Faculty/Presenter Disclosure
Faculty: Bruce Mohr MD
No relationships with commercial interests
No financial support
No honorarium from CAEP
No “in-kind” support
LDK is Off-Label use of Ketamine (sub-anesthetic
dosing)
• summarize ED LDK research
• suggest when it might be most useful
• suggest when to avoid it
• how to use it
• provide some case examples
3
Objectives
PAINTodd KH, Ducharme J, et al. Pain in the Emergency Department: results of the pain and emergency medicine
initiative (PEMI) multi centre study J. Pain 2007;8460-6.
• Opioids most commonly used, Morphine especially
• Many different kinds of pain
• Many different kinds of patients
• Complex interplay of receptors - peripheral and central
• ED Docs are THE ACUTE PAIN SPECIALISTS
• “A Little Bit of This and a Little Bit of That”
• LDK is just another potential tool
Ketamine dosing
• Ketamine as induction agent 1-2 mg/kg
• Ketamine dissociative dose = >0.7 mg/kg
• Ketamine partially dissociative dose = 0.3-0.7 mg/kg
• Ketamine Recreational = 0.2-0.5 mg/kg
• Ketamine Subdissociative dose = 0.3 mg/kg
• Low-Dose Ketamine = 0.1 - 0.3 mg/kg
PSA
LDK (0.1-0.3 mg/kg) - Mechanism of Action as an Analgesic
• blockade of CNS N-methyl-D-aspartic acid (NMDA) postsynaptic receptors
• sensory association areas in cortex, limbic system and thalamus are
depressed (CNS effect)
• reduces neuronal hyperexcitability of spinal nociceptive neurons leading to
central sensitization and chronic pain states
• LDK augments the opioid presynaptic reduction in transmitter release from
afferent C fibres (pain-carrying fibres)
• blockade of PNS Na+ channels
• inhibits nitric oxide synthase (reduces NO levels which are involved in pain
perception in CNS and PNS)
•NMDAPNS
CNS
LDK - Pre-hospital and ED research
• less narcotics required when combined with LDK (5)
• ketamine 0.1-0.3 mg/kg safe and feasible in a diverse ED
population (6)
• sub-dissociative dose (0.3 mg/kg) comparable to morphine
0.1mg/kg in safety and effectiveness (7,8)
• useful in ED patients with high tolerance to narcotics (9)
• more rapid onset of pain control using LDK plus reduced dose IV
Hydromorphone (3)
• LDK has a morphine-sparing effect (11)
• better pain relief for LDK plus IV Morphine at 30, 60, 120 min (12)
LDK - (I used it as an adjunct to opiates,
propofol, benzodiazepines…”this and that”)
• Multi-traumas
• fractures/discos - ski boot removal,
“unpackaging”, reduction and
splinting/casting
• nasal fracture reduction
• severe sciatica/nerve pain
• flank/abdominal pain
LDK - suggested indications
• when more rapid relief of pain desired
• when opioids suboptimal or ineffective
• when want to minimize opioid use because of concerns
re: respiratory/CV depression
• Complex Regional Pain Syndrome, peripheral
neuropathic pain, spinal chord injury pain, lower limb
ischemic rest pain, chronic phantom limb pain (14)
LDK - mitigating side effects
• “LLD” 0.1 - 0.15 mg/kg
• kids are kool, with adults be kareful
• slow push or short infusion(13)
• the Art of patient suggestion
• adjunctive midazolam/ondansetron prn
• Caution!! Preparations: 10 mg/ml, 50 mg/ml, 100 mg/ml
• bedside monitoring (optional)
• precautions (exclusion criteria in some studies) with: elderly, active
coronary disease, unstable psychiatric disease*, serious co-morbidities
(liver, kidney)
References1.Todd KH, Ducharme J, et al. Pain in the Emergency Department: results of the pain and emergency medicine initiative (PEMI) multi
centre study J. Pain 2007;8460-6.
2.Galinski,M et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J Emerg
Med (2007) 25,385-390
3.Ahern,TL et al. Affective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J
Emerg Med (2013) 31 847-851
4.Aroni, Filippia et al. Pharmacolgical Aspects and Potential new Clinical Applications of 5.Ketamine: Reevaluation of an Old Drug. J
Clin Pharmacol 2009;49:957-964
5.Johansson et al. The effect of combined treatment with morphine sulphate and low-dose ketamine in a prehospital setting.
Scandinavian J of trauma, Resus and Emerg Medicine 2009, 17:61 doc:10.1 186/1757-7241-17-61
6.Terence L. et al, The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED.
Am J of Emerg Med 33 (2015) 197-201
7. Motov,S et al. Intravenous Subdissociative-dose Ketamine versus Morphine for analgesia in the ED: A randomized Controlled trial.
Annals of Emergency medicine volume 66, no 3: sep 2015 pp 222-229
8. Miller, J. et al. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J of Emerg Med 33
(2015) 402-408
9. Laeben L. et al. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J of Emerg med (2010) 28, 820-827
10. Chauny, JM the Simple Query “do you want more pain medication ?” is not a reliable way to assess acute pain relief in patients in
the ED. CJEM 2018;20(1):21-27 DOI 10.1017/cem.2017.2
11. Galinski,M et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J of
Emerg med (2007) 25, 385-390
12. Beaudoin, FL et al. Low-dose ketamine improves pain relief in patients receiving IV opioids for acute pain in the ED: results of a
randomized double-blind clinical trial. Acad Emerg Med 2014;21:1194-1202
13. Motov S. et al. A prospective randomized double-dummy trial comparing IV push LDK to short infusion ketamine for treatment of
pain in the ED
14. Visser, E. The role of ketamine in pain management. Biomed Pharmacother. 2996;60:341-348