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The Effectiveness of Intranasal Ketamine on Intramuscular Ketamine Injection Pain Among Children in the Emergency
Hadi Mirfazaelian1,2, Ali Salar Darafshi1, Mojtaba Sedaghat3
1Emergency Medicine Department, Tehran University of Medical Sciences.
Insights
Intranasal ketamine significantly reduced injection pain in children in the emergency department. However, potential adverse effects may limit its widespread use for pediatric pain management.
Area of Science:
- Pediatric Emergency Medicine
- Pain Management
- Pharmacology
Background:
- Children experience significant distress in the emergency department (ED), often due to pain.
- Parenteral ketamine, while effective for analgesia and sedation, causes injection pain and anxiety.
- Intranasal (IN) ketamine offers a potential alternative for analgesia, bypassing painful administration routes.
Purpose of the Study:
- To evaluate the efficacy of IN ketamine in reducing injection pain before intramuscular ketamine administration in children.
- To assess the safety and adverse effects associated with IN ketamine for pre-procedural analgesia.
Main Methods:
- A randomized, double-blind, placebo-controlled trial was conducted in the ED.
- Participants received either 1.5 mg/kg IN ketamine or sterile water placebo.
- Injection pain was measured using the FLACC scale; sedation time and adverse events were also recorded.
Main Results:
- IN ketamine significantly reduced median injection pain scores from 10 (placebo) to 1 (P <0.001).
- Sedation times were comparable between groups (80.9±33.6 min vs. 86.4±19.8 min, P=0.07).
- Adverse events included vomiting (16.7% vs. 4.2%) and transient hypoventilation (7%) in the IN ketamine group.
Conclusions:
- IN ketamine is effective in alleviating injection-related pain in pediatric ED patients.
- The observed adverse event profile, including vomiting and hypoventilation, may restrict its routine clinical application.
- Further research is needed to optimize the risk-benefit ratio for IN ketamine use in children.
Objective:
Children in the emergency department (ED) experience distress due to many factors, such as pain. Although ketamine has analgesic and sedative effects, its parenteral administration causes pain and anxiety. It is notable that ketamine can be administered intranasally for analgesia. We hypothesized that the administration of intranasal (IN) ketamine for analgesia before intramuscular ketamine injection would diminish the injection pain without any adverse effect.
Methods:
This study was a randomized, double-blind, placebo-controlled clinical trial conducted in the ED. The IN ketamine group received a dose of 1.5 mg/kg intranasally diluted to 1 mL, while the placebo group received 1 mL of sterile water. Injection pain was assessed using the FLACC scale (0 to 10), encompassing the face, leg, activity, cry, and consolability. Sedation time and adverse effects were also assessed.
Result:
Eighty-four patients were enrolled. While the median (IQR) injection pain score in the placebo group was 10 (10 to 10), it was 1 (0 to 5) in the intervention group ( P <0.001). The sedation time in the control group was 80.9±33.6 minutes and 86.4±19.8 in the intervention arm ( P= 0.07). After excluding intraoral procedures, 7 (16.7%) and 2 (4.2%) patients had vomiting in the intervention and placebo groups, respectively. In addition, 3 (7%) patients of the IN-ketamine group had hypoventilation that was resolved with simple airway maneuvers.
Conclusion:
Although IN ketamine demonstrated efficacy in reducing injection-related pain, its adverse event profile may limit its practicality in routine settings.
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