Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial. J Trauma Acute Care Surg 2019 Nov;87(5):1181-1188
Date
08/20/2019Pubmed ID
31425468DOI
10.1097/TA.0000000000002479Scopus ID
2-s2.0-85074184716 (requires institutional sign-in at Scopus site) 19 CitationsAbstract
BACKGROUND: Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population.
METHODS: A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 μg·kg·min or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events.
RESULTS: Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted.
CONCLUSION: Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients.
LEVEL OF EVIDENCE: Therapeutic, level I.
Author List
Kugler NW, Carver TW, Juul J, Peppard WJ, Boyle K, Drescher KM, Szabo A, Rein L, Somberg LB, Paul JSAuthors
Thomas W. Carver MD Associate Professor in the Surgery department at Medical College of WisconsinKarin E. Drescher MD Adjunct Associate Professor in the Anesthesiology department at Medical College of Wisconsin
Nathan W. Kugler MD Assistant Professor in the Surgery department at Medical College of Wisconsin
William J. Peppard PharmD Trauma/Surgical Critical Care Pharmacist in the Pharmacy department at Froedtert Hospital
Lisa E. Rein Biostatistician III in the Institute for Health and Equity department at Medical College of Wisconsin
Aniko Szabo PhD Professor in the Institute for Health and Equity department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
Acute PainAge Factors
Aged
Aged, 80 and over
Analgesics
Dose-Response Relationship, Drug
Double-Blind Method
Female
Glasgow Coma Scale
Humans
Infusions, Intravenous
Injury Severity Score
Ketamine
Male
Pain Management
Pain Measurement
Prospective Studies
Rib Fractures
Treatment Outcome
