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Sub-Dissociative Ketamine and Fentanyl to Treat Moderate to Severe Pain

Sponsor
Mercy Health Ohio (Other)
Overall Status
Terminated
CT.gov ID
NCT03959852
Collaborator
(none)
6
Enrollment
1
Location
3
Arms
6.6
Actual Duration (Months)
0.9
Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The objective of this study is to evaluate the potential opioid-sparing effect associated with the novel combination of fentanyl and sub-dissociative ketamine in adult patients with moderate to severe pain in the emergency department.

Condition or Disease Intervention/Treatment Phase
Phase 4

Detailed Description

Pain is a very common complaint in the emergency department (ED). The use of opioids to treat moderate to severe pain has increased over the last decade as well as the number of opioid related deaths. In 1999 to 2016, more than 630,000 people died from a drug overdose. Treatment for acute pain has been assessed in the ED, with review of several different pain medications. Sub-dissociative ketamine (SDK) has become a valuable treatment option for acute pain and in recent years, has been of increased interest due to the growing concerns regarding opioid abuse and opioid shortage in the United States. Sub-dissociative ketamine, an NMDA receptor antagonist, has been studied in dose ranges of 1-4.5 mg/kg for dissociative sedation, as well as dose ranges of 0.1-0.3 mg/kg to treat pain. The onset of action for an IV dose of 2 mg/kg has been studied, with onset usually within 30 seconds after injection and anesthetic effect lasting 5-10 minutes. Common side effects include elevated blood pressure, diplopia or nystagmus, nausea and vomiting. More rare and more severe side effects in dissociative doses include respiratory depression, emergency phenomenon, tonic and clonic movements, and anaphylaxis. However, these were rarely, if ever seen, findings in sub-dissociative doses. Several studies indicate that SDK is a safe and effective alternative to opioids for patients with complaints of moderate to severe pain that provides adequate analgesic effect by itself. In particular, several studies have compared SDK versus morphine, particularly looking at pain in individuals with abdominal pain, flank pain, low back pain or musculoskeletal pain, and acute fractures. SDK has also shown to decrease opioid consumption and the need for rescue analgesia. The studies showed that that there was no difference in average pain scores, but the amount of morphine required was significantly decreased. SDK has proven to be a safe alternative, but the side effects, although short, make it less desirable to use. To the investigator's knowledge, there has never been a study focusing on the use of combination fentanyl and SDK. Fentanyl, an opioid agonist, has been studied in low dose forms of 2 mcg/kg for pain, moderate dose forms of 2-20 mcg/kg for major surgical procedures, and high dose forms of 20-50 mcg/kg for orthopedic and open heart surgeries. Onset of action is almost immediate when given IV, and maximal effect of the drug may take several minutes. The usual duration of action is 30-60 minutes. Common side effects include hypertension, hypotension, dizziness, blurred vision, nausea, vomiting and laryngospasm. Serious side effects included respiratory depression, apnea, rigidity, bradycardia, serotonin syndrome, adrenal insufficiency, and if left untreated could cause cardiac arrest and circulatory depression. There have been several combination studies with SDK, but none regarding fentanyl and ketamine. In one study, combination SDK and reduced dose hydromorphone produced rapid pain relief without significant side effects. Another study indicated that morphine and SDK both provided adequate pain relief alone, but combined morphine and SDK required less morphine administration, had faster onset of relief, and provided sustained reduction in pain intensity for up to 2 hours.

Study Design

Study Type:
Interventional
Actual Enrollment :
6 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Masking:
Single (Participant)
Primary Purpose:
Treatment
Official Title:
A Combination Study With Sub-Dissociative Ketamine and Fentanyl to Treat Moderate to Severe Pain in the Emergency Department
Actual Study Start Date :
Nov 18, 2019
Actual Primary Completion Date :
Jun 5, 2020
Actual Study Completion Date :
Jun 5, 2020

Arms and Interventions

Arm Intervention/Treatment
Active Comparator: Sub-Dissociative Ketamine alone

0.3 mg/kg of Sub-Dissociative Ketamine IV administered over at least 1 minute

Drug: Ketamine
0.3 mg/kg of Sub-Dissociative Ketamine IV administered over at least 1 minute
Other Names:
  • Ketamine Hydrochloride

    		•
    Active Comparator: Fentanyl alone

    1 mg/kg of Fentanyl IV administered over at least 1 minute

    Drug: Fentanyl
    1 mg/kg of Fentanyl IV administered over at least 1 minute
    Other Names:
  • Fentanyl Citrate

    		•
    Experimental: Sub-dissociative Ketamine and Fentanyl

    Combined dose of 0.15 mg/kg of Sub-dissociative Ketamine and 0.5 mg/kg of Fentanyl IV administered over at least 1 minute

    Combination Product: Fentanyl and Ketamine
    Combined dose of 0.15 mg/kg of Sub-dissociative Ketamine and 0.5 mg/kg of Fentanyl IV administered over at least 1 minute.

    Outcome Measures

    Primary Outcome Measures

    1. Analgesia of combination fentanyl and SDK as assessed using the pain scale 1-10 [ED encounter (less than 24 hours)]

      Analgesia of combination fentanyl and SDK as assessed using the pain scale 1-10

    2. Analgesia of fentanyl as assessed using the pain scale 1-10 [ED encounter (less than 24 hours)]

      Analgesia of fentanyl as assessed using the pain scale 1-10

    3. Analgesia of ketamine as assessed using the pain scale 1-10 [ED encounter (less than 24 hours)]

      Analgesia of katamine as assessed using the pain scale 1-10

    Secondary Outcome Measures

    1. OARRS report [ED encounter (less than 24 hours)]

      A retrospective review of OARRS report will be performed with each patient.

    2. Opioid sparing response as assessed by number of times additional rescue doses of fentanyl were required [ED encounter (less than 24 hours)]

      Opioid sparing response as assessed by number of times additional rescue doses of fentanyl were required

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    18 Years to 65 Years
    Sexes Eligible for Study:
    All
    Accepts Healthy Volunteers:
    Yes
    Inclusion Criteria:

    • 18 - 65 years old

    • Moderate pain defined as 4-6 out of 10, severe pain defined as ≥ 7 out of 10 as defined by the numeric rating pain scale (NRS)

    • Proficient in reading and understanding English

    • Are deemed by the attending physician to require opioid therapy.

    Exclusion Criteria:

    • Inability to give consent,

    • Inability to use the numeric rating scale (NRS) score

    • Long-term use of opioids, history of chronic pain

    • Known substance abuse known as excessive use of a drug such as (e.g. alcohol, narcotics or cocaine)

    • Known hypersensitivity to ketamine or fentanyl

    • Pregnancy

    • Alcohol intoxication

    • Depression

    • Anxiety

    • Chronic obstructive pulmonary disease

    • Asthma

    • Cirrhosis

    • On dialysis

    • Acute ischemic stroke

    • Heart rate (HR) less < 60 bpm or > 120 bpm

    • Systolic blood pressure (SBP) < 90 mmHg or > 180 mmHg

    • Ischemic heart disease

    • Ketamine prior to arrival

    • Trauma patients

    • Sepsis or septic shock

    • Weight > 100 kg.

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 St. Elizabeth Boardman Hospital Boardman Ohio United States 44512

    Sponsors and Collaborators

    • Mercy Health Ohio

    Investigators

    • Study Director: David Gemmel, Director of Research

    Study Documents (Full-Text)

    None provided.

    More Information

    Additional Information:

    Publications

    Responsible Party:
    Mercy Health Ohio
    ClinicalTrials.gov Identifier:
    NCT03959852
    Other Study ID Numbers:
    • 18-040
    First Posted:
    May 22, 2019
    Last Update Posted:
    Sep 11, 2020
    Last Verified:
    Sep 1, 2020
    Studies a U.S. FDA-regulated Drug Product:
    Yes
    Studies a U.S. FDA-regulated Device Product:
    No
    Product Manufactured in and Exported from the U.S.:
    No
    Keywords provided by Mercy Health Ohio
    Moderate
    Severe
    Pain
    Additional relevant MeSH terms:
    Acute Pain
    Fentanyl
    Ketamine

    Study Results

    No Results Posted as of Sep 11, 2020