Written by Megan Hilbert
Nebulized ketamine may be the newest way to treat both acute and chronic pain in the Emergency Department.
Why does this matter?
The management of pain is a constant battle in the ED, and the provider has many factors to take into account when selecting analgesic medication. With nebulized ketamine, the provider may be able to achieve clinically meaningful reduction in pain while decreasing side effects seen with intravenous ketamine administration, avoiding the unpleasant intranasal route, and bypassing opioids all together.
All you need is Neb
This was a randomized, double-blind superiority trial comparing 3 doses (0.75mg/kg, 1mg/kg, 1.5mg/kg) of breath-actuated nebulized ketamine for the management of acute and chronic pain. Quick background: breath-actuated nebulized ketamine has 20-40% of the bioavailability as compared to IV route with a duration of 20-40 minutes.
The primary outcome was difference in pain scores measured at 30 minutes. And while all doses demonstrated clinically significant pain reduction, there was no additional benefit to the higher doses. To add context to their secondary outcomes (adverse events and need for rescue analgesia), the authors compared these data to their prior studies on IV ketamine and morphine (things that we in the ED are much more comfortable with). Clinical pain reductions were on par with the degree of pain relief seen with IV ketamine and morphine. Adding even more to the appeal, the authors point to a reduction in adverse effects and less need for rescue analgesia.
While several limitations exist to the broad application of this route of administration of ketamine – both with availability of the equipment and need for patient education – the results are pretty groovy.
Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med. 2021 Dec;78(6):779-787. doi: 10.1016/j.annemergmed.2021.04.031. Epub 2021 Jul 3.