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Ketamine for Adult Patients who Have Suffered Painful and Traumatic Injuries: A Review of Clinical Effectiveness, Cost-Effectiveness, Safety and Guidelines

Last updated: March 6, 2014
Project Number: RC0528-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
Pain from traumatic injury can result in several adverse physiological effects. Therefore, it is important to manage acute pain before it causes respiratory, cardiovascular, and hemodynamic instability.

Technology
Ketamine, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, has sedative, anesthetic, and analgesic properties. The use of low-dose ketamine in the pre-hospital setting is gaining favour because it offers a profound analgesic effect while maintaining cardiovascular stability, spontaneous respiration, and protective airway reflexes.

Issue
There are concerns about the safety of ketamine for trauma patients, especially those with traumatic brain or eye injuries, because of its potential to worsen these injuries. It is unclear if such concerns extend to the use of ketamine for analgesia, where doses are generally lower. A review of the clinical effectiveness, safety, and cost-effectiveness of ketamine and guidelines for its use in adult patients who have experienced painful and traumatic brain or eye injury, the optimal dose and its safety in adults with moderate to severe pain from traumatic injury who are conscious, and its safety compared with fentanyl and morphine in this population will help inform the use of ketamine in trauma patients.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 443 citations, with 21 additional articles identified from other sources. After screening the abstracts, 44 were deemed potentially relevant, and 1 randomized controlled trial met the criteria for inclusion in this review.

Key Messages

  • For patients with head trauma, the analgesic effect of ketamine is similar to that of morphine.
  • No information on the clinical effectiveness and safety of ketamine in adult patients with painful and traumatic eye injuries was found.
  • No cost-effectiveness information or guidelines on ketamine in adult patients with painful and traumatic brain and eye injuries were found.
  • No information on the optimal dose of ketamine in adults with moderate to severe pain from traumatic injury who are conscious was found.
  • No information on the safety of low-dose ketamine compared with fentanyl and morphine for adults with moderate to severe pain from traumatic injury was found.

Question

  1. What are the clinical effectiveness and safety issues of ketamine for adult patients who have suffered painful and traumatic brain or eye injury?
  2. What is the optimal dose of ketamine (IV, IM, and intranasally) and the safety surrounding its use at this dose in adults with moderate to severe pain from traumatic injury who are conscious?
  3. What are the safety issues regarding the use of ketamine at low doses when compared to fentanyl and morphine for adults with moderate to severe pain from traumatic injury?
  4. What is the cost-effectiveness of using ketamine for adult patients who have suffered painful and traumatic brain or eye injury?
  5. What are the guidelines associated with the use of ketamine for adult patients who have suffered painful and traumatic brain or eye injury?

Key Message

One study failed to show a difference between ketamine and morphine for analgesic effect in a post hoc analysis of a subset of patients with head trauma. No published trials were identified examining the clinical effectiveness and safety of ketamine in adult patients who have suffered painful and traumatic eye injury. No published trials were identified examining the optimal dose of ketamine in adults with moderate to severe pain from traumatic injury who are conscious. No published trials were identified examining the safety of low dose ketamine as compared to fentanyl and morphine for adults with moderate to severe pain from traumatic injury. No economic evaluations or evidence-based guidelines regarding the use of ketamine in adult patients who have suffered painful and traumatic brain and eye injuries were identified.