Low-dose ketamine vs morphine for

acute pain in the ED: a randomized

controlled triaL
Joshua P. Miller, Steven G. Schauer, Victoria J. Ganem, Vikhyat S. Bebarta
Published on Maret 1, 2015; Open Access Journal Oktober 2018

Presented by
Fahreza Achmad F
Opioids, commonly morphine, are the standard treatment of moderate and severe, acute
pain in the ED. However, many patients report inadequate pain control in the ED

In addition, the serious adverse effect profile of opioids can be underappreciated given their
common use in the ED. In 2012, the Joint Commission release da Sentinel Event Alert, which
state dt hatopioid analgesics rank among the drugs most frequently associated with adverse
drug events.
 Ketamine, however, has a very large therapeutic window. Overdoses
from 5 to 100 times the therapeutic dose have been reported without
adverse outcomes. In addition, the adverse effect profile of ketamine
(elevated pulse and blood pressure, hallucinations, emergence) is much
different from that of opioids (decreased pulse, blood pressure, and
respiratory rate, sedation).

Ketamine has been a dissociative agent (1,5-2mg/kg intravenous) but

low dose (<0,55 mg/kg IV) was reported as analgesia without dissociation

Safe and efficacious analgesia

 The goal of this study was to compare the ability of low-dose ketamine and morphine to
reduce acute pain as measured by the numeric rating scale (NRS). In addition, we describe
the details of ketamine analgesia over time in an ED population. Finally, it also sought to
examine the reduction of pain as measured by provider and nurse satisfaction scores
 METHODS

Study design • Our study was a prospective,randomized,controlled,double-blinded,

and setting
superiority trial comparing the efficacy of IV low-dose ketamine to
IV morphine for moderate to severe acute pain in the ED setting.

Settings • The study was conducted in a military, level 1 trauma center ED,
where approximately 80000 ED patients are treated annually.
 • NRS pain scale
• Richmond Agitation-Sedation Scale
Measures •
•
Vital Signs
Adverse effect
• Repeating dose

Data Analysis • Estimated group SDs of 2 for a 2-sided test with a

significance level alfa of .05
 RESULTS

 45 patients were enrolled (mean age 30 ± 1 years).

 Demographic baseline and variables NRS score was similar (7,1)
 29 (51.1%) of the patients were in the morphine group and 431(48.9%) in the low dose
ketamine group and 30 patients both treatment group.
 The maximum change in NRS pain score from baseline, low dose ketamine was 4.9. The
maximum change in morphine group was 5.
 The NRS scores as a percentage change from baseline between 2 group that morphine group
was a steady trend of reduced pain over time.
 Second dose was administered in 38% patients in morphine group and 54% in low dose
ketamine group. A third dose was requested for 14% of the morphine and 25 % patients
ketamine group.
 Systolic blood pressure was differences but no differences in diastolic blood pressure, heart
rate, respiratory rate or oxygen saturations.
 Adverse effect was found on 58% patients in low ketamine group and 12 patients in
morphine group.

Low dose ketamine Morphine

Nausea, Hallucinations Dysphoria Nausea

Dizziness Vomiting, numbness Headache
Vomiting, lightheaded, decreased sauration

 The median provider satisfaction was 4 for low dose ketamine group same
with morphin
 DISCUSSION

 Low dose ketamine was not superior to morphine in the maximum change of NRS pain score from baseline
 The maximum reduction in pain scores for low-dose ketamine was seen immediately after the infusion was
complete and was sustained for only 5 to 10 minutes. In the morphine group, a similar maximum reduction in
pain scores was reached 100 minutes after the infusion was complete
 Short duration contribute to increased rate of repeat dosing in ketamine (54%)
 Despite the inability of low-dose ketamine to sustain its maximum analgesic effect, there was greater than
50% reduction in pain scores for 2 hours at all interval.
 Vital signs were similar as well, although there were statistically significant differences in systolic and
diastolic blood pressure between the groups. These differences were secondary to both decreases in blood
pressure in the morphine group and increases in blood pressure in the low-dose ketamine group
 Limitation
 Only ≈20% of the ED patients are uniformed active military service members.
Most of the patients are civilians who have similar demographic
characteristics compared with other civilian EDs at a level 1 trauma and
tertiary care centers. In addition,the generalizability of our results may be
limited, asour data were collected from a single medical center.
 Small sample size
 The analgesic dose of ketamine is not standardized
 Measure of sedation and agitations has not been validated
 Serume levels of the drug not obtained
 CONCLUSION

However, these 2
In ED patients with acute, medications produced
moderate-severe pain, similar adverse effects, as
low-dose ketamine did well as provider and
not provide a superior nurse satisfaction scores.
maximum reduction in In addition, low-dose
NRS pain scores compared ketamine induced
with morphine. analgesic effects within 5
minutes of infusionand
provided amoderate
reductionin pain for 2
hours.
TERIMA KASIH