Can A Registered Nurse In Tennessee Push Ketamine Ivp

April x, 2017

Low-Dose Ketamine for Astute Pain in the ED: Four Push vs Brusque Infusion?

Written by Salim Rezaie
Insubordinate EM
Medical Category: Procedures and Skills

Background: Ketamine's function in the ED has expanded in recent years. The clinical reasons for this get in easy to understand why, and include analgesia, amnesia, and anesthesia. Amazingly, ketamine does not merely reduce acute pain, just information technology also decreases persistent chronic and neuropathic pain as well. More chiefly, use of low-dose ketamine (0.i – 0.3 mg/kg Four) has been demonstrated to be opioid sparing. Some of the major problems with IV push low-dose ketamine include its adverse effects, such as feelings of unreality, nausea/vomiting, and dizziness. Many emergency medical providers have anecdotally noticed a decrease in agin effects when ketamine is given slowly. In the paper nosotros are reviewing today, the authors tried to see if increasing the elapsing of the ketamine from IV push button (3 – five min) to a slow infusion (10 – 15 min) could mitigate some of these effects, while maintaining analgesic efficacy.

What They Did:

Randomized patients presenting to the ED with astute abdominal, flank, or musculoskeletal pain with an initial pain score of ≥5 to: Ketamine 0.3mg/kg by either IV Push (over 5min) or Brusque Infusion (0.3mg/kg mixed in 100mL normal saline solution over 15min) with Placebo Double-Dummy (both groups got an iv push button, and an infusion).

Outcomes:

Principal Result: Safety Efficacy at 5, xv, thirty, 60, 90, and 120 min post administration
- Side Effects Rating Scale of Dissociative Anesthetics (SERSDA): Measures the severity of 9 adverse furnishings with a score of 0 – 4 for each agin effect. 0 = side effects absent and 4 = agin effect is bothersome
- Richmond Agitation-Sedation Scale (RASS): A score of -four.0 – 4.0 with -4 = deeply sedated, 0 = alarm and calm, and four = combative
Secondary Outcomes:
- Analgesic Efficacy via Numerical Pain Rating Scale (NRS): A score of 0 – 10
- Changes in Vital Signs
- Need for Rescue Analgesia

Inclusion:

Adults 18 – 65 years of age presenting to the ED
Primary complaint for management of acute abdominal, flank, back, traumatic chest or musculoskeletal pain
Intensity of pain ≥5 on the Numeric Pain Rating Scale
Able to Consent

Exclusion:

Pregnancy
Breast Feeding
Altered Mental Status
Allergy to Ketamine
Weight <46kg or >115kg
Unstable vital signs (SBP <90 or >180mmHg, Pulse charge per unit <50 or >150bpm, and RR <10 or >xxx BPM)
Medical history of astute head or heart injury
Seizure
Intracranial hypertension
Renal or hepatic insufficiency
Alcohol or drug abuse
Psychiatric Illness
Contempo (4h earlier) analgesic apply

Results:

48 patients enrolled in the study

Median Severity of Feeling of Unreality on SERDSA at 5 min
- IVP: 3.0
- SI: 0.0
- P=0.001
Median RASS Scale at 5 min
- IVP -two.0
- SI: 0.0
- P = 0.01
Decrease in Hateful Pain Scores from Baseline to 15 min
- IVP: 5.2 +/- 3.53
- SI: 5.75 +/- 3.48
No Statistical Differences with Respect to Changes in Vital Signs and Need for Rescue Medication
At that place was no statistical difference on the SERSDA calibration for 8 of the variables measured: headache, fatigue, dizziness, hearing, vision, mood alter, discomfort, hallucination.

Strengths:

Double dummy design: All participants received a corresponding placebo in order to keep patients and providers blinded
Dummy Iv push or Slow infusion given simultaneously to maintain blinding
Treating providers, patients and the data collecting research squad blinded to medication route received
No difference in baseline pain

Limitations:

Convenience Sample: Patients not enrolled consecutively (Only Monday – Friday 8a – 8p)
Single center report
Small sample size did not allow for assessment of variance in safety profiles of the ii routes of administration (i.e. statistical significance) or for possible differences in the other SERSDA assessed agin furnishings.

Word:

If patients required additional pain medication thirty min after study drug administration, 0.1mg/kg 4 morphine was offered equally a rescue analgesic.
Several studies have shown a correlation to side effects of low-dose ketamine with rapid rates of infusion. The pharmacologic reason for this is ketamine's lipophilicity allows for rapid penetration of the blood-brain barrier and rapid saturation of the NMDA/glutamate receptors.
Excluded head / eye injured patients despite ample evidence that ketamine is condom in these populations.
The authors note that in their establishment a xv min infusion is billed the same as an Four push.
1 effect with slow infusion would be the availability of an infusion pump, however the authors discuss hanging the infusion, and running over approximately 15 min, without using an infusion pump. This saves time setting up the pump, and saves the issue of running out of pumps. Nosotros emailed the atomic number 82 author Sergey Motov about this and his response was as follows:

"In my ED, we do not routinely use an IV infusion pump for a short infusion of SDK. After half-dozen years of doing and then we have had no major adverse effects. Our nurses and ED pharmacists are very comfy with a no pump approach by adjusting the flow rate to a 15 min fourth dimension frame. Furthermore, we cap the max dose at 30 mg fifty-fifty if patient'south weight exceeds 100 kg which adds additional safety/comfort to our staff. This only applies to short infusion. For continuous drips we use IV infusion pumps. "

Author Decision: "Low-dose ketamine given as a short infusion is associated with significantly lower rates of feeling of unreality and sedation with no difference in analgesic efficacy in comparison to intravenous push."

Clinical Take Domicile Bespeak: Low dose ketamine of 0.3mg/kg, mixed into 100mL of Normal Saline given over slow infusion (15 minutes) has a decreased side effect (i.e hallucinations or dizziness) and equal analgesic profile when compared to IV push (five minutes) low dose ketamine.

References:

Motov Due south et al. A Prospective Randomized, Double-Dummy Trial Comparison Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – seven. PMID: 28283340

For More Thoughts on This Topic Checkout:

Bryan Hayes at The PharmERToxGuy: How to Administer Low-Dose IV Ketamine for Pain in the ED
Ken Milne at The SGEM: SGEM #198 – Better Slow Downwardly – Push vs Short Infusion of Depression Dose Ketamine for Hurting in the Emergency Section

Mail Peer Reviewed Past: Rob Bryant (Twitter: RobJBryant13)

The following 2 tabs alter content below.

Bio
Latest Posts

Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)

Creator & Founder of Insubordinate EM

Low-Dose Ketamine

Desire to support rebelem?