Low Dose Ketamine Versus Morphine for Moderate to Severe Pain in the Emergency Department
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|ClinicalTrials.gov Identifier: NCT01835262|
Recruitment Status : Completed
First Posted : April 18, 2013
Results First Posted : August 27, 2015
Last Update Posted : February 29, 2016
|First Submitted Date ICMJE||April 12, 2013|
|First Posted Date ICMJE||April 18, 2013|
|Results First Submitted Date ICMJE||July 29, 2015|
|Results First Posted Date ICMJE||August 27, 2015|
|Last Update Posted Date||February 29, 2016|
|Study Start Date ICMJE||April 2013|
|Actual Primary Completion Date||May 2014 (Final data collection date for primary outcome measure)|
|Current Primary Outcome Measures ICMJE
||Numeric Rating Scale of Pain [ Time Frame: 30 minutes ]
We will compare efficacy as a difference between 2 groups in pain score at 30 minutes post-analgesic administration. The primary outcome is the difference between 2 groups in pain score at 30 minutes. Pain will be measured via Numeric rating scale from 0 to 10 with 0 being no pain, 5 being moderate pain, and 10 being severe pain
|Original Primary Outcome Measures ICMJE
||Pain Relief [ Time Frame: 120 minutes ]
We will compare efficacy as a difference between 2 groups in pain relief from the baseline (at triage) to 30 minutes post-analgesic administration. The primary outcome is the difference between 2 groups in pain relief at 30 minutes. Pain will be measured via likert scale from 0 to 10 with 0 being no pain, 5 being moderate pain, and 10 being worst possible pain.
|Current Secondary Outcome Measures ICMJE||Not Provided|
|Original Secondary Outcome Measures ICMJE
||Rescue analgesia [ Time Frame: 60 minutes ]
The secondary outcome is the need for rescue analgesia at 30 or 60 min - intravenous fentanyl at 1mcg/kg. The pharmacist will document in the data collection sheet whether or not the rescue analgesia was given and at what time it was given to the study patient.
|Current Other Pre-specified Outcome Measures||Not Provided|
|Original Other Pre-specified Outcome Measures||Not Provided|
|Brief Title ICMJE||Low Dose Ketamine Versus Morphine for Moderate to Severe Pain in the Emergency Department|
|Official Title ICMJE||Low Dose Ketamine Versus Morphine for Moderate to Severe Pain in the Emergency Department: A Prospective, Randomized, Double-Blind Study|
|Brief Summary||The primary objectives of the study are to evaluate the efficacy of subdissociative dose intravenous ketamine compared with intravenous morphine in relieving acute pain in the ED. Secondary objectives will include the rate of adverse effects and need for rescue analgesia. The hypothesis is that intravenous administration of subdissociative dose ketamine at 0.3 mg/kg is superior to intravenous morphine at 0.1mg/kg in treating moderate and severe acute pain in patients presenting to the ED.|
Rationale: Opioids are traditionally accepted as a cornerstone of acute pain management in the Emergency Department (ED). Morphine is one of the most commonly used parenteral opioid analgesics whose initial dose of 0.1 mg/kg has been extensively researched and recommended for control of severe acute pain in the ED. However, intravenous administration of opioids is associated with thefollowing side effects: hypotension, respiratory depression, dizziness, pruritis and nausea. In addition, in patients with pre-existing renal and/or hepatic insufficiency, these effects may be pronounced and require interventions. Thus, the administration of an equipotent analgesic that does not cause hypotension and respiratory depression would enhance patient safety in the ED.
Ketamine is a noncompetitive N-methyl D-aspartate (NMDA) receptor antagonist that blocks the release of excitatory neurotransmitter glutamate and provides anesthesia, amnesia and analgesia by virtue of decreasing central sensitization and "wind-up" phenomenon. Due to its high lipid solubility, ketamine rapidly crosses the blood-brain barrier, provides rapid onset of action (peak concentration at is reached 1 minute after IVP) and rapid recovery to baseline (duration of action 5-15 minutes after IVP) (1). When given at subdissociative doses of 0.1-0.5 mg/kg, either as an adjunct to opioid analgesic or as a solo agent, ketamine provides good analgesia while preserving airway patency, ventilation, and cardiovascular stability (2). In addition, a small dose of ketamine may increase the analgesic potency of opioids thus decreasing their dosing requirements (3). Based on the aforementioned facts, ketamine offers an attractive option for providing safe and convenient pain control for patients in the ED.
A double-blind trial of 40 adult patients with acute musculoskeletal trauma compared low-dose ketamine administered by subcutaneous infusion (0.1 mg/kg/h) with intermittent intravenous morphine (0.1 mg/kg IV every 4 hours ) and demonstrated better pain relief, less sedation and less nausea and vomiting with ketamine infusion than with intermittent morphine. In addition, none of the patients in the ketamine group required supplementary analgesia (4). A prospective, randomized trial compared two analgesic regimens, morphine with ketamine (K group) or morphine with placebo (P group) for severe acute pain in 73 trauma patients with a visual analog scale (VAS) score of at least 60/100. Morphine was administered at 0.1mg/kg; patients in the K group received 0.2 mg/kg of intravenous ketamine over 10 minutes while patients in the P group received isotonic sodium chloride solution. The results showed comparable change in VAS score at 30 minutes (34 mm (K) vs. 39 mm (P)) but reduced morphine consumption in the ketamine group (0.14 mg/kg (K) vs 0.2 mg/kg (P)) (5).
A chart review analysis of 35 ED patients receiving low dose ketamine at doses 0.1mg-0.6mg/kg in addition to intravenous morphine demonstrated a decrease in pain intensity for 54% of the patients by a documented 3 point pain decrease on a 10-point scale. The ketamine doses ranged from 5 mg to 35 mg with median dose of 10 mg and mean dose of 15.7mg. In addition, only one patient had a brief dysphoric reaction that did not require intervention (6).
Hypothesis: Intravenous administration of subdissociative dose ketamine at 0.3 mg/kg is superior to intravenous morphine at 0.1 mg/kg in treating moderate and severe acute pain in patients presenting to the ED.
Methods: Prospective, randomized, double-blind trial evaluating and comparing analgesic effect of intravenous Ketamine administered in sub-dissociative doses: 0.3 mg/kg given over 10 minutes with intravenous Morphine given at 0.1mg/kg as a single IVP.
Description: Once patient is triaged, an initial pain score will be assessed and patient's stated weight will be recorded in the chart. Patients will then have an initial evaluation by an attending ED physician and once found to be eligible for the study (deemed by treating physician to warrant administration of intravenous analgesia) patient will be randomized to receive either morphine at 0.1 mg /kg given as IVP or ketamine at 0.3 mg/given as IVP. Patients' vital signs will be recorded at triage, at the beginning of the study and at 15, 30, 60, 90, 120 minutes post-administration. Patients will be placed on a monitor and continuous pulse oximetry (oxygen saturation), blood pressure, heart rate and respiratory rate will be recorded. We will compare efficacy as a difference between 2 groups in pain relief from the baseline (at triage) to 30 minutes post-analgesic administration. The primary outcome is the difference between 2 groups in pain relief at 30 minutes. The secondary outcome is side effects. We will compare the safety profile of each analgesic with respect to incidence of hypotension, respiratory depression, nausea and vomiting, pruritis, need for an opioid reversal agent (naloxone), tachycardia, laryngospasm, hypersalivation, dizziness, agitation and need for benzodiazepines (midazolam) administration for symptomatic evidence of emergence reaction. All the data will be entered and analyzed via SPSS. Data analyses will include frequency distributions, and ANOVA to assess a difference in pain scores between the groups at various time points. All patients will be analyzed with an intent to treat analysis. However, a subgroup analysis will be done for any emergence reaction or event which occurs often.
|Study Type ICMJE||Interventional|
|Study Phase ICMJE||Phase 4|
|Study Design ICMJE||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
|Study Arms ICMJE||
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Status ICMJE||Completed|
|Actual Enrollment ICMJE
|Original Estimated Enrollment ICMJE
|Actual Study Completion Date ICMJE||May 2014|
|Actual Primary Completion Date||May 2014 (Final data collection date for primary outcome measure)|
|Eligibility Criteria ICMJE||
|Ages ICMJE||18 Years to 55 Years (Adult)|
|Accepts Healthy Volunteers ICMJE||Yes|
|Contacts ICMJE||Contact information is only displayed when the study is recruiting subjects|
|Listed Location Countries ICMJE||United States|
|Removed Location Countries|
|NCT Number ICMJE||NCT01835262|
|Other Study ID Numbers ICMJE||12/09/VA01
12-09-VA01 ( Other Identifier: Maimonides Medical Center IRB )
|Has Data Monitoring Committee||No|
|U.S. FDA-regulated Product||Not Provided|
|IPD Sharing Statement ICMJE||
|Current Responsible Party||Antonios Likourezos, Maimonides Medical Center|
|Original Responsible Party||Same as current|
|Current Study Sponsor ICMJE||Antonios Likourezos|
|Original Study Sponsor ICMJE||Same as current|
|Collaborators ICMJE||Not Provided|
|PRS Account||Maimonides Medical Center|
|Verification Date||October 2015|
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP