Welcome to the second episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and links to curated FOAMed supportive educational materials for EM learners.
This month's discussion: Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A Randomized Controlled Trial. Karen J. Bowers MD, MS, Kelly B. McAllister, PharmD, MBA, Meredith Ray, PhD, MPH, and Corey Heitz MD, MS.
LISTEN NOW: Author Interview with Karen Bowers, MD
Karen J. Bowers MD, MS, MEd
Emergency Medicine Resident, PGY-2
Emory University School of Medicine
**This article will be open access digitally until June 30, 2017. Read it in full here.**
Objective: To measure and compare total opioid use and number of opioid doses in patients treated with opioids versus ketamine in conjunction with opioids, pain scores up to 2 hours after presentation in the ED and patient satisfaction in patients treated with opioids versus ketamine in conjunction with opioids, and to monitor and compare side effects in patients treated with opioids versus ketamine in conjunction with opioids.
Methods: Randomized, double-blinded, placebo-controlled trial at a single center academic emergency department evaluating the use of ketamine versus placebo in conjunction with opioids for moderate to severe pain. Patients who had received an initial dose of opioid analgesia were randomized to receive either 0.1 mg/kg ketamine or placebo prior to protocol-cased dosing of additional opioid analgesia, if required. Over 120 minutes, subjects were assessed for pain level (0-10), satisfaction with pain control (0-4), side effects, sedation level, and need for additional pain medication. Total opioid dose, including the initial dose, was compared between groups.
Results: 63 subjects were randomized to the placebo group and 53 to the ketamine group. No significant differences were found in demographics between the groups. Patients receiving ketamine reported lower pain scores over 120 minutes than patients receiving placebo (p = 0.015). Total opioid dose was lower in the ketamine group (mean SD = 9.95 +/- 4.83 mg) compared to placebo (mean SD = 12.81 +/- 6.81 mg; p = 0.02). Satisfaction did not differ between groups. Fewer patients in the ketamine group required additional opioid doses. More patients reported light-headedness and dizziness in the ketamine group.
Conclusions: Ketamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs. 19%), but the side effect profile appears tolerable.
Related #FOAMed educational resources:
Review of Dr. Beaudoin's (faculty at Brown University) research on low dose Ketamine for Acute pain, by EM Cases: Low Dose Ketamine Analgesia
EM Crit: "Opioid Free ED". Podcast with Dr. Motov, who published a comparison of 0.3 mg/kg of ketamine versus morphine and found it to be just as good. Also see Dr. Motov's website, painfree-ed.com, where you will find many related resources.
Our friends at NUEM review of Dr. Motov's study: Ketamine versus Morphine for Pain Control
Ped EM Morsels: Ketamine for Analgesia
EM Docs: Ketamine for Analgesia in the ED
Faculty Reviewer: Dr. Gita Pensa