How to Administer Low-Dose IV Ketamine for Pain in the ED

Back in 2015, Dr. Sergey Motov’s (@painfreeED) group published a study demonstrating the efficacy of low-dose ketamine compared to morphine for analgesia in the ED. Here’s my quick analysis of that study as a UMEM pearl. The question, though, is how best to administer the 0.3 mg/kg IV ketamine dose while minimizing the risk of adverse effects.

Fortunately, Dr. Motov’s group has just published a follow-up study addressing that exact question.

What They Did

    • Prospective, randomized, double-blind, double-dummy trial comparing safety and analgesic efficacy of IV low-dose ketamine given as a push dose (over 5 minutes) versus given as a short infusion mixed in 100 mL 0.9% sodium chloride (over 15 minutes)
    • Pain scores, vital signs, and adverse effects were recorded at baseline, 5, 15, 30, 60, 90, and 120 minutes
    • Overall rates and specific severity levels of side effects were recorded in accordance with the Side Effects Rating Scale for Dissociative Anesthetics (SERSDA)
    • Patients < 46 kg or > 115 kg were excluded.

What They Found

      • 24 patients were enrolled in each group
      • At 5 min:
        • Median severity of feeling of unreality was 3.0 on SERSDA scale for the IV push group versus 0.0 for the short infusion group (p = 0.001).
        • Median sedation on RASS scale was greater in IV push group −2.0 versus 0.0 in short infusion group (p = 0.01).
      • Decrease in mean pain scores from baseline to 15 min was similar across groups.
      • No difference between groups for changes in vital signs or need for rescue medication.

Application to Clinical Practice

If you’re using low-dose ketamine for acute pain in the ED, or developing guidelines for its use, administer it in 100 mL over 15 minutes.

Note: A second study utilized this same approach with positive results (J Emerg Med 2017).

Reference

Motov S, Mai M, Pushkar I, et al. A prospective randomized, double-dummy trial comparing intravenous push dose of low dose ketamine to short infusion of low dose ketamine for treatment of moderate to severe pain in the emergency department. Am J Emerg Med. 2017 Mar 3. Epub ahead of print. PMID 28283340

1 thought on “How to Administer Low-Dose IV Ketamine for Pain in the ED”

  1. Many of our providers have been turned off of ketamine for pain due to the adverse effects they see. This may open the door to more use. That being said, I’m curious if anyone has implemented this process. Given restrictions on controlled substance handling and USP 797 limitations for mixing non-emergent sterile products outside of an ISO Class 5 hood, I anticipate lots of delays having each dose mixed in pharmacy and delivered. Makes me wish I had a counter-top hood in the ED . . . Any suggestions?

    Like

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