon Rank-Sum test. Linear regression was used to assess the association between the change in NRS pain scores within 60 min and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid.
Results: From 3796 patient encounters screened for receipt of ketamine, 384 patients met inclusion criteria including 258 in the low-dose group, and 126 in the high-dose group. The primary reason for exclusion was incomplete documentation of pain scores, or ketamine used for sedation. Median baseline pain scores were 8.2 in the low-dose group and 7.8 in the high-dose group (difference 0.5; 95% CI 0 to 1, p = 0.04). Both groups demonstrated significant reductions in their mean NRS pain scores within 60 min following the first administration of IV ketamine. There were no differences in the change in pain scores between both groups (-2.2 vs -2.6, mean difference 0.4, 95% CI -0.4 to 1.1, p = 0.34). Use of rescue analgesics (40.7% vs 36.5%, p = 0.43) and adverse effects were similar between groups, including early discontinuation of the ketamine infusion (37.2% vs. 37.3%, p = 0.99). Overall, the most common adverse effects were agitation (7.3%) and nausea (7.0%).
Conclusion: The analgesic efficacy and safety of high-dose sub-dissociative ketamine (≥0.3 mg/kg) was not superior to low-dose (< 0.3 mg/kg) for the management of acute pain in the ED. Low-dose ketamine <0.3 mg/kg is an effective and safe pain management strategy in this population.
Competing Interests: Declaration of Competing Interest The authors of this study have no conflicts of interest to disclose.
(Copyright © 2023 Elsevier Inc. All rights reserved.)
Databáze: MEDLINE
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