EFFECTS OF INTRANASAL KETAMINE VS FENTANYL ON PAIN REDUCTION FOR EXTREMITY INJURIES IN CHILDREN

Frey TM, Caruso M, Zhang N, Zhang Y, Mittiga MR. JAMA Pediatrics 2018. doi:10.1001/jamapediatrics.2018.

This prospective, double-blind, randomized clinical trial sought to compare intranasal ketamine with intranasal fentanyl for pain reduction in a tertiary children's emergency department for children presenting with an extremity injury. The authors state that pain continues to be underdiagnosed and undertreated, especially in children. Furthermore, they also state that there may be a delay in children obtaining pain medication owing to the need and time to obtain intravenous access. Some children may have a genetic predisposition to diminished opioid sensitivity or an opioid allergy, and there are potential serious adverse effects with opioids.

Inclusion criteria included the following: age 8 to 17 years, acute extremity injury, visual analog scale score (VAS) higher than 35 mm (moderate to severe pain), and legal guardian presence. Exclusion criteria included the following: injury to the head, chest, abdomen, or spine; Glasgow Coma Scale score lower than 15; nasal trauma; history of psychosis, ketamine, or fentanyl allergy; and opioid administration before arrival. Of the children enrolled (n = 90), 45 received ketamine and 45 received fentanyl. The primary outcome was the reduction in VAS score 30 minutes after pain mediation administration.

The researchers found that ketamine provided effective analgesia that is noninferior to fentanyl. They also found that ketamine had an increase in adverse side effects that were minor and transient. The found that intranasal ketamine may be an appropriate alternative to intranasal fentanyl.