Today I am joined by a good friend Sergey Motov, MD. Sergey is an EM doc with a particular interest in pain management in the ED. Sergey recently, as part of a approved study, ran an entire ED shift without a single administration of an opioid for pain. Can it be done?
The Pain-Free ED
Sergey has an amazing site, with resources and lectures: The Pain-Free ED
The Concept and Rationale of an Opioid-Free ED: Why do we need alternative to opioids in the ED?
No consensus on optimum opioid doses (weight-based, fixed, nurse initiated?)
- http://www.ncbi.nlm.nih.gov/pubmed/24210367
- http://www.ncbi.nlm.nih.gov/pubmed/23264318
- http://www.ncbi.nlm.nih.gov/pubmed/20825766
- http://www.ncbi.nlm.nih.gov/pubmed/16898939
Poor titration practices
Overdosing hydromorphone/ under-dosing morphine
Severe side effects ( especially geriatric patients)
Begetting Addiction
Regulatory concerns of prescribing opioids.
Concept of Multimodal Receptor/Channel Targeted Analgesia (RCTA)
Cox Inhibition
COX 1-2 – NSAIDS ( renal colic, back pain; by honoring “Analgesic Ceiling” concept)
COX 2 -Cox 3 – Acetaminophen (as well as TRPV1( capsaicin receprots) , cannabis, endogenous opioids)
- http://shortcoatsinem.blogspot.com/2012/03/iv-acetaminophen-all-rage.html
- http://www.anesthesiologynews.com/download/SR122_WM.pdf
- http://emj.bmj.com/content/early/2011/02/28/emj.2010.104687
- http://www.beat-journal.com/BEATJournal/index.php/BEAT/article/view/45
- http://www.ncbi.nlm.nih.gov/pubmed/25197573
- http://www.ncbi.nlm.nih.gov/pubmed/24381620
- http://www.ncbi.nlm.nih.gov/pubmed/22186009
NMDA antagonism- ketamine ( IV push, drip, continuous infusion as adjunct to opioids or single agents)
- http://www.ncbi.nlm.nih.gov/pubmed/25197290
- http://www.ncbi.nlm.nih.gov/pubmed/23602757
- http://www.ncbi.nlm.nih.gov/pubmed/23159425
- http://www.ncbi.nlm.nih.gov/pubmed/23041484
- http://www.ncbi.nlm.nih.gov/pubmed/20837262
- Update: Sergey just published a comparison of 0.3 mg/kg to good dose of morphine and ketamine was at least as good.
GABA receptors-propofol ( intractable migraine headache), partially gabapentin
- http://www.ncbi.nlm.nih.gov/pubmed/?term=propofol+for+migraine+in+the+ED
- http://www.ncbi.nlm.nih.gov/pubmed/25040321
- http://www.ncbi.nlm.nih.gov/pubmed/24381692
- http://www.ncbi.nlm.nih.gov/pubmed/23187986
- http://www.ncbi.nlm.nih.gov/pubmed/10759925
Alpha-2 Central Agonists-clonidine, dexmedetomidine
- http://www.ncbi.nlm.nih.gov/m/pubmed/23706726/
- http://f1000.com/prime/reports/m/2/90/
- http://www.pedsanesthesia.org/meetings/2006annual/syllabus/NewerModalitiesforPainManagement-McClain.pdf
- http://link.springer.com/article/10.1007%2FBF01712245
Central calcium receptors- gabapentin, pregabalin
- http://www.ncbi.nlm.nih.gov/pubmed/25411680
- http://www.ncbi.nlm.nih.gov/pubmed/22786518
- http://www.ncbi.nlm.nih.gov/pubmed/21412914
- http://www.ncbi.nlm.nih.gov/pubmed/19588419
Sodium Channel Blockade-lidocaine, bupivacaine
Local Anesthetic
Topical, myofascial blocks, trigger point injections, paravertebral/paracervical/occipital blocks
Intraarticular Injections
- http://www.ncbi.nlm.nih.gov/pubmed/10530535
- http://www.ncbi.nlm.nih.gov/pubmed/21491392
- http://www.ncbi.nlm.nih.gov/pubmed/25066879
- http://www.ncbi.nlm.nih.gov/pubmed/22436475
- http://www.ncbi.nlm.nih.gov/pubmed/18783486
US guided-regional anesthesia
- http://www.ncbi.nlm.nih.gov/pubmed/21883635
- http://www.ncbi.nlm.nih.gov/pubmed/18606327
- http://www.ncbi.nlm.nih.gov/pubmed/22030184
- http://www.ncbi.nlm.nih.gov/pubmed/17499669
- http://www.ncbi.nlm.nih.gov/pubmed/?term=Liebmann+O%2C+2006
- http://www.ncbi.nlm.nih.gov/pubmed/?term=Wathen+JE%2C+2007
- http://www.ncbi.nlm.nih.gov/pubmed/24343768
- http://www.ncbi.nlm.nih.gov/pubmed/23758305
- http://www.ncbi.nlm.nih.gov/pubmed/22494596
- http://www.ncbi.nlm.nih.gov/pubmed/21570238
Systemic IV lidocaine
- http://www.ncbi.nlm.nih.gov/pubmed/25147364
- http://www.ncbi.nlm.nih.gov/pubmed/24768290
- http://www.ncbi.nlm.nih.gov/pubmed/24660158
- http://www.ncbi.nlm.nih.gov/pubmed/22559856
Nitrous oxide
Poorly understood as to what receptor it hits–NMDA??
- http://m.jems.com/article/patient-care/using-nitrous-oxide-manage-pain
- http://m.emj.bmj.com/content/20/3/214.full
- http://www.ncbi.nlm.nih.gov/pubmed/7224273
- http://www.ncbi.nlm.nih.gov/pubmed/16299211
- http://www.ncbi.nlm.nih.gov/pubmed/16966390
- http://www.ncbi.nlm.nih.gov/pubmed/3056711
- http://www.ncbi.nlm.nih.gov/pubmed/22151676
Practical considerations
- Dual/triple analgesic combinations
- Different classes of analgesic agents with unique pharmacologic and physiologic actions provide synergistic analgesia
- Smaller doses of each agent result in decrease potential for drug-related adverse events
- Less sedation, early ambulation, and decreased LOS in the ED by non-opioid analgesia.
- Intravenous /intranasal/ subcutaneous routes
- Transdermal route to go home with (e.g. lidocaine/clonidine patches)
- Major contribution from Regional Anesthesia/Analgesia
- IV drips in the ED (2-6h) of ketamine/Lidocaine/Dexmedetomidine
- Overall patient satisfaction
Future research
- Creation of solid analgesic algorithms as an alternative to opioid analgesia in the ED
- Role of compounded pharmaceuticals (creams/ointments) in acute pain management.
- Cannabis for ED pain management
- Liposomal Bupivacaine
- Transdermal PCAs of any of the above meds
Opioid-Free Shift in the ED Suggested Protocols
The rational of an opioid–free shift in the ED is to evaluate the feasibility of controlling acute painful conditions without oral and parenteral opioid analgesics by using alternative multimodal pain –mediated receptors/channels targeted analgesia(RCTA) as initial treatment modalities. All patients to be eligible for rescue opioid analgesia (morphine, fentanyl, hydromorphone) at 20 min if pain is still severe enough and warrants parenteral analgesia.
Combinations of two or even three medications might be warranted:
Abdominal pain (renal colic)
- IV Ketorolac-10-15 mg IVP (or Ibuprofen 400 mg if they can take PO)
- IV Acetaminophen-1g over 15 min
- IV Lidocaine -1.5 mg/kg of 2% Lidocaine (cardiac) over 10-15 min
Abdominal Pain (non-traumatic)
- IV Ketorolac-10-15 mg IVP (or Ibuprofen 400 mg if they can take PO)
- IV Acetaminophen-1g over 15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
Abdominal Pain (traumatic)
- IV Acetaminophen-1 g over 15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
Back pain (oral meds)
- Ibuprofen-400-800 mg
- Acetaminophen -1000mg
- Methocarbamol 500 mg-1500 mg
- Diazepam-5 mg
Update: Listener and ED Intensivist, Kit Tainter, also recommends Tizanidine
Back Pain (parenteral)
- IV Ketorolac 10-15 mg (or Ibuprofen 400 mg if they can take PO)
- IV Acetaminophen-1 g over 15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
- IV Lidocaine -1.5 mg/kg of 2% Lidocaine( cardiac) over 10-15 min
- IV Clonidine-0.3-2 mcg/kg/hr drip
Headache
- IV Metoclopramide -10 mg
- IV Diphenhydramine-25-50 mg
- IV Prochlorperazine-10mg
- IV Ketorolac-10-15 mg (or Ibuprofen 400 mg if they can take PO)
- SQ Sumatriptan (migraine)-6mg
- IV Propofol (intractable Migraine)-10mg ivp q5 min
- IV Haldol-2.5 mg, IV Droperidol -2-5 mg
- Refractory cases-Ketamine at 0.2-0.3 mg/kg short infusion ( 10 min)
Musculoskeletal Pain: REGIONAL NERVE BLOCKS( IF SUITABLE)
- PO Ibuprofen-400-800 mg
- PO Acetaminophen-500-1000mg
- PO Naproxen-375 mg
- IV Ketorolac-10-15 mg
- IV Acetaminophen-1g over 15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
Neuropathic Pain
- PO Ibuprofen-400-800 mg
- PO Gabapentin-100-300 mg
- PO Prednisone-25-50 mg
- PO Clonidine 0.1-0.2 mg
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
- IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h ( 2% cardiac Lidocaine)
- IV Dexemedetomidine-0.2-0.3 mcg/kg/hr drip
- IV Clonidine-0.3-2 mcg/kg/hr drip
Post-Operative Pain
- IV Acetaminophen-1g over 10-15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
- IV Dexemedetomidine-0.2-0.7 mcg/kg/hr drip
Dental Pain
- Dental Blocks
- PO Ibuprofen -400-800 mg
- PO Acetaminophen-500-1000mg
Burns
- PO Ibuprofen-400-800 mg
- PO Acetaminophen-500-1000mg
- PO Naproxen-375 mg
- IV Acetaminophen-1g over 15 min
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
- IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h (2% cardiac Lidocaine)
- IV Dexemedetomidine-0.2-0.7 mcg/kg/hr drip
- IV Clonidine-0.3-2 mcg/kg/hr drip
Sickle Cell Painful Crisis
- PO Ibuprofen-800mg
- PO Hydroxyurea-100mg
- IN Ketamine 1mg/kg (no more than 1ml per nostril)
- IV Ketamine-0.3 mg/kg over 10 min, + IV drip at 0.15 mg/kg /hr
- IV Lidocaine -1.5.-2.5 mg/kg /hr drip x2-4 h (2% Cardiac Lidocaine)
- IV Dexemedetomidine-0.2-0.3 mcg/kg/hr drip
Post-Publication Review
I had the podcast vetted by Christopher Page, MD. Dr. Page is the Division Chief of the pain service at Stony Brook Hospital and just a great guy. The only thing Dr. Page questioned in the post is whether Cox-3 actually exists. Much like Pluto, this enzyme may actually not deserve true elite status. It may be simply a variant of Cox-2, though multiple theories abound.
Additional New Information
More on EMCrit
EMCrit 302 – Pain Management Update with Sergey Motov(Opens in a new browser tab)
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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It is great that non-anesthesiologists will do nerve blocks in the ED! Whatever is best for the patient should be done, and nothing magical (except training) about an anesthesiologist doing it.
My only comment/criticism of this podcast is the constant referral to COX “receptors”. No such thing. COX is an enzyme…
Keep up the great work!
Oops. Forgot my particulars: Philip Jones MD MSc FRCPC, Assoc Prof, University of Western Ontario
In terms of nerve blocks, I’ve been told that untreated acute pain often leads to chronic pain, and so is there any evidence that acute pain treated with nerve blocks is less likely to develop into chronic pain than pain treated with opioids? The thought being that targeting pain at the distal nerve fibres rather than at the dorsal root would leave less ‘space’ for hard wiring the pain fibres or even simply that pain is more completely treated with a nerve block?
Thanks
Dan
(Just a 2nd year paramedic student from New Zealand)
Fantastic pick-up; post changed.
I’m always a fan of any proponents of ketamine and dexmeditomidine use! I’m gravely concerned with the routine use of ketorolac for non-traumatic abdominal pain in the potentially volume depleted patient though (sbo, acute abdomen, etc). Most of these patients are in fact dehydrated. Too must risk for iatrogenic contribution to aki.
Fantastic episode, and a topic that’s applicable to the entire spectrum of ED patients, not just the critically ill. One thing that wasn’t really discussed much was how to get patients to buy into this (and, perhaps, nurses). I think the expectations that you create about pain management can be as important as the actual drugs, particularly in the more chronic population. I’d love to hear comments from others on what’s worked for them.
The approach I use to convince patients to not get opioids is to tell them that I am here to take care of them and then briefly describe the reason why I think they have pain. At the same time I introduce them to analgesics that are more suitable for their painful conditions with the premise that if pain is not optimized, I will use opioids as a rescue analgesics. Success rate 80%. As far as nursing participation goes, I use” demonstrate/educate/execute” approach. I take nurse at the bedside and use new analgesics modalities with explanations of rationale/advantages and possible… Read more »
Jordan: As an ED nurse I’ve worked in three different EDs and conjecture that most nurses would share the author’s goal of minimizing opiate use. One crux is technical. Nursing school is woefully inadequate for critical care training and most of what an RN learns is from empirical observation and inductive reasoning of pt and MD behavior. (I would like to see these standards change in the future). We tend to associate ketamine with conscious sedation, lots of documentation, a prolonged recovery phase and a generally high work load. In many shops (mine included) to get this to go live… Read more »
Interesting listening! As a paramedic my analgesia options are REALLY limited and we use opioids almost exclusively(morphine and fentanyl). What are Sergey’s thoughts on chest pain (cardiac or not) as this was not mentioned. Also how do his specific protocols get effected if the patient has had pre-hospital opioids?
Thank you for your questions. I am very much aware of analgesic constraints in pre-hospital arena and I do not think that we can avoid opioids in managing pain in pre-hospital settings. But you might try following options: For chest pain ( cardiac) I would recommend to use nitrates, aspirin and if you have availability, nitrous oxide. For non-cardiac CP, if you have, use low-dose ketamine at 0.3-0.4 mg/kg IVP over 5-10 min IV or 1 mg/kg IN. If not, IV/IN Fentanyl. If patients receive pre-hospital opioids and still in pain upon arrival to the hospital, I use combinations of… Read more »
10-15 mg seems like a low dose of Ketorolac, we’re using 30-60 mg IM or 30 mg IV. Is this the one case where EMS is actually using higher dosages than the ED?
No Chris, the EMS is doing exactly what are majorities if not all ED’s are doing with respect to
administering much larger doses of parenteral Ketorolac. There is no need to use more than 10 mg per dose for pure analgesic effect regardless of the settings.
Sergey
Sergey (and Braden),
Many thanks for the reply! As our usage is purely for analgesic effects I’ll see what I can do to get our protocols adjusted.
There is evidence demonstrating the analgesic ceiling of ketorolac is ~10-15 mg. Any more than that and you do not get any additional analgesic effect but do significantly increase the risk of adverse effects.
Exactly! http://www.medscape.com/viewarticle/811301
Thanks for the podcast!
One issue that I often have with NSAIDs, particularly in older patients, is that almost everyone seems to have a contraindication to their use, whether from chronic disease or other medications.
For IV, there are other options out there, but for PO, after acetaminophen, what’s your next choice?
Thanks again
Bryan, I use Ibuprofen at doses 400 mg three times a day for 3 days only( analgesic ceiling 1200mg per 24h). If there is a true contraindication to NSAID’s, I would consider PO neurontin, PO Prednisone for inflammatiory/neuropathic pain, trigger point injections/myofascial injections in the ED and lidocaine ( lidoderm) patches for acute and neuropathic pain.
A great episode. As an ED registrar working in the UK I find your comments about paracetamol (acetaminophen) very intruguing. IV paracetamol is pretty much ubiquitous for analgesia in UK ED’s for both adults and children and has been for a very long time now regardless of the vast cost differences. In fact People are so used to prescribing it that I now find a worrying trend of IV paracetamol being used to treat fever, despite the fact that there is no evidence (that I am aware of) that it is superior to oral paracetamol for the treatment of pyrexia… Read more »
For your post op pain suggestion, are you using Tylenol plus dex or Tylenol plus ketamine? Or are you using ketamine and dex simultaneously?
I really enjoyed the episode. I was wondering if you could address oral gabapentin. Our neurosurgeons love it, but I have been less impressed, both with the pharmaceutical company malfeasance associated with it plus the high amount of neuropsychiatric side effects. Do you have any tips for a regimen to start patients on a daily dose of gabapentin? Do you start low and increase over several days- weeks?
Is there any role for benzos in pain management? I have heard anesthesiologist talking about the pain triangle: COX inhibitors, opiates, GABA.
Dr. Motov: How did you convince your hospital to allow the use of medications such as ketamine drips in the ED. In most hospital I have worked at, a ketamine drip would be restricted to an intubated or ICU patient. Same would go for a lidocaine infusion.
As an ED nurse I LOVE this research. We need better evidence based non-narcotic options that WORK. One question though.. Using various non-narcotic options for pain control is great, but isn’t the idea to use options that aren’t addictive and/or cause habituation? I would think benzos, ketamine, and/or precedex could potentially be just as bad. Regardless, I think a lot of what ER providers deal with is not just pain control itself, but the patient and/or families unrealistic expectations that we are going wave our magic wand to make them pain free. There is a plethora of non-medicinal options that… Read more »
Leon, I don’t usually see patients right aftyer surgery.But I do see them 2-5 days post-op I use ketamine drip as single agent and if pain is sevwere enough, combination of ketamine and dexemedetomidine is my nex option.
I rarely use IV acetaminophen as its not available to me i nmy ED on regular bases. But when I really need it, I use IV acetamenophen/IV ketamine combo.
Sergey
I only use gabapnetin for neuropathic pain in the ED and I start at 300 mg single dose once ( 250mg single dose from surgcial literature proved to priovide significant pain relief). I send pt home with RX of gabapentin 300 tid x3 days and with increeament buy a 100 mg per dose every 3 days and referral to pain clinic/specialist/ PMD
Derek, I haev spent nearly 3 years researching, teaching and at times publishing data on use of low-dose ketamine in the ED that includes IV pushes and short/long term infussion. I was able to present this data to my Chair and was given a green light to go ahead and subsequently had great response from my colleagues, residents and nurses. Having a clinical pharmacist in the ED is a big help. The same goes for IV lidocaine
Sergey
Derek,
I don’t think that there is enough data to support use of benzodiazepines for analagesia. They may very well decrsease pain by indirect way of decresing anxiety. In rare cases, they might be used as adjuvants but caution needs to be taken with respect to benzodiazepine sdie effects profile.
Sergey
yes, I wonder if that anesthesiologist was referring to the triangle of ANESTHESIA rather than analgesia. That would describe multi-modal anesthesia nicely.
Makes senses. Thanks.
HI. One more think i’d like to add in acute back pain is IV Dexamethosone as per a recent article on Medscape! (http://www.medscape.com/viewarticle/831783)
Did you see the parody music video on opioid use and misuse in the ED? Fun use of #SoMe to address serious problem. Did a blog post on http://www.theSGEM.com recently
http://youtu.be/g-W4DvP0qQg
#foamed #MedEd
Ken milne
Western university
Skeptics’ Guide to EM
amazing!
What do you send your patient home on who had severe pain managed with iv ketamine in the er (for instance, for a burn, renal colic or significant msk injury)?
Mary, the outpatient ( post-ED) analgesia is a very tough topic to discuss without opioids. In reality, the analgesic options for patients with fractures and burns are still evolve around opioids. I have tried combinations of acetaminophen/ibuprofen with oral clonidine for burns, same combination with gabapentin but had suboptimal pain relief with patients returning to the ED in 12-24 h. Similarly, pain due to extremities fractures even if you do regional block in the ED, still warrants short course of 48 h of short acting opioid analgesics. I am not sending patients home on oral Ketamine ( that is just… Read more »
Thanks for a great podcast. Any thoughts on inhaled methoxyflurane, used at sub therapeutic doses? Still used in Australia by prehospital and by dentists, though I believe not used in the U.S.
Sorry, I meant sub anaesthetic doses. Mike Gualano
Dear Mike, methoxyflurane is not available to me in our ED. I don’t think its avaiable in any ED in the US.
Dosage of ketamine for abscess drainage in opioid dependent patient? I just tried 0.3mg/kg over 10 minutes, then performed an I and D on 2 large abscesses. While there was some nystagmus, the patient was conversational. He complained that the medication didn’t help. Would you recommend a larger dose in the opioid dependent patient e.g. on methadone? Thanks for a great podcast!!
Joe, I would still use 0.3 mg/kg dose in combination with regional block with bupivacaine( if amenable) or Dexmedetomidine at 0.2 mcg/kg/hr short drip ( 30 min).
You can also stat patient on the Ketamine drip at 0.2mg/kg/hr rigth after the bolus dose ( but it will take much longer for the procedure to be performed.
Loved this podcast. Thanks for sooo many useful tips and backing for a philosophy that is helpful. Also, I’ve used colchicine a LOT for gout along with lido derm patches and had good results. I also like colchicine for pericarditis. A funny anecdote for me was a pt who had a subtle MI and presented four days out. He was in the ER a long time and his EKG showed some evolution to pericarditis which freaked out the Hospitalist. As I left the hospital, I txtd him to use Colchicine and said ” of course he has pericarditis ! ”… Read more »
I love Colchicine for acute gouty attack. Great pain relief and satisfaction.
Thank you for mentioning this medication.
Sergey
Dr. Motov: Regarding your 12/24 comment: “For renal colic patients at discharge I use ibuprofen and tamsulosin.” The problem I see with your suggested regimen is the nausea & vomiting often seen with renal colic & the possibilty of the pt. not being able to keep oral meds down. There is only one NSAID besides ASA that I know of available in suppository form: Indomethacin. What do you think of the idea of Indomethacin suppositories for short-term pain relief in Renal Colic patients in the home environment? If it works for Gout, I would think it might work well for… Read more »
Dear Ms.Knight-Meigs,
You are bringing a very good point and an excellent analgesic modality for patient with renal colic and intractable nausea and vomiting. There is a good evidence to support its use for patients who are unable to take oral meds due to severe n/v. I don’t personally have much experience with it but I will surely consider to add this formulary to my analgesic amentarium upon patients discharge from the ED. Thank you very much!
Sergey
anybody had experience with topicals like voltaren? was used on me with ACL tear in Switzerland in 2000. Trouble is, the injury never was painful, and only on one knee so no control.
or for other uses? thanks
As someone who has suffered from akathisia in the ER while being treated for a migrane and associated emesis, the side effect profile of prochlorperazine leaves much to be desired. SubQ sumatriptan and oral ondansetron (my autoinjector has kept me out of the ER for years now) coupled with any of the OTC NSAIDs, or toradol seems to be a favorite combination of the handful of neurologists I’ve had.
Just a periodic ER patient’s take on Migraine pain management.
Robert Szasz
I’ve used Ketamine a few times for pain control, at doses probably a bit lower than what you recommend. The times I’ve used it, although it seem to help with the patient’s pain, they were basically tripping, repeatedly saying they felt very bizarre. What’s your experience with that? How do you deal with this side effect of ketamine?
Dear Azan,
I use short infusion of 10-15 minutes with any dose of IV ketamine I use for pain and I tell patients that they might feel weird for very brief period of time
I’ve started using TIZANIDINE in my back pain regimen as well, as a “muscle relaxer,” which I believe is a useful analgesic adjunct as well. It’s an alpha-2 agonist, like clonidine, but allegedly more centrally-acting (like dexmedetomidine). Costs a little more than clonidine, but may have less risk for hypotension, and less mental status depression (and behavior reinforcement) than benzodiazepines.
I would also like to plug DROPERIDOL for opioid tolerance and chronic pain syndromes: http://www.ncbi.nlm.nih.gov/pubmed/20832967
No financial disclosures.
Kit Tainter, MD
UCSD Emergency Medicine and Anesthesia Critical Care
Do you still have drop? I haven’t had any due to shortages for 2 years now
Wonderful talk! Thanks!
When you are dripping these folks on Ketamine or dex or clonidine or lidocaine, how long are you doing this? I guess I am thinking of the patients you expect to discharge (bad muscle spasm or renal colic). How often do you have to resort to the drips? 10%, 50%?
Thanks Sergey & Scott.
Enjoyed the talk.
I have a few questions about ketamine.
Would its analgesic effect be as short as its sedative effect , less than 30 min?
What about using IM ketamine for children where IV line access might be difficult to achieve immediately ?
Is monitoring preferred, necessary or not needed after giving ketamine & how soon can I discharge patient home after a dose of ketamine ?
Dear Ibrahim,
The analgesic effects of low dose ketamine ( I use 03.mg/kg over 10 min) lasts fro about 30-45 min. But if you combine it with an infusion at 0.1-0.15 mg/kg/hr, it will last at least for 2-3 h.
I use IN Ketamine at 1-2mg/kg instead of IM injection for pain control. I only use IM ketamine for emergent sedation of combative patients.
No monitoring needed and I usually discharge pt home 45 -60 min after ketamine administration ( once pain is optimized)
I like the idea of multi-modal analgesia, something the WHO has been promoting for such a long time, but as you say in the podcast you are not suggesting opiates be removed as they are so useful. Some of the drugs discussed here both medical and nursing staff are less familiar with and there would inevitably be a period of increased risk if large scale changes were made to an EDs analgesic policy whilst staff became used to what to look for. My question is about the mind-altering effect of some of the drugs discussed, many of them can alter… Read more »
Dear Dr. Greenway, Thank you very much for your comments. In regards to your question, over the course of past five years I have been using variety of opioids, non-opioid analgesics, and antipsychotics or sedative medications in order to manage different painful conditions in the ED. I have not yet encountered a problem with severe impairment of a mental status of a patient that would preclude him/her to make a conscious decision about their care including a consent for the procedure. I heavily rely on titration of opioids which results in absolute minimum of mental impairment. Low-dose Ketamine analgesia (… Read more »
Dr. Motov, I looked at the PubMed link for ketamine that you have listed. I have seen many of these, but I am unable to find any data on the dose over 10 min then infusing the same per hour for 1-2 hours. Do you have any published data on this? My hospital uses this for sedation and for IV push, but they are leery on infusions. I have see a lot of agitation/dysphoria with 0.25-0.5 mg/kg/doses as a single push.
Jason Stone, MD
EM Attending
any thoughts on haldol for chronic pain in the setting of psychiatric drug seeking behavior ?
Brian Goodhue, DO
Due to anesthesia constraints on what drugs ED physicians are allowed to use, many of my facilities are a little (ok a few years) late on jumping on the non-narcotic train. However, with the recent press and CDC opioid recommendations, I feel it is the perfect time to gain some autonomy and bring ketamine, dexemedetomidine, and IV lidocaine into our arsenals. That being said, one of my facilities has brought up the Drake article from 2015 Academic Emergency Medicine and is requiring me to overcome his conclusions in order to implement such a protocol. Other than demonstrating that many hospitals… Read more »