- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT06284473
Ketamine as a Supplement to Local Anesthesia for Minor Procedures (INK-MP)
Intranasal Ketamine as a Supplement to Local Anesthesia to Reduce Pain Associated With Minor Procedures in the Emergency Department
This trial is a double-blind randomized controlled clinical trial of adults and children (ages 7 to less than 70 years). Patients who present to the ED and who undergo minor bedside procedures that require local anesthesia will be divided into two groups: The first group will be treated with 0.7 mg/kg intranasal ketamine as well as standard local anesthesia for the procedure (treatment cohort). The second group will be treated with a volume-based dose of intranasal saline solution as well as standard local anesthesia for the procedure (control cohort). The primary aim is to assess whether patients in the treatment cohort report lower pain scores on the Numerical Rating Scale (NRS-100) when compared to patients in the control cohort. For adult patients, a secondary aim is to compare agitation between the two cohorts using the Richmond Agitation Sedation Scale (RASS) and, for pediatric patients, a secondary aim is to compare alertness between the two cohorts using the University of Michigan Sedation Scale (UMSS).
Results obtained from specific procedures will be analyzed on a spectrum of complexity and general length of recovery time. Scientific achievements may include finding a safe and effective way to reduce pain and discomfort during minor procedures in the Emergency Department. Additionally, it would provide opportunities for more research on sub-dissociative doses of ketamine during minor procedures: a topic in which there is still a gap in the published research
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Patient experiences in the emergency department (ED) are commonly painful and uncomfortable, particularly when patients must undergo procedures. Managing acute pain and procedural pain for minor procedures in the ED can be challenging. Ketamine is an N-methyl-D aspartate receptor agonist gaining popularity in clinical settings and has also been shown in several studies to potentially treat depression. Several randomized clinical studies have shown that ketamine is a comparable pain relief medication to opioid analgesics in both acute pain and traumatic settings. Its uses for pain control in the ED have been extensively studied with evidence supporting its safety and efficacy. Ketamine can be administered in different ways including intravenously and intranasally. Intravenously, doses above 1 mg/kg of ketamine can induce dissociation- this dose is commonly used for procedural sedation. At lower doses, specifically sub-dissociative doses, ketamine (SDK) acts to alleviate pain (cancerous, neuropathic, and perioperative). Trials using intravenous SDK suggest efficacy similar to traditional intravenous opioid analgesics.
SDK is currently being utilized by emergency medicine physicians in the ED for pain control in doses up to 0.3 mg/kg intravenously and up to 1 mg/kg intranasally. Additionally, the use of SDK in the ED is also supported by the American College of Emergency Physicians. While the literature has extensively documented and supported the safety and efficacy of SDK, there is a gap in the literature for its use in the management of pain for minor procedures in the ED. Intranasal ketamine may be a valuable supplement to standard medical treatment in procedures that would not normally require intravenous access. Minor procedures requiring local anesthesia performed in the ED can still be painful including but not limited to suturing, incision and drainage of an abscess, and digital blocks. Traditionally, many of these procedures are completed using only local anesthesia. Soft tissue and/or very large abscess are sometimes not alleviated by local anesthesia alone. The use of intranasal ketamine to alleviate pain during these and other painful procedures may provide patients with more comfort and pain relief than local anesthesia alone. Dosing for chronic pain and acute pain differ in that chronic pain typically requires higher doses than acute pain. Side effects are related to ketamine dosage and administration type. Thus, patients treated for chronic pain with higher doses of SDK often experience more side effects than patients with acute pain treated with lower doses of SDK. Additionally, compared to placebo and opioid groups in various studies, ketamine was associated with greater risk of neurological, psychological, and minor cardiologic effects. However, the opioid groups typically had a higher risk for major cardiopulmonary effects. The most common side effect of intranasal SDK are bad taste in the mouth, dizziness, and sleepiness. A dose of 0.7 mg/kg IN ketamine has been determined to be a suitable analgesic dose for patients with pain in the ED. While studies have shown the efficacy and safety of using ketamine for pain control, no studies to date have looked at its possible use to decrease pain during minor procedures in the ED.
The investigators aim to determine if a sub-dissociative dose of 0.7 mg/kg intranasal ketamine is a desirable choice to reduce pain associated with minor procedures requiring local anesthesia in the ED. These procedures include incision and drainage of an abscess, laceration repairs requiring sutures, nerve blocks (specifically digital nerve blocks), and other minor procedures requiring local anesthesia. The investigators hypothesize that adult and pediatric patients presenting to the ED and undergoing painful minor procedures will report lower pain scores when treated with 0.7 mg/kg intranasal ketamine in addition to standard local anesthesia than patients who receive a volume-based dose of saline solution with standard local anesthesia (control). Additionally, the investigators hypothesize that patients in the treatment cohort will report few side-effects as measured by the Richmond Agitation Sedation Scale (RASS)(i.e., for adult patients) or University of Michigan Sedation Scale (UMSS) (i.e., for pediatric patients). The minor procedures listed above typically require the use of local anesthesia but do not typically require intravenous access. Thus, the use of intranasal ketamine instead of intravenous analgesia minimizes the changes that would be made to the current standard of carrying out these procedures.
In order to avoid a potential confounder of variation in baseline pain severity of the different procedures, only patients undergoing minor procedures that have a similar pain profile will be randomized. Additional aims of the study include decreasing perceived agitation using RASS or UMSS. Collecting data on pain and total discomfort using the NRS-100 point pain scale will provide a unidimensional measurement of patients' subjective interpretation of their pain. The investigators hope to demonstrate that using ketamine at 0.7 mg/kg for associated pain during minor procedures is efficacious and minimizes adverse side effects of ketamine.
Study Type
Enrollment (Estimated)
Phase
- Phase 4
Contacts and Locations
Study Contact
- Name: Shannon Lovett, MD
- Phone Number: 708-327-2549
- Email: slovett@lumc.edu
Study Contact Backup
- Name: Trent Reed, DO
- Phone Number: 708-216-4117
- Email: treed1@lumc.edu
Study Locations
-
-
Illinois
-
Maywood, Illinois, United States, 60153
- Recruiting
- Loyola University Medical Center
-
Contact:
- Trent Reed, DO
- Phone Number: 708-216-4117
- Email: treed1@lumc.edu
-
Contact:
- Shannon Lovett, MD
- Phone Number: 847-951-2936
- Email: slovett@lumc.edu
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Child
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Undergoing Minor Procedure in the ED
- Weight not to exceed 115kg
Exclusion Criteria:
- Altered Mental Status
- Pregnancy
- Breastfeeding
- Acute head or eye injury
- Intercranial Hypertension
- Hx of seizures
- Hx of chronic pain
- Unstable vital signs
- Allergy to Ketamine
- Hepatic or Renal Insufficiency
- Hx of Psychiatric Illness
- Hx of alcohol/drug abuse
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Intranasal Ketamine
Participants assigned to this arm will receive intranasal ketamine administered at 0.7mg/kg along with normal lidocaine local sedation
|
Ketamine is an N-methyl-D aspartate receptor agonist
|
Placebo Comparator: Placebo
Participants assigned to this arm will receive volume-based dose of intranasal saline administered along with normal lidocaine local sedation
|
Intranasal saline flushes pollen, dust, and other debris from nasal passages.
It also removes excess mucus and adds moisture
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Immediate pain
Time Frame: 15 minutes
|
Pain will be measured using the numeric rating scale which is a scale ranging from 0 to 100, where higher values report greater pain
|
15 minutes
|
Acute pain
Time Frame: 30 minutes
|
Pain will be measured using the numeric rating scale which is a scale ranging from 0 to 100, where higher values report greater pain
|
30 minutes
|
Delayed pain
Time Frame: 60 minutes
|
Pain will be measured using the numeric rating scale which is a scale ranging from 0 to 100, where higher values report greater pain
|
60 minutes
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Immediate agitation
Time Frame: 15 minutes
|
For adults, agitation will be measured using the Richmond Agitation Sedation Scale (RASS) which is a 10-point scale (range: -5 to +4), where higher scores reflect greater agitation.
|
15 minutes
|
Acute agitation
Time Frame: 30 minutes
|
For adults, agitation will be measured using the Richmond Agitation Sedation Scale (RASS) which is a 10-point scale (range: -5 to +4), where higher scores reflect greater agitation.
|
30 minutes
|
Delayed agitation
Time Frame: 60 minutes
|
For adults, agitation will be measured using the Richmond Agitation Sedation Scale (RASS) which is a 10-point scale (range: -5 to +4), where higher scores reflect greater agitation.
|
60 minutes
|
Immediate alertness
Time Frame: 15 minutes
|
For pediatric patients, agitation will be measured using the University of Michigan Sedation Scale (UMSS) which assesses the level of alertness on a five-point scale ranging from 0 (awake and alert) to 4 (unarousable).
|
15 minutes
|
Acute alertness
Time Frame: 30 minutes
|
For pediatric patients, agitation will be measured using the University of Michigan Sedation Scale (UMSS) which assesses the level of alertness on a five-point scale ranging from 0 (awake and alert) to 4 (unarousable).
|
30 minutes
|
Delayed alertness
Time Frame: 60 minutes
|
For pediatric patients, agitation will be measured using the University of Michigan Sedation Scale (UMSS) which assesses the level of alertness on a five-point scale ranging from 0 (awake and alert) to 4 (unarousable).
|
60 minutes
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Trent Reed, DO, Loyola University
Publications and helpful links
General Publications
- Karlow N, Schlaepfer CH, Stoll CRT, Doering M, Carpenter CR, Colditz GA, Motov S, Miller J, Schwarz ES. A Systematic Review and Meta-analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. Acad Emerg Med. 2018 Oct;25(10):1086-1097. doi: 10.1111/acem.13502. Epub 2018 Jul 17.
- Lee EN, Lee JH. The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis. PLoS One. 2016 Oct 27;11(10):e0165461. doi: 10.1371/journal.pone.0165461. eCollection 2016.
- Miller JP, Schauer SG, Ganem VJ, Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J Emerg Med. 2015 Mar;33(3):402-8. doi: 10.1016/j.ajem.2014.12.058. Epub 2015 Jan 7.
- Motov S, Rockoff B, Cohen V, Pushkar I, Likourezos A, McKay C, Soleyman-Zomalan E, Homel P, Terentiev V, Fromm C. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015 Sep;66(3):222-229.e1. doi: 10.1016/j.annemergmed.2015.03.004. Epub 2015 Mar 26.
- Beaudoin FL, Lin C, Guan W, Merchant RC. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial. Acad Emerg Med. 2014 Nov;21(11):1193-202. doi: 10.1111/acem.12510.
- Shrestha R, Pant S, Shrestha A, Batajoo KH, Thapa R, Vaidya S. Intranasal ketamine for the treatment of patients with acute pain in the emergency department. World J Emerg Med. 2016;7(1):19-24. doi: 10.5847/wjem.j.1920-8642.2016.01.003.
- Optimizing the Treatment of Acute Pain in the Emergency Department. Ann Emerg Med. 2017 Sep;70(3):446-448. doi: 10.1016/j.annemergmed.2017.06.043. No abstract available.
- Shimonovich S, Gigi R, Shapira A, Sarig-Meth T, Nadav D, Rozenek M, West D, Halpern P. Intranasal ketamine for acute traumatic pain in the Emergency Department: a prospective, randomized clinical trial of efficacy and safety. BMC Emerg Med. 2016 Nov 9;16(1):43. doi: 10.1186/s12873-016-0107-0.
- Zekry O, Gibson SB, Aggarwal A. Subanesthetic, Subcutaneous Ketamine Infusion Therapy in the Treatment of Chronic Nonmalignant Pain. J Pain Palliat Care Pharmacother. 2016 Jun;30(2):91-8. doi: 10.3109/15360288.2016.1161690. Epub 2016 Apr 19.
- Hanna AF, Armstrong JS, Smith AJ. Effects of Intravenous Ketamine Infusions in a Neuropathic Pain Patient with Lichen Sclerosus et Atrophicus. Case Rep Dermatol. 2016 Jun 6;8(2):164-70. doi: 10.1159/000446528. eCollection 2016 May-Aug.
- Payne CG, Edbrooke DL, Davies GK. Minor procedures in the accident and emergency department: can Entonox help? Arch Emerg Med. 1991 Mar;8(1):24-32. doi: 10.1136/emj.8.1.24.
- Allen CA, Ivester JR Jr. Ketamine for Pain Management-Side Effects & Potential Adverse Events. Pain Manag Nurs. 2017 Dec;18(6):372-377. doi: 10.1016/j.pmn.2017.05.006. Epub 2017 Jul 23.
- Reynolds SL, Studnek JR, Bryant K, VanderHave K, Grossman E, Moore CG, Young J, Hogg M, Runyon MS. Study protocol of a randomised controlled trial of intranasal ketamine compared with intranasal fentanyl for analgesia in children with suspected, isolated extremity fractures in the paediatric emergency department. BMJ Open. 2016 Sep 8;6(9):e012190. doi: 10.1136/bmjopen-2016-012190.
- Reynolds SL, Bryant KK, Studnek JR, Hogg M, Dunn C, Templin MA, Moore CG, Young JR, Walker KR, Runyon MS. Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures. Acad Emerg Med. 2017 Dec;24(12):1430-1440. doi: 10.1111/acem.13313. Epub 2017 Nov 3.
- Bouida W, Bel Haj Ali K, Ben Soltane H, Msolli MA, Boubaker H, Sekma A, Beltaief K, Grissa MH, Methamem M, Boukef R, Belguith A, Nouira S. Effect on Opioids Requirement of Early Administration of Intranasal Ketamine for Acute Traumatic Pain. Clin J Pain. 2020 Jun;36(6):458-462. doi: 10.1097/AJP.0000000000000821.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pain
- Neurologic Manifestations
- Wounds and Injuries
- Pain, Procedural
- Lacerations
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Central Nervous System Depressants
- Peripheral Nervous System Agents
- Analgesics
- Sensory System Agents
- Anesthetics, Dissociative
- Anesthetics, Intravenous
- Anesthetics, General
- Anesthetics
- Excitatory Amino Acid Antagonists
- Excitatory Amino Acid Agents
- Ketamine
Other Study ID Numbers
- 212154
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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