Efficacy and Safety of Intranasal Ketamine for Acute Pain Management in the Emergency Setting: A Systematic Review and Meta-Analysis

Summary & key facts

This systematic review and meta-analysis pooled seven randomized trials with 1760 adults seen in emergency departments (search to 21 May 2021). It found no clear difference in short-term pain scores between intranasal (IN) ketamine and IV analgesics or placebo at 5, 15, 25, 30, and 60 minutes. The need for extra (rescue) pain medicine did not differ significantly. Reported side effects were generally mild and short-lived. The authors conclude IN ketamine appears not worse than IV options for short-term ED pain relief, but the evidence has limits and is not definitive.

Key facts:

• The review included seven randomized controlled trials with a total of 1760 adult patients presenting to emergency departments.
• The literature search covered studies up to 21 May 2021 and the review protocol was registered in PROSPERO (CRD42020213391).
• There was no significant difference in pain scores between IN ketamine and IV analgesics or placebo at measured times: 5 minutes (MD 0.94, p = 0.26), 15 minutes (MD 0.15, p = 0.74), 25 minutes (MD 0.24, p = 0.62), 30 minutes (MD −0.05, p =
• The need for rescue analgesics showed no significant difference: odds ratio 1.66 (95% CI 0.57–4.86), p = 0.35. This analysis had substantial heterogeneity (I2 = 70%).
• Only mild adverse effects were reported with IN ketamine, such as fatigue, dizziness, euphoria, and nausea, which usually did not require treatment.
• The paper notes IN ketamine has an estimated bioavailability of 25–50%. Analgesic effects may begin within about 10 minutes and can last up to 60 minutes. The typical IN analgesic dose cited is about 1 mg/kg.
• The authors state their results suggest IN ketamine is non-inferior to IV analgesics and may have a role in ED acute pain management, but they also note limitations in the evidence and do not claim definitive superiority.

Abstract

Due to overcrowding, personnel shortages, or problematic intravenous (IV) cannulation, acute pain management is often sub-optimal in emergency departments (EDs). The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of intranasal (IN) ketamine for adult acute pain in the emergency setting. We searched and identified studies up to 21 May 2021 via PubMed, Scopus, Web of Science, Cochrane Database, and Google Scholar. The random-effects model with 95% confidence intervals (CIs) was used to estimate mean differences (MDs) and odds ratios (ORs). The I2 statistic and Cochran's Q test were used to determine heterogeneity. The protocol was registered in PROSPERO (CRD42020213391). Seven randomised controlled trials were included with a total of 1760 patients. There was no significant difference in pain scores comparing IN ketamine with IV analgesics or placebo at 5 (MD 0.94, p = 0.26), 15 (MD 0.15, p = 0.74), 25 (MD 0.24, p = 0.62), 30 (MD -0.05, p = 0.87), and 60 (MD -0.42, p = 0.53) minutes. There was also no significant difference in the need for rescue analgesics between IN ketamine and IV analgesics (OR 1.66, 95% CI: 0.57-4.86, p = 0.35, I2 = 70%). Only mild adverse effects were observed in patients who received IN ketamine. Our results suggest that IN ketamine is non-inferior to IV analgesics and may have a role in acute pain management among adults in the ED.

Topics

Anesthesia and Pain Management Anesthesia and Sedative Agents Pediatric Pain Management Techniques

Categories

Anesthesiology and Pain Medicine Health Sciences Medicine

Tags

Adverse effect Alternative medicine Anesthesia Confidence interval Emergency department Internal medicine Ketamine Medicine Meta-analysis Odds ratio Pathology Placebo Psychiatry