Andis Graudins, MBBS, PhD
Robert Meek, MBBS, MClinEpi
Dianna Egerton-Warburton, MBBS, MClinEpi
Ed Oakley, MBBS
Robert Seith, MBBS
Annals of Emergency Medicine, March 2015, Volume 65, Issue 3, pigs 248-254.e1
Intranasal use of medications is becoming increasingly popular in the pediatric population. Medications that are helpful with pain or procedures can be administered rapidly without the need for the trauma of an IV. While most of us are familiar with fentanyl and midazolam, now maybe there is another agent we could use. and yes, that would be the drug that seems to have the most potential uses that keeps coming up, ketamine.
This study was randomized, controlled, double-blind, intention to treat study comparing intranasal fentanyl to intranasal ketamine for moderate to severe pain. The primary outcome was median reduction of pain rating at 30 minutes after administration of study medications. Inclusion criteria were patients aged 3-13 years weighing less than 50 kg (due to limitations of amount that could be given intranasal) with an isolated limb injury. Moderate to severe pain was defined as greater than 6 on an age appropriate scale. Exclusion criteria included patients with medication allergy, use of serotonergic antidepressants, nasal trauma or aberrant anatomy, or multiple trauma with head injury and loss of consciousness.
All qualified patients first receive ibuprofen following study drug administration, unless given in 4 hours prior. Subjects received either intranasal ketamine at 1 mg/kg or intranasal fentanyl at 1.5 ug/kg. A total of 80 subjects were recruited with a final number of 36 in the ketamine group and 37 in the fentanyl group. Patients had similar baseline characteristics.
Their results showed similar pain reductions between both study groups at their primary outcome of 30 minutes, as well as secondary outcomes of 15 and 60 minutes following study drug administration. However, ketamine was associated with more adverse events, which included dizziness and drowsiness. Hallucinations and dysphoria were also reported in four and three patients respectively without mention of what those reactions actually entailed
Conclusions: ketamine is an effective alternative intranasal analgesic for children with moderate to severe pain from limb injury, and I would have to agree with that assessment. This was a relatively small study, however the results suggest that ketamine is an option and could potentially be used in the right patient. So as they say "Keep Calm and Ketamine On."
Submitted by Dr. Michael Craddick, PGY-1