|
1
|
Montague M, Hopson C, Layton C, Fishe J, Norse A, Webb LK, Duran-Gehring P, Bertrand A, Brailsford J, Munson T, Wang R, Menze N, Perl K, Hendry P, Sheikh S. Outcomes of an Emergency Department opioid alternatives Program implemented within a safety-net hospital system. BMC Emerg Med 2025; 25:5. [PMID: 39773452 PMCID: PMC11707854 DOI: 10.1186/s12873-024-01168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 12/30/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND The ongoing opioid epidemic in the United States has reinforced the need to provide multimodal and non-opioid pain management interventions. The PAMI-ED ALT program employed a multifaceted approach in the Emergency Department (ED) developing electronic health record (EHR) pain management order panels and discharge panels, as well as educating patients, clinicians, and ED staff on opioid alternatives, including non-pharmacologic interventions. The primary objective of this analysis was to compare changes in opioid and non-opioid analgesic administrations and prescribing in ED patients with select pain conditions (renal colic, headache, low back, and non-low back musculoskeletal pain) before and after implementation of PAMI ED-ALT. Secondary outcomes included characterizing changes in 30-day ED all-cause recidivism and hospital all-cause admissions within these pain populations. METHODS Demographics, opioid and opioid alternative utilization, hospital admission, 30-day ED returns and change in pain intensity score were collected from January 2019-March 2020 (pre-program implementation) and January 2021-March 2023 (post-program implementation) for both the ED aggregate and program target pain populations. RESULTS Pain management order panel utilization increased throughout the post-implementation period. When comparing pre to post program data, there was a reduction in opioid administrations and prescriptions for most of the target pain conditions, as well as within the ED aggregate population. Opioid alternative administrations and prescriptions increased for all pain conditions except renal colic. Hospital admissions decreased significantly amongst those with low back pain and headache/migraine and 30-day ED returns significantly declined in those with musculoskeletal pain. CONCLUSION Our findings demonstrate an opioid-alternatives program implemented within a safety-net hospital system serving a predominantly socially disadvantaged patient population can lead to changes in ED pain management and potentially reduce 30-day ED recidivism and hospitalizations.
Collapse
Affiliation(s)
- Magda Montague
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Charlotte Hopson
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Claire Layton
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
- Integrated Data Repository, University of Florida, Gainesville, FL, USA
| | - Jennifer Fishe
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Ashley Norse
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - L Kendall Webb
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Petra Duran-Gehring
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Andrew Bertrand
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Taylor Munson
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Rui Wang
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Nolan Menze
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Katelyn Perl
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| |
Collapse
|
|
2
|
Ingrosso G, Cleare AJ, Juruena MF. Is there a risk of addiction to ketamine during the treatment of depression? A systematic review of available literature. J Psychopharmacol 2025; 39:49-65. [PMID: 39688236 DOI: 10.1177/02698811241303597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2024]
Abstract
BACKGROUND Ketamine has demonstrated both rapid and sustained efficacy in treating depression, especially in treatment-resistant cases. However, concerns regarding the addictive potential of ketamine during long-term depression treatment persist among clinicians. AIM This review aimed to summarise the evidence on addiction phenomena associated with ketamine treatment of depression. METHODS A comprehensive search was conducted in MEDLINE, Embase, PsycInfo and Global Health databases, with additional relevant studies identified through reference lists. Sixteen studies were included, comprising six randomised controlled trials, three single-arm open-label studies, one retrospective study, three case series and three case reports, for a total of 2174 patients. RESULTS The studies employed various routes of administration, including intravenous, intramuscular, intranasal, oral and sublingual. Ketamine was administered in the racemic form, except for the studies that utilised intranasal esketamine. Among the included population, four patients were reported to exhibit clear signs of tolerance to the antidepressant effect of ketamine or dependence on the drug, while the majority did not. Cases of addiction phenomena reported in studies that did not meet the inclusion criteria are also discussed. CONCLUSIONS Despite the heterogeneity in study designs and outcome assessment methods, the review underscores the relative safety of ketamine treatment for adult patients with depression, emphasising the importance of medically supervised administration, vigilant monitoring and judicious dosing. Future long-term studies employing quantitative scales to assess dependence phenomena could contribute to strengthening the evidence for the safe and effective use of ketamine in the treatment of depression.
Collapse
Affiliation(s)
- Gianmarco Ingrosso
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Anthony J Cleare
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mario F Juruena
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
|
3
|
Wang J, Doan LV. Clinical pain management: Current practice and recent innovations in research. Cell Rep Med 2024; 5:101786. [PMID: 39383871 PMCID: PMC11513809 DOI: 10.1016/j.xcrm.2024.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 09/17/2024] [Accepted: 09/19/2024] [Indexed: 10/11/2024]
Abstract
Chronic pain affects one in five adults. It is not only a major cause of disability for individual patients but also a driver of costs for entire healthcare systems. Treatment of pain remains a challenge, and the use of opioids has further led to a concurrent opioid epidemic. In this review, we discuss current standard treatment options for chronic pain, including pharmacological, behavioral, and interventional treatments. In addition, we review ongoing research in different areas that will potentially unlock new therapies.
Collapse
Affiliation(s)
- Jing Wang
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA; Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA; Interdisciplinary Pain Research Program, New York University Grossman School of Medicine, New York, NY, USA.
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA; Interdisciplinary Pain Research Program, New York University Grossman School of Medicine, New York, NY, USA.
| |
Collapse
|
|
4
|
Fiore M, Nasto LA, McCaffery E, Barletta F, Visconti A, Gargano F, Pola E, Pace MC. Pain management in acute musculoskeletal injury: Effect of opioid vs nonopioid medications. World J Orthop 2024; 15:882-890. [PMID: 39318494 PMCID: PMC11417633 DOI: 10.5312/wjo.v15.i9.882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/19/2024] [Accepted: 08/05/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND The use of opioids for pain is linked to an increased risk of developing opioid use disorder, and has resulted in the emergence of the opioid crisis over the last few years. AIM The systematic review question is "How does the use of opioid medications in pain management, compared with non-opioid medications, affect pain intensity over the short, intermediate, and long-term in adults with acute traumatic pain?". METHODS The protocol was prospectively registered on the International Prospective Register of Systematic Reviews: CRD42021279639. Medline and Google Scholar were electronically searched for controlled peer-reviewed studies published in full, with the PICO framework: P: Adult patients with traumatic injuries, I: Opioid medications, C: Non-opioid medications, O: A minimum clinically important difference (MCID) in pain. RESULTS After full-text screening, we included 14 studies in the qualitative synthesis. Of these 14 studies, 12 were randomized clinical trials (RCTs) and 2 were pseudo-RCTs with a total of 2347 patients enrolled. There was heterogeneity in both medication utilized and outcome in these studies; only two studies were homogeneous regarding the type of study conducted, the opioid used, its comparator, and the outcome explored. The MCID was evaluated in 8 studies, while in 6 studies, any measured pain reduction was considered as an outcome. In 11 cases, the setting of care was the Emergency Department; in 2 cases, care occurred out-of-hospital; and in one case, the setting was not well-specified. The included studies were found to have a low-moderate risk of bias. CONCLUSION Non-opioids can be considered an alternative to opioids for short-term pain management of acute musculoskeletal injury. Intravenous ketamine may cause more adverse events than other routes of administration.
Collapse
Affiliation(s)
- Marco Fiore
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| | - Luigi Aurelio Nasto
- Department of Orthopaedics, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| | - Eleni McCaffery
- Department of Emergency Medicine, New York Presbyterian-Brooklyn Methodist Hospital, New York, NY 11215, United States
| | - Fannia Barletta
- Department of Anesthesia and Intensive Care, “San Carlo” Hospital, Potenza 85100, Italy
| | - Angela Visconti
- Department of Anaesthesia, "San Giuliano” Hospital, Giugliano 80014, Italy
| | - Francesca Gargano
- Unit of Anesthesia and Intensive Care, The Fondazione Policlinico Universitario Campus Bio-Medico, Rome 00128, Italy
| | - Enrico Pola
- Department of Orthopaedics, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| |
Collapse
|
|
5
|
Stringfield SB, Waddimba AC, Criss KM, Burgess B, Dosselman LJ, Fichera A, Wells KO, Fleshman J. Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations. J Gastrointest Surg 2024; 28:1009-1016. [PMID: 38523035 DOI: 10.1016/j.gassur.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/12/2024] [Accepted: 02/24/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls. METHODS This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group. RESULTS A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls. CONCLUSION Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.
Collapse
Affiliation(s)
- Sarah B Stringfield
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States.
| | - Anthony C Waddimba
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States; Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Keirsyn M Criss
- College of Medicine, Texas A & M University Health Science Center, Dallas, Texas, United States
| | - Brooke Burgess
- College of Medicine, Texas A & M University Health Science Center, Dallas, Texas, United States
| | - Luke J Dosselman
- University of Texas (UT) Southwestern Medical School, Dallas, Texas, United States
| | - Alessandro Fichera
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
| | - Katerina O Wells
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
| | - James Fleshman
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, United States
| |
Collapse
|
|
6
|
Ruhe MM, Veldhuis LI, Azijli-Abdelloui K, Schepers T, Ridderikhof ML. Prehospital analgesia in suspected hip fracture patients: adherence to national prehospital pain management guidelines. Eur J Trauma Emerg Surg 2024; 50:937-943. [PMID: 37957364 DOI: 10.1007/s00068-023-02385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate. METHODS This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied. RESULTS From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores. CONCLUSION In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.
Collapse
Affiliation(s)
- Michelle Manon Ruhe
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Lars I Veldhuis
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Kaoutar Azijli-Abdelloui
- Department of Emergency Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Tim Schepers
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Milan L Ridderikhof
- Department of Emergency Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| |
Collapse
|
|
7
|
Gupta S, Tomar DS. Am I Sedated or in Pain? Please Monitor by Brain. Indian J Crit Care Med 2024; 28:607. [PMID: 39130379 PMCID: PMC11310675 DOI: 10.5005/jp-journals-10071-24744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
How to cite this article: Gupta A, Tomar DS. Am I Sedated or in Pain? Please Monitor by Brain. Indian J Crit Care Med 2024;28(6):531-532.
Collapse
Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| | - Deeksha S Tomar
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| |
Collapse
|
|
8
|
De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
Collapse
Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
| |
Collapse
|
|
9
|
Liu H, Li D, Yuan H, Sun T, Li P, Cai Z, Shen C. Improved Short-Term Prognosis of Pediatric Partial-Thickness Burns: Emergency Conservative Debridement Under Topical Anesthesia. Pediatr Emerg Care 2024; 40:390-394. [PMID: 38459619 DOI: 10.1097/pec.0000000000003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVES Early wound management for pediatric patients with partial-thickness burns in the emergency department remains debatable. This study aims to evaluate the value of emergency conservative debridement under topical anesthesia in improving short-term prognosis of pediatric partial-thickness burns. METHODS This retrospective cohort study enrolled children with partial-thickness thermal burns presenting to the emergency department within 6 hours postburn. All the enrolled patients were divided into 2 groups: the debridement group and the dressing group. The associations between emergency conservative debridement and time to reepithelialization was analyzed by using Kaplan-Meier curves with log rank test and multivariate Cox regression analysis. Moreover, the associations between emergency conservative debridement and in-hospital cost and length of stay were also evaluated. RESULTS All baseline characteristics between groups were comparable (all P > 0.05). Emergency conservative debridement under topical anesthesia significantly decreased the median value of time to reepithelialization (13 vs 14 days, P = 0.02). Cox regression analysis showed that emergency conservative debridement significantly improved wound reepithelialization after adjusting for burn size (odds ratio, 4.07; 95% confidence interval, 1.64-10.11; P < 0.01). The mean length of stay of patients receiving conservative wound debridement was lower than that of patients in the wound dressing group (14.3 ± 7.3 vs 18.8 ± 10.4 days, P < 0.01), but not in terms of mean in-hospital cost per 1% total body surface area (2.8 ± 1.9 vs 3.0 ± 2.1 × 103 RMB per 1% total body surface area, P = 0.58). CONCLUSIONS Emergency conservative debridement of pediatric partial-thickness burns under topical anesthesia significantly improves the wound healing outcomes without increasing health care burden.
Collapse
Affiliation(s)
- Hailiang Liu
- From the Department of Burns and Plastic Surgery, the Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | | | | | | | | | | |
Collapse
|
|
10
|
Arango-Posada MDM, Prada-Escobar AI, Marín-Hernández C, Monsalve-Franco V, Restrepo-Bernal D. Successful treatment for serious depression with suicidal risk in a heart transplant patient. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2024; 53:210-216. [PMID: 39127545 DOI: 10.1016/j.rcpeng.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Major depressive disorder is related to unfavourable outcomes in patients with severe comorbidities. In transplant patients, major depression is associated with worse clinical outcomes. CASE REPORT We present the case of a 55-year-old man with a heart transplant due to heart failure of ischaemic origin. Six months after the transplant he developed depressed mood, anhedonia and suicidal ideation with a score of 20/27 on the PHQ-9 depression screening scale. After receiving mirtazapine 30 mg/night for a week and persisting with a high suicide risk, it was decided to administer ketamine infusion for 24 h, with which a significant improvement in mood was observed, and the disappearance of suicidal ideation 24 h after the infusion. DISCUSSION Depression in transplant patients is a factor associated with graft loss and post-transplant mortality, in addition to favouring other negative outcomes such as deep vein thrombosis. CONCLUSIONS Ketamine infusion was shown to be an effective and safe option to treat major depression with suicidal risk in a heart transplant patient.
Collapse
|
|
11
|
Almodibeg B, Forget P. Challenges of acute pain management in older patients. Age Ageing 2024; 53:afae061. [PMID: 38557666 DOI: 10.1093/ageing/afae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Indexed: 04/04/2024] Open
Abstract
Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.
Collapse
Affiliation(s)
- Bader Almodibeg
- Anaesthesia Technology Department, King Khalid University-College of Applied Medical Sciences, Khamis Mushait, Asir, Saudi Arabia
- Epidemiology Group-Institute of Applied Health Sciences, University of Aberdeen-School of Medicine, Medical Sciences and Nutrition, Foresterhill Health Campus, Aberdeen AB25 2ZD, UK
- Pain AND Opioids after Surgery (PANDOS) Research Group, European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
| | - Patrice Forget
- Epidemiology Group-Institute of Applied Health Sciences, University of Aberdeen-School of Medicine, Medical Sciences and Nutrition, Foresterhill Health Campus, Aberdeen AB25 2ZD, UK
- Pain AND Opioids after Surgery (PANDOS) Research Group, European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
- Department of Anaesthesia, NHS Grampian, Aberdeen, UK
- IMAGINE UR UM 103, Anesthesia Critical Care, Emergency and Pain Medicine Division, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| |
Collapse
|
|
12
|
Wang J, Doan LV, Axelrod D, Rotrosen J, Wang B, Park HG, Edwards RR, Curatolo M, Jackman C, Perez R. Optimizing the use of ketamine to reduce chronic postsurgical pain in women undergoing mastectomy for oncologic indication: study protocol for the KALPAS multicenter randomized controlled trial. Trials 2024; 25:67. [PMID: 38243266 PMCID: PMC10797799 DOI: 10.1186/s13063-023-07884-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/15/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Mastectomies are commonly performed and strongly associated with chronic postsurgical pain (CPSP), more specifically termed postmastectomy pain syndrome (PMPS), with 25-60% of patients reporting pain 3 months after surgery. PMPS interferes with function, recovery, and compliance with adjuvant therapy. Importantly, it is associated with chronic opioid use, as a recent study showed that 1 in 10 patients continue to use opioids at least 3 months after curative surgery. The majority of PMPS patients are women, and, over the past 10 years, women have outpaced men in the rate of growth in opioid dependence. Standard perioperative multimodal analgesia is only modestly effective in prevention of CPSP. Thus, interventions to reduce CPSP and PMPS are urgently needed. Ketamine is well known to improve pain and reduce opioid use in the acute postoperative period. Additionally, ketamine has been shown to control mood in studies of anxiety and depression. By targeting acute pain and improving mood in the perioperative period, ketamine may be able to prevent the development of CPSP. METHODS Ketamine analgesia for long-lasting pain relief after surgery (KALPAS) is a phase 3, multicenter, randomized, placebo-controlled, double-blind trial to study the effectiveness of ketamine in reducing PMPS. The study compares continuous perioperative ketamine infusion vs single-dose ketamine in the postanesthesia care unit vs placebo for reducing PMPS. Participants are followed for 1 year after surgery. The primary outcome is pain at the surgical site at 3 months after the index surgery as assessed with the Brief Pain Inventory-short form pain severity subscale. DISCUSSION This project is part of the NIH Helping to End Addiction Long-term (HEAL) Initiative, a nationwide effort to address the opioid public health crisis. This study can substantially impact perioperative pain management and can contribute significantly to combatting the opioid epidemic. TRIAL REGISTRATION ClinicalTrials.gov NCT05037123. Registered on September 8, 2021.
Collapse
Affiliation(s)
- Jing Wang
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA.
- Department of Neuroscience and Physiology, NYU Grossman School of Medicine, New York, NY, USA.
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA.
| | - Deborah Axelrod
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Binhuan Wang
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Hyung G Park
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Robert R Edwards
- Department of Anesthesia, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Carina Jackman
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Raven Perez
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
|
13
|
Song C, Wang D, Chen B. A systematic review and meta-analysis comparing the efficacy and safety of ketamine versus morphine for the treatment of acute pain. Minerva Anestesiol 2024; 90:77-86. [PMID: 37930103 DOI: 10.23736/s0375-9393.23.17561-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Ketamine is reported as a potent opioid alternative that provides significant reduction in pain with no severe adverse events. However, some studies didn't find its use satisfactory and reported less reduction in pain score with ketamine. The purpose of this study is to compare the efficacy and safety of ketamine versus morphine for the treatment of acute pain in emergency situations. EVIDENCE ACQUISITION The PubMed, MEDLINE, PsycINFO EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov websites were queried in accordance with the PRISMA guidelines in order to locate relevant studies. According to the predefined PICOS criteria, articles were included and event data pertaining to changes in Visual Analog Scale or Numeric Rating Scale pain scales were extracted. Using RevMan and MedCalc, a meta-analysis was conducted to compare the effects of ketamine and morphine for the treatment of acute pain. EVIDENCE SYNTHESIS Twelve studies met the criteria for inclusion in this meta-analysis. Ketamine was found to be more effective than morphine at reducing pain scores, with an odds ratio of 0.60 (95% CI 0.48 to 0.76). Similarly, no severe adverse events related to ketamine were reported in any study, and it has a low-risk ratio of 0.78 (95% CI 0.70 to 0.87). Egger's Test P values (0.3052) and Begg's Test P values (0.3869) indicate a low risk of bias, and the Bland-Altman plot demonstrates a high degree of concordance. CONCLUSIONS Ketamine is a potent and effective alternative to morphine for the management of acute pain, and it reduces pain score significantly with minimal side effects.
Collapse
Affiliation(s)
- Cheng Song
- Department of Anesthesiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Dong Wang
- Department of Anesthesiology, First People's Hospital of Yongkang, Yongkang, China
| | - Bin Chen
- Department of Anesthesiology, Hospital of Integrated Traditional Chinese and Western Medicine of Taizhou, Taizhou, China -
| |
Collapse
|
|
14
|
Nair A, Dudhedia U, Thakre M, Borkar N. Efficacy of memantine premedication in alleviating postoperative pain- A systematic review and meta-analysis. Saudi J Anaesth 2024; 18:86-94. [PMID: 38313717 PMCID: PMC10833015 DOI: 10.4103/sja.sja_398_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 02/06/2024] Open
Abstract
Many premedication agents with opioid-sparing properties have been used in patients undergoing various elective surgeries. Memantine is an N-methyl-D-aspartate (NMDA) receptor antagonist that has been used by many researchers as an opioid-sparing strategy. Various databases like PubMed, Scopus, Cochrane Library, and clinicaltrials.gov were searched after registering the review protocol in PROSPERO for randomized-controlled trials (RCTs) that investigated the efficacy and safety of memantine premedication in adult patients undergoing various elective surgeries. The risk of bias (RoB-2) scale was used to assess the quality of evidence. From the 225 articles that were identified after a database search, 3 studies were included for a qualitative systematic review and a quantitative meta-analysis. The pooled analysis revealed that the use of memantine provided better pain scores at 2nd (mean difference: -0.82, 95% CI: -1.60, -0.05, P = 0.04) with significant heterogeneity (P = 0.06; I² =71%), and 6 hours postoperatively (mean difference: -1.80, 95% CI: -2.23, -1.37, P < 0.00001), but not at 1 hour. The sedation scores at 1 hour were higher in the memantine group but comparable in the 2nd hour. The number of doses of rescue analgesia and nausea/vomiting in the postoperative period was comparable in both groups. The results of this review suggest that memantine premedication could provide better pain scores in the immediate postoperative period with acceptable adverse effects. However, the current evidence is insufficient to suggest the routine use of memantine as a premedication before elective surgeries.
Collapse
Affiliation(s)
- Abhijit Nair
- Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, Ibra-414, Sultanate of Oman
| | - Ujjwalraj Dudhedia
- Department of Anaesthesiology and Pain Management, Dr. L. H. Hiranandani Hospital, Powai Mumbai, Maharashtra State, India
| | - Manish Thakre
- Department of Psychiatry, Government Medical College, Nagpur, Maharashtra State, India
| | - Nitinkumar Borkar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| |
Collapse
|
|
15
|
Yılmaz M, Kudu E, Sanri E, Karacabey S, Akoglu H, Denizbasi A. Comparison of the Analgesic Effects of Low-Dose Ketamine Versus Fentanyl in Patients With Long Bone Fractures in the Emergency Department: A Prospective Observational Study. Cureus 2023; 15:e46344. [PMID: 37920629 PMCID: PMC10618853 DOI: 10.7759/cureus.46344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/04/2023] Open
Abstract
Aim and background In most emergency departments (ED), opioids are the primary analgesic agents for trauma patients. However, safe alternative drugs are required because of possible adverse effects. Ketamine, an anesthetic agent, provides satisfactory analgesia at low doses and is an alternative drug that has begun to be used in numerous areas with fewer side effects. This study aimed to compare low-dose ketamine and fentanyl infusions in terms of their pain-relieving effects and observed adverse effects in patients presenting to the ED with isolated long bone fractures. Materials and methods This single-center observational study was conducted in the ED of the Marmara University Pendik Training and Research Hospital between August 2018 and December 2019. Patients diagnosed with isolated long bone fractures who were administered low-dose ketamine or fentanyl rapid infusions for pain relief were included in the study. Patient pain scores were evaluated using the visual analog scale (VAS) with a standard horizontal 10-centimeter line. The primary outcome of the study was to compare the changes in pain at 30 and 60 min after medication administration for each group. Results A total of 100 patients were included in the study. Ketamine infusion was administered to 48% (n=48) of the patients as a pain reliever. After 60 min of observation, pain was significantly reduced in both study groups. However, the pain scores at baseline (p=0.319), 30 min (p=0.631), and 60 min (p=0.347) after treatment were similar in both groups. In terms of the observed adverse effects, dizziness was more common in the ketamine group (p=0.010). Conclusion The results of this study showed that low-dose ketamine infusion (0.3 mg/kg/h) had a similar effect to fentanyl infusion (1 mcg/kg/h) as a pain reliever in patients with isolated long bone fractures in the ED.
Collapse
Affiliation(s)
- Muhammet Yılmaz
- Emergency Medicine, Marmara University School of Medicine, Istanbul, TUR
| | - Emre Kudu
- Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, TUR
| | - Erkman Sanri
- Emergency Medicine, Marmara University School of Medicine, Istanbul, TUR
| | - Sinan Karacabey
- Emergency Medicine, Marmara University School of Medicine, Istanbul, TUR
| | - Haldun Akoglu
- Emergency Medicine, Marmara University School of Medicine, Istanbul, TUR
| | - Arzu Denizbasi
- Emergency Medicine, Marmara University School of Medicine, Istanbul, TUR
| |
Collapse
|
|
16
|
Beaudrie-Nunn AN, Wieruszewski ED, Woods EJ, Bellolio F, Mara KC, Canterbury EA. Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department. Am J Emerg Med 2023; 70:133-139. [PMID: 37290249 DOI: 10.1016/j.ajem.2023.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 04/07/2023] [Accepted: 05/20/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Acute pain accounts for over 70% of Emergency Department (ED) visits. Sub-dissociative dose ketamine (0.1-0.6 mg/kg) is safe and effective for the management of acute pain in the ED. However, the optimal dose of intravenous ketamine that provides effective analgesia and minimizes the risk of adverse effects has yet to be identified. The objective of this study was to describe an effective analgesia dose range of IV ketamine for acute pain in the ED. METHODS This multi-center, retrospective cohort study evaluated adult patients who received analgesic and sub-dissociative dose ketamine for the management of acute pain between May 5, 2018, and August 30, 2021, in 21 emergency departments at academic, community, and critical access hospitals across four states. Patients were excluded if they received ketamine for an indication other than pain, such as procedural sedation or intubation, or for whom there was incomplete documentation for the primary outcome. Patients who received a ketamine dose <0.3 mg/kg were stratified into the low-dose group, and those who received a dose of 0.3 mg/kg or higher to the high-dose group. The primary outcome was change in pain scores within 60 min using a standard 11-point numeric rating scale (NRS). Secondary outcomes included incidence of adverse effects and use of rescue analgesics. Continuous variables were compared between dose groups using student t-test or Wilcoxon Rank-Sum test. Linear regression was used to assess the association between the change in NRS pain scores within 60 min and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid. RESULTS From 3796 patient encounters screened for receipt of ketamine, 384 patients met inclusion criteria including 258 in the low-dose group, and 126 in the high-dose group. The primary reason for exclusion was incomplete documentation of pain scores, or ketamine used for sedation. Median baseline pain scores were 8.2 in the low-dose group and 7.8 in the high-dose group (difference 0.5; 95% CI 0 to 1, p = 0.04). Both groups demonstrated significant reductions in their mean NRS pain scores within 60 min following the first administration of IV ketamine. There were no differences in the change in pain scores between both groups (-2.2 vs -2.6, mean difference 0.4, 95% CI -0.4 to 1.1, p = 0.34). Use of rescue analgesics (40.7% vs 36.5%, p = 0.43) and adverse effects were similar between groups, including early discontinuation of the ketamine infusion (37.2% vs. 37.3%, p = 0.99). Overall, the most common adverse effects were agitation (7.3%) and nausea (7.0%). CONCLUSION The analgesic efficacy and safety of high-dose sub-dissociative ketamine (≥0.3 mg/kg) was not superior to low-dose (< 0.3 mg/kg) for the management of acute pain in the ED. Low-dose ketamine <0.3 mg/kg is an effective and safe pain management strategy in this population.
Collapse
Affiliation(s)
| | - Erin D Wieruszewski
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, United States of America.
| | - Emily J Woods
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States of America.
| | | |
Collapse
|
|
17
|
Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
Collapse
Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
| |
Collapse
|
|
18
|
Fjendbo Galili S, Nikolajsen L, Papadomanolakis-Pakis N. Subanaesthetic single-dose ketamine as an adjunct to opioid analgesics for acute pain management in the emergency department: a systematic review and meta-analysis. BMJ Open 2023; 13:e066444. [PMID: 36972961 PMCID: PMC10069507 DOI: 10.1136/bmjopen-2022-066444] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/12/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness of a subanaesthetic single-dose ketamine (SDK) as an adjunct to opioids for acute pain in emergency department (ED) settings. DESIGN Systematic review and meta-analysis. METHODS A systematic search was performed in MEDLINE, Embase, Scopus and Web of Science through March 2022. Randomised controlled trials (RCTs) that investigated SDK as an adjunct to opioids in adult patients for any painful condition in ED settings were selected. Two reviewers screened studies, extracted data and assessed study quality. Data were pooled using random-effects models. The primary outcome was mean pain intensity score measured at baseline, >0-15 min, >15-30 min, >30-45 min, 60 min, 90 min and 120 min. Secondary outcomes included need for rescue analgesia, adverse events and patient satisfaction. Results were reported as mean differences (MDs) and risk ratios. Statistical heterogeneity was calculated using the I 2 statistic. RESULTS Eight RCTs were included (n=903). Studies were judged to be at moderate to high risk of bias. Mean pain intensity scores were significantly lower 60 min after study drug administration favouring adjuvant SDK (MD -0.76; 95% CI -1.19 to -0.33), compared with opioids alone. There was no evidence of differences in mean pain intensity scores at any other time point. Patients who received adjuvant SDK were less likely to require rescue analgesia, no more likely to experience serious side effects and had higher satisfaction scores, compared with opioids alone. CONCLUSIONS Available evidence suggests adjuvant SDK can have an effect on lowering pain intensity scores. Although reduction of pain scores was not clinically significant, the combination of reduced pain intensity and reduced opioid requirements suggest the results could be clinically important and support the potential utility of SDK as an adjunct to opioids to treat acute pain in adult ED patients. However, current evidence is limited and higher quality RCTs are needed. PROSPERO REGISTRATION NUMBER CRD42021276708.
Collapse
Affiliation(s)
- Stine Fjendbo Galili
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
- Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | |
Collapse
|
|
19
|
Altirkistani BA, Ashqar AA, Bahathiq DM, Bougis SM, Aljabri AM, Hanafi S. The Effectiveness of Ketamine Versus Opioids in Patients With Acute Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e36250. [PMID: 37069869 PMCID: PMC10105627 DOI: 10.7759/cureus.36250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/18/2023] Open
Abstract
Opioids are the mainstay of treatment for acute pain in the emergency department. However, its misuse led to the investigation of alternative effective analgesic options for acute pain complaints such as ketamine. Therefore, this systematic review and meta-analysis aimed to determine the effectiveness of ketamine in comparison to opioids in the management of acute pain. This was a systematic review and meta-analysis of randomized controlled trials comparing ketamine to opioids for the relief of acute pain in the ED. Eligible studies were identified by searching the following electronic databases: Medline, Embase, and Central. Studies utilizing either the visual analog scale (VAS) or the numeric rating scale (NRS) for pain scoring in ketamine vs opioids were included. The revised Cochrane risk-of-bias tool for randomized trials was utilized. A random-effects model was performed, and all outcomes were pooled by the inverse variance weighting method. The total number of studies that met the criteria of systematic reviews was nine of which seven of them were included in the meta-analysis with 789 participants. The overall effect of NRS trials was the standardized mean difference (SMD) = -0.07, 95% confidence interval (CI) -0.31 to 0.17, P-value = 0.56, I2 =85%. While VAS trials showed an overall effect of SMD = -0.02, 95% CI -0.22 to 0.18, P = 0.84, I2 = 59%). Moreover, higher adverse events were reported in opioids; however, this was not statistically significant (SMD = 1.23, 95% CI 0.93-1.64, P = 0.15, I2 =38%). Ketamine for immediate pain relief at 15 minutes could be an effective alternative to opioids, but its overall effect in comparison to opioids for improving the pain has not shown a statistically significant difference. There was high heterogeneity in the included studies; thus, a sub-group analysis was performed.
Collapse
|
|
20
|
Zanza C, Romenskaya T, Zuliani M, Piccolella F, Bottinelli M, Caputo G, Rocca E, Maconi A, Savioli G, Longhitano Y. Acute Traumatic Pain in the Emergency Department. Diseases 2023; 11:diseases11010045. [PMID: 36975594 PMCID: PMC10046963 DOI: 10.3390/diseases11010045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Trauma is a major cause of mortality throughout the world. Traumatic pain—acute, sudden, or chronic—is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Patients’ perceptions of pain assessment and management have become an important criterion and relevant outcome measure for healthcare institutions. Several studies show that 60–70% of ER patients experience pain, and more than half of them express a feeling of sorrow, which can be moderate or severe, at triage. The few studies that have analyzed how pain is assessed and managed in these departments agree that approximately 70% of patients receive no analgesia or receive it with remarkable delay. Specifically, less than half of the patients receive treatment for pain during admission and 60% of discharged patients have higher intensity pain than at admission. Trauma patients are also the ones who most commonly report low satisfaction with pain management. Associated with this lack of satisfaction, we can describe the poor use of tools for measuring and recording pain, poor communication among caregivers, inadequate training in pain assessment and management, and widespread misconceptions among nurses about the reliability of patients’ estimation of pain. The aim of this article is to review the scientific literature to explore the methodologies of pain management in trauma patients attending the emergency room and analyzing their weaknesses as a starting point to improve the approach to this, unfortunately too often, underestimated issue. A literature search was performed using the major databases to identify relevant studies in indexed scientific journals. The literature showed that the multimodal approach in trauma patients is the best approach to pain management. It is becoming increasingly crucial to manage the patient on multiple fronts. Drugs acting on different pathways can be administered together at lower doses, minimizing risks. Every emergency department must have staff trained in the assessment and immediate management of pain symptoms as this allows the reduction of mortality and morbidity and shortens hospital stays, contributing to early mobilization, reduced hospital costs, and enhanced patient satisfaction and quality of life.
Collapse
Affiliation(s)
- Christian Zanza
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
- Correspondence:
| | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
| | - Marta Zuliani
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Fabio Piccolella
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Maria Bottinelli
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Giorgia Caputo
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Eduardo Rocca
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Antonio Maconi
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| |
Collapse
|
|
21
|
Doan LV, Li A, Brake L, Ok D, Jee HJ, Park H, Cuevas R, Calvino S, Guth A, Schnabel F, Hiotis K, Axelrod D, Wang J. Single-Dose of Postoperative Ketamine for Postoperative Pain After Mastectomy: A Pilot Randomized Controlled Trial. J Pain Res 2023; 16:881-892. [PMID: 36942305 PMCID: PMC10024470 DOI: 10.2147/jpr.s389564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/24/2022] [Indexed: 03/17/2023] Open
Abstract
Background and Objectives Perioperative ketamine has been shown to reduce opioid consumption and pain after surgery. Ketamine is most often given as an infusion, but an alternative is single-dose ketamine. Single-dose ketamine at up to 1 mg/kg has been shown to reduce symptoms of depression, and a wide range of dosages has been used for pain in the emergency department. However, limited data exists on the tolerability and efficacy of a single-dose of ketamine at 0.6 mg/kg for pain when administered immediately after surgery. We conducted a pilot study of single-dose ketamine in patients undergoing mastectomy with reconstruction, hypothesizing that a single-dose of ketamine is well tolerated and can relieve postoperative pain and improve mood and recovery. Methods This is a randomized, single-blind, placebo-controlled, two-arm parallel, single-center study. Thirty adult women undergoing mastectomy with reconstruction for oncologic indication received a single-dose of ketamine (0.6mg/kg) or placebo after surgery in the post-anesthesia care unit (PACU). Patients were followed through postoperative day (POD) 7. The primary outcome was postoperative pain measured by the Brief Pain Inventory (BPI) pain subscale on POD 1 and 2. Secondary outcomes include effects on opioid use, PROMIS fatigue and sleep, mood, Quality of Recovery-15, and the Breast Cancer Pain Questionnaire. Results Side effects were minor and not significantly different in frequency between groups. The ketamine group reported lower scores on the BPI pain severity subscale, especially at POD 7; however, the difference was not statistically significant. There were no statistically significant differences between ketamine and placebo groups for the secondary outcomes. Conclusion A single-dose of ketamine at 0.6mg/kg administered postoperatively in the PACU is well tolerated in women undergoing mastectomy and may confer better pain control up to one week after surgery. Future studies with larger sample sizes are necessary to adequately characterize the effect of postoperative single-dose ketamine on pain control in this population.
Collapse
Affiliation(s)
- Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Correspondence: Lisa V Doan, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 240 E 38th St, 14th Floor, New York, NY, 10016, USA, Tel +1 212201-1004, Email
| | - Anna Li
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Lee Brake
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Deborah Ok
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Hyun Jung Jee
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Hyung Park
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Randy Cuevas
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Steven Calvino
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Karen Hiotis
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
|
22
|
Chubbs B, Wang J, Archer S, Chrenek C, Khullar A, Wolowyk M, Swainson J. A survey of drug liking and cravings in patients using sublingual or intranasal ketamine for treatment resistant depression: A preliminary evaluation of real world addictive potential. Front Psychiatry 2022; 13:1016439. [PMID: 36465297 PMCID: PMC9714431 DOI: 10.3389/fpsyt.2022.1016439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
Ketamine has gained rapid popularity as a treatment option for treatment resistant depression (TRD). Though seen only in limited contexts, ketamine is a potential drug of abuse, addiction and diversion. Clinical ketamine studies to date have not systematically evaluated factors relevant to addiction risk in patients with TRD, but in treating patients with ketamine, risks of potential harms related to addiction must be considered. As clinical access to intravenous ketamine programs is limited in much of Canada, these considerations become even more important for clinicians who elect to offer patients less supervised, non-parenteral forms of ketamine treatment. This study explores factors relevant to addiction risk in a real-world sample of 33 patients with TRD currently or previously treated with sublingual (SL) or intranasal (IN) ketamine in the community. First, patients were surveyed using a Drug Liking and Craving Questionnaire (DLCQ) to assess their level of drug liking and craving for ketamine, and to screen for symptoms of a ketamine use disorder. Second, the pharmacy records of these patients were reviewed for red flags for addiction such as dose escalation or early refills. Third, surveys were administered to the treating psychiatrists of patients who had discontinued ketamine to determine if abuse concerns contributed to reason for discontinuation. Though limited to a small sample, results indicate that ketamine is not a universally liked or craved substance in patients with TRD. Prescribers of non-parenteral ketamine should monitor patients and prescribe cautiously. Factors related to addiction (as in the DLCQ) should be explored for clinicians to consider individual risk/benefit for judicious use of ketamine in patients with TRD.
Collapse
Affiliation(s)
- Brittany Chubbs
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Jay Wang
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Shaina Archer
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Carson Chrenek
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | | | - Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
|
23
|
Balachandran A, Tassone VK, Adamsahib F, Di Passa AM, Kuburi S, Demchenko I, Ladha KS, Bhat V. Efficacy of ketamine for comorbid depression and acute or chronic pain: A systematic review. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 3:1022767. [PMID: 36353699 PMCID: PMC9638121 DOI: 10.3389/fpain.2022.1022767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022]
Abstract
Pain and depression frequently co-occur. Due to its antidepressant and analgesic properties, ketamine has been used for the management of treatment-resistant depression and pain. This systematic review examined the literature on the efficacy of sub-anesthetic doses of ketamine in individuals experiencing comorbid depression and chronic pain (CDCP), as well as comorbid depression and acute pain (CDAP). A secondary objective was to provide an assessment of dosage, route, and adverse effects of ketamine treatment for CDCP and CDAP. A literature search was conducted on MEDLINE, PsycINFO, and Embase databases, coupled with a manual screening of the bibliography sections of included articles. In addition, registered ongoing and planned trials were searched on Clinicaltrials.gov. The end date of the search was April 9th, 2022. Included studies assessed changes in depression and pain in patients receiving at least one sub-anesthetic dose of ketamine. Assessment of quality was conducted using the GRADE checklist. Of the 7 CDCP clinical trials, 3 reported a reduction in depression and pain, 3 reported a reduction in depression or pain only, and 1 reported no improvement in either comorbidity. Among the 7 CDAP clinical trials, 4 studies found improvements in depression and pain while the remaining 3 reported improvements in only one parameter. Ten of the 12 case studies and 2 of the 3 observational studies assessing CDCP and CDAP found improvements in pain and depression scores post-treatment with effects of variable duration. The planned methodologies of the registered clinical trials are in line with those of the published research. Preliminary evidence supports the efficacy of ketamine in treating CDCP and CDAP. However, the current review identified a small number of heterogeneous studies with mixed results, preventing comprehensive conclusions. More longitudinal placebo-controlled studies are needed to identify the effects of ketamine for patients with CDCP and CDAP.
Collapse
Affiliation(s)
- Aksharra Balachandran
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Vanessa K. Tassone
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Fathima Adamsahib
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Anne-Marie Di Passa
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Sarah Kuburi
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Ilya Demchenko
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Karim S. Ladha
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Venkat Bhat
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada,Krembil Research Institute, University Health Network, Toronto, ON, Canada,Correspondence: Venkat Bhat
| |
Collapse
|
|
24
|
Alenzi E. The effectiveness of ketamine compared to opioid analgesics for management of acute pain in children in the emergency department: systematic review. Am J Emerg Med 2022; 61:143-151. [DOI: 10.1016/j.ajem.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/27/2022] [Accepted: 08/03/2022] [Indexed: 10/31/2022] Open
|
|
25
|
Fahad Najam M, Jafri N. A Comparison Between the Effectiveness of Ketamine Bolus and Intradermal Lidocaine in Reducing Acute Postoperative Pain. Cureus 2022; 14:e26563. [PMID: 35936181 PMCID: PMC9349481 DOI: 10.7759/cureus.26563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective In light of the scarcity of data and research about the management of pain in a low-resource setting, we conducted this study with a view to assessing the effectiveness of intravenous ketamine in comparison to that of intradermal lidocaine in reducing postoperative pain. Postoperative pain can lead to significant morbidity, longer hospital stay, and the development of chronic pain. Our study was formulated to assess the effectiveness of a ketamine bolus in comparison to intradermal lidocaine at the wound site in terms of decreasing pain scores postoperatively. Methods In our study, 99 patients were randomly selected to undergo inguinal hernia repair under spinal anesthesia. After obtaining informed consent from the participants and approval from the hospital ethical committee, the patients were randomly classified into the following three groups: the lidocaine group (group A), the ketamine group (group B), and the control group (group C). The patients in the lidocaine group received 0.6 mL/kg of 0.25% lidocaine (1.5 mg/kg) infiltration at the wound site. The ketamine group was given a 50-mg ketamine bolus at the end of the operation, and the control group did not receive either ketamine or intradermal lidocaine at the wound site. Postoperative pain was recorded using the Visual Analog Scale (VAS) scoring and the results were compared. The time of the first request for analgesia was also recorded. Results The pain scores measured via VAS scores were higher in patients who received intradermal lidocaine (group A) at the wound site as compared to group B that received a bolus of 50-mg ketamine (p<0.0001); the control group (group C) had pain scores higher than both groups A and B (p=0.0001). Conclusion Based on our findings, administering ketamine bolus can significantly decrease VAS scores and reduce the incidence of chronic post-surgical pain as compared to lidocaine infiltration. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, provides excellent pain relief and analgesia, which decreases overall pain scores.
Collapse
|
|
26
|
Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
|
|
27
|
Chumpitazi CE, Chang C, Atanelov Z, Dietrich AM, Lam SH, Rose E, Ruttan T, Shahid S, Stoner MJ, Sulton C, Saidinejad M. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open 2022; 3:e12664. [PMID: 35310402 PMCID: PMC8918119 DOI: 10.1002/emp2.12664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/12/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.
Collapse
Affiliation(s)
- Corrie E. Chumpitazi
- Department of PediatricsDivision of Emergency Medicine, Baylor College of Medicine, Texas Children's HospitalHoustonTexasUSA
| | - Cindy Chang
- Department of Pediatrics, Division of Emergency MedicineCincinnati Children's Hospital Medical Center, University of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Zaza Atanelov
- North Florida Regional Medical Center Emergency DepartmentHCA/University of Central Florida College of Medicine ConsortiumFloridaUSA
| | - Ann M. Dietrich
- Department of Pediatrics and Emergency MedicineUniversity of South Carolina College of MedicineGreenvilleNorth CarolinaUSA
| | - Samuel Hiu‐Fung Lam
- Department of Emergency MedicineSutter Medical Center SacramentoSacramentoCaliforniaUSA
| | - Emily Rose
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Tim Ruttan
- Dell Children's Medical Center, Department of PediatricsThe University of Texas at Austin Dell Medical School, US Acute Care SolutionsAustinTexasUSA
| | - Sam Shahid
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Michael J. Stoner
- Nationwide Children's HospitalThe Ohio State University College of MedicineColumbusOhioUSA
| | - Carmen Sulton
- Emory University School of MedicineChildren's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Mohsen Saidinejad
- Department of Emergency MedicineHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | | |
Collapse
|
|
28
|
Casamento A, Niccol T. Efficacy and safety of ketamine in mechanically ventilated intensive care unit patients: a scoping review. CRIT CARE RESUSC 2022; 24:71-82. [PMID: 38046843 PMCID: PMC10692604 DOI: 10.51893/2022.1.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients. Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance. We included studies that described the use of ketamine for postoperative and emergency department management of pain and in the critically unwell, mechanically ventilated population. Results: There are few randomised controlled trials evaluating ketamine's utility in the ICU. The evidence is predominantly retrospective and observational in nature and the results are heterogeneous. Available evidence is summarised in a descriptive manner, with a division made between high dose and low dose ketamine. Ketamine's pharmacology and use as an analgesic agent outside of the ICU is briefly discussed, followed by evidence for use in the ICU setting, with particular emphasis on analgesia, sedation and intubation. Finally, data on adverse effects including delirium, coma, haemodynamic adverse effects, raised intracranial pressure, hypersalivation and laryngospasm are presented. Conclusions: Ketamine is used in mechanically ventilated ICU patients with several potentially positive clinical effects. However, it has a significant side effect profile, which may limit its use in these patients. The role of low dose ketamine infusion in mechanically ventilated ICU patients is not well studied and requires investigation in high quality, prospective randomised trials.
Collapse
Affiliation(s)
- Andrew Casamento
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Intensive Care Unit, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Niccol
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
| |
Collapse
|
|
29
|
Melcer T, Walker GJ, Dye JL, Walrath B, MacGregor AJ, Perez K, Galarneau MR. Is Prehospital Ketamine Associated With a Change in the Prognosis of PTSD? Mil Med 2022; 188:usac014. [PMID: 35104347 DOI: 10.1093/milmed/usac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/30/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury. MATERIALS AND METHODS We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine). RESULTS Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl. CONCLUSIONS The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.
Collapse
|
|
30
|
Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med 2022; 54:165-171. [DOI: 10.1016/j.ajem.2022.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022] Open
|
|
31
|
Swainson J, Klassen LJ, Brennan S, Chokka P, Katzman MA, Tanguay RL, Khullar A. Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing. CNS Drugs 2022; 36:239-251. [PMID: 35165841 PMCID: PMC8853036 DOI: 10.1007/s40263-022-00897-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
Collapse
Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada. .,Misericordia Community Hospital, Edmonton, AB, Canada.
| | | | - Stefan Brennan
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK Canada
| | - Pratap Chokka
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Chokka Center for Integrative Health, Edmonton, AB Canada
| | - Martin A. Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON Canada ,Department of Psychiatry, Northern Ontario School of Medicine, Thunder Bay, ON Canada ,Department of Psychology, Lakehead University, Thunder Bay, ON Canada ,Department of Psychology, Adler Graduate Professional School, Toronto, ON Canada
| | - Robert L. Tanguay
- Department of Psychiatry and Department of Surgery, University of Calgary, Calgary, AB Canada ,The Newly Institute, Calgary, AB Canada ,Hotchkiss Brain Institute and Mathison Centre for Mental Health, Calgary, AB Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Northern Alberta Sleep Clinic, Edmonton, AB Canada
| |
Collapse
|
|
32
|
Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft. Sci Rep 2021; 11:23753. [PMID: 34887486 PMCID: PMC8660833 DOI: 10.1038/s41598-021-03141-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/23/2021] [Indexed: 11/21/2022] Open
Abstract
Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns' registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14-22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.
Collapse
|
|
33
|
Corkery JM, Hung WC, Claridge H, Goodair C, Copeland CS, Schifano F. Recreational ketamine-related deaths notified to the National Programme on Substance Abuse Deaths, England, 1997-2019. J Psychopharmacol 2021; 35:1324-1348. [PMID: 34092131 PMCID: PMC8600594 DOI: 10.1177/02698811211021588] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ketamine is a phencyclidine derivative with dissociative anaesthetic properties. Increasing numbers of individuals in England take ketamine recreationally. Information on deaths arising from such use in England is presented. METHODS Cases were extracted on 31 January 2020 from the National Programme on Substance Abuse Deaths database, based on text searches of the cause of death, coroner's verdict and positive toxicology results for the terms 'ketamine' or 'norketamine'. FINDINGS During 1997-2005, there were <5 deaths p.a. in which ketamine was implicated. Numbers increased until 2009 (21), plateauing until 2016; thereafter, deaths have risen to about 30 p.a. Decedents' characteristics (N = 283): male 84.1%, mean age 31.2 (SD 10.0) years, employed 56.5%, drug use history 79.6% and living with others 60.3%. Ketamine was detected with other substances in most cases. Main (74.6%) underlying cause of death was accidental poisoning. Ketamine may have impaired judgement in other cases. CONCLUSIONS Although controlled, recreational ketamine use and related fatalities continue to increase. Consumers need to be more aware of the potentially fatal risks they face.
Collapse
Affiliation(s)
- John Martin Corkery
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, Department of Clinical, Pharmaceutical
and Biological Sciences, University of Hertfordshire, Hatfield, Hertfordshire,
UK
- John Martin Corkery, Psychopharmacology,
Drug Misuse and Novel Psychoactive Substances Research Unit, Department of
Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire,
Room 2F419, Health Research Building, College Lane Campus, Hatfield, Herts AL10
9AB, UK.
| | - Wan-Chu Hung
- Institute of Pharmaceutical Sciences,
King’s College London, London, UK
| | - Hugh Claridge
- National Programme on Substance Abuse
Deaths, St George’s, University of London, London, UK
- Population Health Research Institute,
St George’s, University of London, London, UK
| | - Christine Goodair
- National Programme on Substance Abuse
Deaths, St George’s, University of London, London, UK
- Population Health Research Institute,
St George’s, University of London, London, UK
| | - Caroline S Copeland
- Institute of Pharmaceutical Sciences,
King’s College London, London, UK
- National Programme on Substance Abuse
Deaths, St George’s, University of London, London, UK
- Population Health Research Institute,
St George’s, University of London, London, UK
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and
Novel Psychoactive Substances Research Unit, Department of Clinical, Pharmaceutical
and Biological Sciences, University of Hertfordshire, Hatfield, Hertfordshire,
UK
| |
Collapse
|
|
34
|
Usman MA. Should Ketamine Not Be Banned? A Scoping Review. Disaster Med Public Health Prep 2021; 17:e47. [PMID: 34664549 DOI: 10.1017/dmp.2021.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although the importance of ketamine in clinical practice and in resource-poor settings and disaster zones, several attempts were made to reschedule it because of the issues around its misuse. Resisting future moves to reschedule ketamine is important for its continuous availability where needed. This scoping review addresses the question of whether ketamine should or should not be banned and the state of preparedness of low resource settings if ketamine petitions become successful in the future. METHODS A search was performed using PubMed and Google Scholar to identify articles published in the English language from March 2015 to August 2020. The articles were searched with a wide range of priori search terms related to the research questions. The selection of articles was based on relevance and eligibility. RESULTS Seventy-five articles were selected and grouped into 4 ethical themes. The search revealed that several articles addressed the importance of ketamine, pharmacology, misuse, supply, and consequences of a ketamine ban; however, none addressed how resource-poor countries should prepare for a future without the overreliance of ketamine. CONCLUSION Four ketamine petitions in about 10 years are an indication that another may resurface soon; therefore, it is important to continue to study the clinical importance of ketamine while discouraging its overreliance for clinical practice.
Collapse
Affiliation(s)
- Mohammed Adinoyi Usman
- Department of Anaesthesiology and Intensive Care, Usmanu Danfodiyo University Teaching Hospital, Sokoto State, Nigeria
| |
Collapse
|
|
35
|
Seak YS, Nor J, Tuan Kamauzaman TH, Arithra A, Islam MA. Efficacy and Safety of Intranasal Ketamine for Acute Pain Management in the Emergency Setting: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10173978. [PMID: 34501425 PMCID: PMC8432265 DOI: 10.3390/jcm10173978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/07/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
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.
Collapse
Affiliation(s)
- Yee Sin Seak
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Junainah Nor
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (J.N.); (M.A.I.)
| | - Tuan Hairulnizam Tuan Kamauzaman
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Ariff Arithra
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (J.N.); (M.A.I.)
| |
Collapse
|
|
36
|
Vysokovsky M, Avital G, Betelman-Mahalo Y, Gelikas S, Fridrich L, Radomislensky I, Tsur AM, Glassberg E, Benov A. Trends in prehospital pain management following the introduction of new clinical practice guidelines. J Trauma Acute Care Surg 2021; 91:S206-S212. [PMID: 34039920 DOI: 10.1097/ta.0000000000003287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001). CONCLUSION Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE Therapeutic/care management, level III.
Collapse
Affiliation(s)
- Moshe Vysokovsky
- From the The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (M.V., G.A., Y.M., S.G., A.M.T., A.B.); Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (M.V.); Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel (G.A.); Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (L.F.); The National Center for Trauma and Emergency Medicine research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel (I.R.); Department of Medicine 'B'. Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer; affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.M.T.); The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel (E.G., A.B.); Uniformed Services University of the Health Sciences, Bethesda, Maryland (E.G.); and Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (E.G.)
| | | | | | | | | | | | | | | | | |
Collapse
|
|
37
|
Scoville JP, Joyce E, Hunsaker J, Reese J, Wilde H, Arain A, Bollo RL, Rolston JD. Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:6-13. [PMID: 33733680 DOI: 10.1093/ons/opab040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/25/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.
Collapse
Affiliation(s)
- Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - Joshua Hunsaker
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jared Reese
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Herschel Wilde
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Amir Arain
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert L Bollo
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA
| | - John D Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, USA.,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, Utah, USA
| |
Collapse
|
|
38
|
Elmoheen A, Nazal AF, Zubaidi O, Siddiqui UA, Alhatou M. Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar. Qatar Med J 2021; 2021:19. [PMID: 34285886 DOI: 10.5339/qmj.2021.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/24/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar. METHODS An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed. RESULTS Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist. CONCLUSION The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.
Collapse
Affiliation(s)
- Amr Elmoheen
- Emergency Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdullah F Nazal
- Pain Management Section, Department of Anesthesiology, ICU and Perioperative Medicine, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osman Zubaidi
- Research, Development and Medical, Upjohn-A Division of Pfizer, Doha, Qatar
| | - Urooj A Siddiqui
- Research, Development and Medical, Upjohn-A Division of Pfizer, Dubai, UAE
| | - Mohammed Alhatou
- Neuromuscular Division, Hamad Medical Corporation, Doha, Qatar; Neurology Division, Department of Medicine, Al Khor Hospital, Doha, Qatar
| |
Collapse
|
|
39
|
Zhou JY, Hamilton P, Macres S, Peña M, Tang S. Update on Ketamine. Adv Anesth 2021; 38:97-113. [PMID: 34106842 DOI: 10.1016/j.aan.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jon Y Zhou
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA.
| | - Perry Hamilton
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/pvham1011
| | - Stephen Macres
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Matthew Peña
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA
| | - Schirin Tang
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4150 V Street, Suite 1200 PSSB, Sacramento, CA 95817, USA. https://twitter.com/SchirinMD
| |
Collapse
|
|
40
|
Punches BE, Berger KM, Freiermuth CE, Soliman SA, Walker QT, Lyons MS. Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department. Pain Manag Nurs 2021; 22:586-591. [PMID: 34099392 DOI: 10.1016/j.pmn.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/27/2021] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, "nurses influence ED pain management" and "adjustments in ED pain management", and an overarching message that "pain management depends on the care team." By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.
Collapse
Affiliation(s)
- Brittany E Punches
- University of Cincinnati College of Nursing, Cincinatti, Ohio; Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | | | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Summer A Soliman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Quinn T Walker
- University of Cincinnati College of Nursing, Cincinatti, Ohio
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
|
41
|
Kaimakliotis P, Ramadugu A, Kang J, McGorisk T, Polick A, Votta-Velis E, Trivedi I. Targeted housestaff intervention reduces opioid use without worsening patient-reported pain scores and improves outcomes among patients with IBD: the "IBD pain ladder". Int J Colorectal Dis 2021; 36:1193-1200. [PMID: 33486534 DOI: 10.1007/s00384-021-03852-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). With the goal of reducing inpatient opioid use among patients with IBD admitted to our inpatient gastroenterology (GI) service, we designed and implemented a standardized, educational intervention providing analgesic decision support to internal medicine and emergency medicine housestaff at our institution. METHODS Pre-intervention data was collected from patients admitted during a 9-month period prior to intervention. Post-intervention patients were identified prospectively. The primary outcome was reduction in aggregate inpatient opioid use in oral morphine equivalents per patient. RESULTS A total of 68 patients with 81 hospitalizations were analyzed. There was no statistically significant difference in baseline admission characteristics between the two groups. Our primary outcome was achieved with a statistically significant reduction in opioid use during hospitalization (43.4 mg vs 7.7 mg; p < 0.01). Secondary outcomes achieved included reduction in new opioid prescriptions upon discharge, reduced hospital length of stay, and reduced 90-day readmission rates. There was no significant difference between patients' pain scores between the two groups. CONCLUSION We believe this intervention, aimed at housestaff education, provides a roadmap for pain management decision-making in this patient population. It is a readily reproducible strategy that can be widely applied to improve inpatient IBD patient care. Importantly, patient experience and pain scores were unchanged despite lower use of inpatient opioid analgesia, highlighting successful opioid-sparing analgesics in most inpatients with IBD.
Collapse
Affiliation(s)
- Pavlos Kaimakliotis
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA.
| | - Ajit Ramadugu
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Jennifer Kang
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Timothy McGorisk
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, IL, USA
| | - Anne Polick
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | | | - Itishree Trivedi
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, IL, USA
| |
Collapse
|
|
42
|
Abstract
Ketamine is a dissociative anesthetic used increasingly as analgesia for different manifestations of pain, including acute, chronic, cancer and perioperative pain as well as pain in the critically ill patient population. Its distinctive pharmacologic properties may provide benefits to individuals suffering from pain, including increased pain control and reduction in opioid consumption and tolerance. Despite wide variability in proposed dosing and method of administration when used for analgesia, it is important all clinicians be familiar with the pharmacodynamics of ketamine in order to appropriately anticipate its therapeutic and adverse effects.
Collapse
Affiliation(s)
- Kelsea Caruso
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
| | - Dion Tyler
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
| | - Abbie Lyden
- Kelsea Caruso, PharmD, Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
- Dion Tyler, PharmD, PGY2 Emergency Medicine Pharmacy Resident, Rosalind Franklin University of Medicine and Science and Northwestern Memorial Hospital, Chicago, IL
- Abbie Lyden, PharmD, BCPS , Associate Professor, Rosalind Franklin University of Medicine and Science, and Emergency Medicine Clinical Pharmacist, Northwestern Memorial Hospital, Chicago, IL
| |
Collapse
|
|
43
|
Alipoor M, Loripoor M, Kazemi M, Farahbakhsh F, Sarkoohi A. The effect of ketamine on preventing postpartum depression. J Med Life 2021; 14:87-92. [PMID: 33767791 PMCID: PMC7982256 DOI: 10.25122/jml-2020-0116] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Postpartum depression is a common disabling psychosocial disorder that could have adverse effects on the life of the mother, infant, and family. The present study was conducted to evaluate the effect of ketamine on preventing postpartum depression in women undergoing caesarian sections considering the relatively known positive effect of ketamine on major depression. The present double-blind, randomized clinical trial was conducted on 134 women undergoing scheduled caesarian sections. Participants were randomly allocated into two groups of control and intervention. To induce anesthesia, 1–2 mg/kg of body weight of Nesdonal and 0.5 mg/kg of body weight of ketamine were used in the intervention group, while only 3–5 mg/kg of body weight Nesdonal was administered in the control group. Data were gathered using the Edinburgh Postnatal Depression Scale (EPDS) in three stages: before the caesarian section and two and four weeks after the caesarian section. Data were analyzed using variance analysis with repeated measures and the Chi-square test. Results of the present study showed that the mean (± standard deviation) of the depression score in the intervention and control groups were 13.78±3.87 and 13.79±4.78(p = 0.98) before the caesarian section, 11.82±3.41 and 14.34±4.29 (p < 0.001) two weeks after and 10.84±3.48 and 13.09±3.79 (p = 0.001) four weeks after the caesarian section, respectively. Using ketamine in the induction of general anesthesia could be effective in preventing postpartum depression. However, further studies are required to strengthen these findings.
Collapse
Affiliation(s)
- Mina Alipoor
- Department of Anesthesiology, School of Paramedical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Marzeyeh Loripoor
- Department of Reproductive Health and Midwifery, School of Nursing and Midwifery; Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Majid Kazemi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Non-Communicable Disease Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Farshid Farahbakhsh
- Department of Anesthesiology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Ali Sarkoohi
- Department of Anesthesiology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| |
Collapse
|
|
44
|
Singh S, Kumar A, Mittal G. Ketamine-polymer based drug delivery system for prolonged analgesia: recent advances, challenges and future prospects. Expert Opin Drug Deliv 2021; 18:1117-1130. [PMID: 33599572 DOI: 10.1080/17425247.2021.1887134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Introduction: With a sharp increase in NSAIDs and opioid use for chronic pain conditions associated with traumatic injuries and diseases, there has been an escalated risk of life-threatening side effects (cardiac and respiratory malfunction), inadvertent overdose, and even death. Their short duration of action and toxicity induces the need to develop extended-release analgesic drug formulations based on safe drugs like ketamine.Areas covered: This review presents progressive breakthroughs in pain control strategies for augmenting patient's comfort and minimizing unnecessary adverse effects associated with NSAIDs and opioids. Advantages of using ketamine, a dissociative anesthetic and potent analgesic over opioids have been elaborated here for the development of advanced sustained-release analgesic drug formulations based on ketamine and polymers (hydrogels, microparticles, and nanoparticles) as mainstream systems. These systems can be very promising in the resource-constrained healthcare set-up where frequent drug dosing at short time intervals is extremely challenging. PubMed, Embase, Google Scholar electronic databases, and clinical websites were used for conducting extensive research.Expert opinion: Controlled drug release analgesic systems can significantly reduce the burden of repeated drug dosing and opioid drug dependency, maximizing the function of analgesic drugs for clinical translation, and improving the quality of life of those living with pain.
Collapse
Affiliation(s)
- Surabhi Singh
- Department of Combat Sciences, Institute of Nuclear Medicine and Allied Sciences, Defence Research & Development Organisation, New Delhi India
| | - Amit Kumar
- Department of Combat Sciences, Institute of Nuclear Medicine and Allied Sciences, Defence Research & Development Organisation, New Delhi India
| | - Gaurav Mittal
- Department of Combat Sciences, Institute of Nuclear Medicine and Allied Sciences, Defence Research & Development Organisation, New Delhi India
| |
Collapse
|
|
45
|
Balzer N, McLeod SL, Walsh C, Grewal K. Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2021; 28:444-454. [PMID: 33098707 DOI: 10.1111/acem.14159] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/06/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED. METHODS Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. RESULTS Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence. CONCLUSION Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.
Collapse
Affiliation(s)
- Nathan Balzer
- From the Department of Medicine Division of Emergency MedicineUniversity of Toronto TorontoOntarioCanada
| | - Shelley L. McLeod
- the Department of Family and Community Medicine University of Toronto TorontoOntarioCanada
- the Schwartz/Reisman Emergency Medicine InstituteSinai Health TorontoOntarioCanada
| | | | - Keerat Grewal
- From the Department of Medicine Division of Emergency MedicineUniversity of Toronto TorontoOntarioCanada
- the Schwartz/Reisman Emergency Medicine InstituteSinai Health TorontoOntarioCanada
| |
Collapse
|
|
46
|
Steiner AR, Rousseau-Blass F, Schroeter A, Hartnack S, Bettschart-Wolfensberger R. Systematic Review: Anesthetic Protocols and Management as Confounders in Rodent Blood Oxygen Level Dependent Functional Magnetic Resonance Imaging (BOLD fMRI)-Part B: Effects of Anesthetic Agents, Doses and Timing. Animals (Basel) 2021; 11:ani11010199. [PMID: 33467584 PMCID: PMC7830239 DOI: 10.3390/ani11010199] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023] Open
Abstract
Simple Summary To understand brain function in rats and mice functional magnetic resonance imaging of the brain is used. With this type of “brain scan” regional changes in blood flow and oxygen consumption are measured as an indirect surrogate for activity of brain regions. Animals are often anesthetized for the experiments to prevent stress and blurred images due to movement. However, anesthesia may alter the measurements, as blood flow within the brain is differently affected by different anesthetics, and anesthetics also directly affect brain function. Consequently, results obtained under one anesthetic protocol may not be comparable with those obtained under another, and/or not representative for awake animals and humans. We have systematically searched the existing literature for studies analyzing the effects of different anesthesia methods or studies that compared anesthetized and awake animals. Most studies reported that anesthetic agents, doses and timing had an effect on functional magnetic resonance imaging results. To obtain results which promote our understanding of brain function, it is therefore essential that a standard for anesthetic protocols for functional magnetic resonance is defined and their impact is well characterized. Abstract In rodent models the use of functional magnetic resonance imaging (fMRI) under anesthesia is common. The anesthetic protocol might influence fMRI readouts either directly or via changes in physiological parameters. As long as those factors cannot be objectively quantified, the scientific validity of fMRI in rodents is impaired. In the present systematic review, literature analyzing in rats and mice the influence of anesthesia regimes and concurrent physiological functions on blood oxygen level dependent (BOLD) fMRI results was investigated. Studies from four databases that were searched were selected following pre-defined criteria. Two separate articles publish the results; the herewith presented article includes the analyses of 83 studies. Most studies found differences in BOLD fMRI readouts with different anesthesia drugs and dose rates, time points of imaging or when awake status was compared to anesthetized animals. To obtain scientifically valid, reproducible results from rodent fMRI studies, stable levels of anesthesia with agents suitable for the model under investigation as well as known and objectively quantifiable effects on readouts are, thus, mandatory. Further studies should establish dose ranges for standardized anesthetic protocols and determine time windows for imaging during which influence of anesthesia on readout is objectively quantifiable.
Collapse
Affiliation(s)
- Aline R. Steiner
- Section of Anaesthesiology, Department of Clinical and Diagnostic Services, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
- Correspondence:
| | - Frédérik Rousseau-Blass
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC J2S 2M2, Canada;
| | - Aileen Schroeter
- Institute for Biomedical Engineering, University and ETH Zurich, 8093 Zurich, Switzerland;
| | - Sonja Hartnack
- Section of Epidemiology, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
| | - Regula Bettschart-Wolfensberger
- Section of Anaesthesiology, Department of Clinical and Diagnostic Services, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
| |
Collapse
|
|
47
|
Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. OBJECTIVE To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. ELIGIBILITY CRITERIA All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. SOURCES OF EVIDENCE PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. CHARTING METHODS Evidence was searched according to clinically relevant topics and PICO questions. RESULTS Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. CONCLUSIONS Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
Collapse
Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
- Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
| |
Collapse
|
|
48
|
Sandberg M, Hyldmo PK, Kongstad P, Dahl Friesgaard K, Raatiniemi L, Larsen R, Magnusson V, Rognås L, Kurola J, Rehn M, Vist GE. Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm. BMJ Open 2020; 10:e038134. [PMID: 33234621 PMCID: PMC7689093 DOI: 10.1136/bmjopen-2020-038134] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Few publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug) in adult prehospital patients with acute pain. METHODS A systematic review of clinical trials assessing prehospital administration of ketamine in analgesic doses compared with other analgesic drugs or no analgesic treatment in adults. We searched PubMed, EMBASE, Cochrane Library and Epistemonikos from inception until 15 February 2020, including relevant articles in English and Nordic languages. We used the Cochrane and Grading of Recommendations Assessment, Development and Evaluation methodologies and exclusively assessed patient-centred outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias. RESULTS We included eight studies (2760 patients). Ketamine was compared with various opioids given alone, and intranasal ketamine given with nitrous oxide was compared with nitrous oxide given alone. Four randomised controlled trials (RCTs) and one cluster randomised trial included 699 patients. One prospective cohort included 27 patients and two retrospective cohorts included 2034 patients. Five of the eight studies had high risks of bias. Pain score with ketamine is probably lower than after opioids as demonstrated in a cluster-RCT (308 patients) and a retrospective cohort (158 patients) study, Δvisual analogue scale -0.4 (-0.8 to 0.0) and Δnumeric pain rating scale -3.0 (-3.86 to -2.14), respectively. Ketamine probably leads to less nausea and vomiting (risk ratio (RR) 0.24 (0.11 to 0.52)) but more agitation (RR 7.81 (1.85 to 33)) than opioids. CONCLUSIONS This systematic literature review finds that ketamine probably reduces pain more than opioids and with less nausea and vomiting but higher risk of agitation. Risk of bias in included studies is high. OTHER Scandinavian society of anaesthesiology and intensive care medicine funded meetings and software. The Norwegian Air Ambulance Foundation funded publication. Otherwise this research received no grant from any agency in the public, commercial or not-for-profit sectors. PROSPERO REGISTRATION NUMBER CRD42018114399.
Collapse
Affiliation(s)
- Mårten Sandberg
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Hyldmo
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Trauma Unit, Sørlandet Hospital, Kristiansand, Norway
| | - Poul Kongstad
- Department of Prehospital Care and Disaster Medicine, Region of Skåne, Lund, Sweden
| | - Kristian Dahl Friesgaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
- Department of Anaesthesiology, Regional Hospital of Horsens, Horsens, Denmark
| | - Lasse Raatiniemi
- Centre for Prehospital Emergency Care, Oulu University Hospital, Oulu, Finland
- Anaesthesia Research group, MRC, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Robert Larsen
- Department of Anaesthesiology and Intensive Care, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Leif Rognås
- Danish Air Ambulance, Aarhus, Denmark
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jouni Kurola
- Centre for Prehospital Emergency Medicine, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Gunn Elisabeth Vist
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| |
Collapse
|
|
49
|
Yin X, Wang X, He C. Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis. Am J Emerg Med 2020; 46:424-429. [PMID: 33131973 DOI: 10.1016/j.ajem.2020.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain. METHOD This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity. RESULTS Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min. CONCLUSION NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.
Collapse
Affiliation(s)
- Xinbo Yin
- Faculty of Nursing, School of Medicine, Hunan Normal University, Changsha, Hunan, China; Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaokai Wang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Caiyun He
- Faculty of Nursing, School of Medicine, Hunan Normal University, Changsha, Hunan, China.
| |
Collapse
|
|
50
|
Watso JC, Huang M, Moralez G, Cramer MN, Hendrix JM, Cimino FA, Belval LN, Hinojosa‐Laborde C, Crandall CG. Low dose ketamine reduces pain perception and blood pressure, but not muscle sympathetic nerve activity, responses during a cold pressor test. J Physiol 2020; 599:67-81. [DOI: 10.1113/jp280706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/01/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Joseph C. Watso
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
| | - Mu Huang
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
- Department of Applied Clinical Research University of Texas Southwestern Medical Center Dallas TX USA
| | - Gilbert Moralez
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
- Department of Applied Clinical Research University of Texas Southwestern Medical Center Dallas TX USA
| | - Matthew N. Cramer
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
| | - Joseph M. Hendrix
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
- Department of Anesthesiology University of Texas Southwestern Medical Center Dallas TX USA
| | - Frank A. Cimino
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
| | - Luke N. Belval
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
| | | | - Craig G. Crandall
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center Dallas TX USA
| |
Collapse
|