Ketamine for pain management

[AlmostJesus]

As a spin off of the ketamine discussion in the droperidol thread, I thought it would be good to have a discussion on low-dose/sub-disassociative dose ketamine for pain management in the ED (and prehospitally)
A quick lit search found a few different studies on it

Low-dose ketamine analgesia: patient and physician experience in the ED.
Richards JR, Rockford RE.
Source

Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA 95817. Electronic address: [email protected].
Abstract
OBJECTIVE:

Low-dose ketamine (LDK) may be useful for treatment for opioid-tolerant patients. We conducted a survey of patients and their treating clinicians regarding LDK for analgesia.
METHODS:

Survey data included the following: vital signs and pain score before and after LDK, demographics, and adverse effects. Treating physicians were queried about reasons for use of LDK and overall satisfaction.
RESULTS:

Twenty-four patients were enrolled: 21 received LDK for analgesia, and 3 received LDK for sedation. Pain level on a visual analog scale (range, 1-10) after LDK was significantly decreased from 8.9 ± 2.1 to 3.9 ± 3.4 (P < .0001). Change in vital signs after administration of LDK was not statistically significant. Overall patient satisfaction with LDK was 55%, and overall physician satisfaction was 72%. Sixteen (67%) of patients would prefer LDK again, and 23 (96%) of physicians would use LDK again for analgesia. Four patients reported an adverse experience, but there were no emergence reactions. Race subanalysis revealed no difference in pain reduction, but whites were least satisfied compared with black and Hispanic patients (P = .02). Physician reasons for using LDK included opioid failure (88%), concern for respiratory depression (17%), concern for multiple opioid allergies (13%), and concern for hypotension (8%). Most (96%) physicians believed that LDK is underused.
CONCLUSION:

Low-dose ketamine may decrease patients' perception of pain. Most were satisfied with LDK for this purpose and would use it again. Whites were least satisfied with the use of LDK for analgesia. Physicians believed that ketamine is underused.

and a couple more
http://www.ncbi.nlm.nih.gov/pubmed/20837262
http://www.sciencedirect.com/science/article/pii/S0196064411017975
http://www.sciencedirect.com/science/article/pii/S0196064412008025

And this is North Memorial's protocol for EMS use of ketamine for pain

If pain is of a traumatic origin (non-cardiac), consider Ketamine 0.5 mg/kg IV/IO/IM (maximum dose 50 mg).
Reassess the patient&#8223;s pain scale and if necessary administer a second dose 0.25 mg/kg IV/IO/IM (15-30 minutes PRN)

So who's using ketamine for pain?

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[Apollyon]

Asked about it in my community ED last night. It counts as procedural sedation, so using it doesn't fly.

 

[Tiger26]

Had a pt in his 80s with metastatic bone cancer on high dose PO and intrathecal dilaudid who came to the ED for unrelenting rib pain.

Gave him 10 mg ketamine over 10 min and the pain completely subsided. Most heartfelt "thank you" I've had in a long time and probably the the most satisfying pt encounter over the past year.

Also used it on an older lady with chronic pain issues who had a nasty glenohumeral fracture waiting to go to the OR--worked really well.

The thing about procedural sedation is that it's a spectrum and the intent of the doc. My intent is for pain control, not sedation. My reply for nurses who get uncomfortable is that I can easily sedate you with benzos or narcotics, and we don't do full procedural monitoring for those drugs when used for pain control or anxiolysis.

 

[Apollyon]

The thing about procedural sedation is that it's a spectrum and the intent of the doc. My intent is for pain control, not sedation. My reply for nurses who get uncomfortable is that I can easily sedate you with benzos or narcotics, and we don't do full procedural monitoring for those drugs when used for pain control or anxiolysis.

In the community, though, my intent is not applicable when P&T has had their say; it doesn't matter what I want to do for pain control or anxiolysis, if the nurses (who give the meds) have hospital regs that say, if it is ketamine (e.g.), the procedural (moderate) sedation protocol is in effect. Ketamine, moderate sedation. Droperidol - not even in the Pyxis. I'm not even sure if it is on formulary. Hospital is 100-bed community hospital in a metro area of 18K.

 

[bougiecric]

Asked about it in my community ED last night. It counts as procedural sedation, so using it doesn't fly.

Same here unfortunately.