As you know I'm a great Fan of Ketamine and currently I'm trying to overcome the big diffidence that surrounds this great medication in Italy!!!!
Just because I spoke a few time ago about Intranasal Medications I decided to search and go deeply inside the Intranasal use of Ketamine.....
Ketamine Intranasal has been studied in the civilian setting as a sedative agent for procedural sedation in childrens and in the military setting by the US Army as an analgesic for battlefield casualties.
1) Procedural sedation in childrens:
Several studies compared Intranasal Ketamine alone or in combination versus other sedatives for procedural sedation with the aim to perform dental procedures, CT scans etc. in childrens:
Summary (Source: look at References):
-Dosage: Ketamine IN 3-9 mg/Kg
-Fast onset time and fast recovery (7+7 min.)
-Good level of sedation (mean sedation score of 4 where 5 is ideal sedation)
-Very safe: Desaturation and respiratory depression occurred in very few cases
-Spray (Atomizer) better than drops: better patient compliance, faster onset of action and faster
recovery from sedation.
2)Analgesia for battlefield injured:
Use of Ketamine IN has been recently implemented by US Army as an alternative to IM Morphine or oral transmucosal fentanyl citrate (OTFC) for Analgesia in Battlefield casualties unable to continue to fight.
Summary ( source: PMI 100 Study):
-Dosage: Ketamine 50 mg intranasal (using nasal atomizer device) - 0,10 ml metered nasal spray (10 mg/spray) Titration up to 5 sprays - interval of 90 seconds between sprays ; Mean titrated Effective dose 43,5 - 46 mg Dosing every 3 hours as required 50 mg IN Ketamine are approximately equivalent to 7,5 mg Morphine IV
-Onset time: 4 min. post dose -Duration of action: 2,0 - 2,5 hours -Avverse effects: Few events reported;for the most modest in severity such as Dizziness, fatigue, nausea changes in vision, feeling of unreality. No allucinations were reported. - Use of Ketamine not allowed in TBI (Traumatic Brain Injuries) and Ocular Traumas.
To summarize: -Use of Ketamine Intranasal for procedural sedation and Analgesia is very promising. -Unfortunately there are still very few studies on this topic and populations took onto consideration are very small. -Use of Ketamine Intranasal for analgesia in adults has been studied just in the military setting (PMI 100 study); I couldn't find anything about the civilian setting. -I couldn't find any study showing statistical frequency of the main two adverse effects of Ketamine ( Laringospasm; Emergence reaction) after its Intranasal use for procedural sedation and Analgesia; In any case these are rare complications even after IV administration of Ketamine with Anaesthetic doses (1 - In two large trials conducted in emergency departments, the risk of laryngospasm in childrens, who are recognized to have a higher incidence of laryngospasm than adults, was 0.4
percent and 0.07 percent. 2- Emergence reaction has been showed to be uncommon and generally associated with higher (anesthetic) doses of Ketamine). Conclusion:
For now Intranasal use of Ketamine for procedural sedation and Analgesia is still OFF-LABEL therefore BE CAREFUL when you opt for this technique; More studies are needed in future; However all the studies available at present showed that Ketamine by Intranasal route of administration is an easy, fast and effective way to perform short sedations and to relieve pain. The future is very promising!!! ....As always have a good day on the edge....
Finally I MADE IT!!!!!!!!
I registered for SMACC 2013 in Sydney (Australia).....The best and most Innovative EM and Critical care Conference in the world.........
I'm going to post updates and pearls from the Conference via Twitter and on this Blog so from MARCH 11 to MARCH 13 stay tuned on this site or follow me on Twitter (@docvpb) and don't miss.... because the Revolution is just Began!!!!!!!!