Saturday, January 19, 2013

...More on Intranasal Ketamine....

Hi Guys!!!

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....



References:
US Army slide show on IN Ketamine
US Army Intranasal Ketamine protocol
Safety and effectiveness of intranasal administration of sedative medications (ketamine, midazolam, or sufentanil) for urgent brief pediatric dental procedures.
Case report: prehospital use of intranasal ketamine for paediatric burn injury.
Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal and intranasal administration.
intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report.
A comparative evaluation of drops versus atomized administration of intranasal ketamine for the procedural sedation of young uncooperative pediatric dental patients: a prospective crossover trial.
Nasal midazolam and ketamine for paediatric sedation during computerised tomography.









             

3 comments:

  1. Hey!

    Thanks for the great post.

    I'm interested in the rationale of the dosing in this study. Do you have a link to it? Or an abstract??

    I have no experience using IN ketamine but am quite interested in the concept. I note that many of the other FOAM resources that I have read about suggest a substantially higher dose. See:

    http://smacc.net.au/2013/01/everybody-has-a-nose-the-intranasal-way-emergency-medicine-for-registrarsresidents/

    http://stemlynsblog.org/2012/11/intranasal-ketamine-mum-nose-best-at-st-emlyns/

    http://prehospitalmed.com/2012/12/30/ketamine-for-primary-care-providers-in-remote-medicine/

    Thanks!

    Brent Thoma @boringem

    ReplyDelete
    Replies
    1. Hi Brent!!!
      Thanks for your comment, is very welcome!!!....
      Here the answer to your question:
      The aim of Military medics in treatment of combat casualties is Analgesia not sedation so the dosage of IN Ketamine is sensibly lower (0,5-1,0 mg/Kg) instead of the dosage used for example in childrens (for procedural sedation) that can reach even 9 mg/Kg... furthermore the Military study PMI100 searched for the minimum dose of IN Ketamine able to give enough pain control without giving cognitive impairment aiming to preserve combat abilities of the casualty... I found this study on the US Defence Department of Health website but unfortunately I could find just the Powerpoint presentation and not the full article !!!
      Thanks again and have a good day on the Edge!!!!!!!!

      Delete
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