Intranasal ketamine = intranasal fentanyl in children with traumatic limb injuries

Reference

Frey TM, Florin TA, Caruso M, Zhang N, Zhang Y, Mittiga MR. Effect of intranasal ketamine vs fentanyl on pain reduction for extremity injuries in children: The PRIME randomized clinical trial. JAMA Pediatrics 2019;173(2):140-146.

Synopsis

These researchers conducted a noninferiority trial in which they randomized children aged 8 to 17 years with moderate to severe pain (visual analog score [VAS] > 35 mm on a 100-mm scale) from an acute painful injury to an extremity to receive a single dose of intranasal ketamine (1.5 mg/kg; n = 44) or a single dose of intranasal fentanyl (2 mcg/kg; n = 42). More than 80% of the children in each group had a fracture. The researchers evaluated pain on the VAS at baseline and then 15, 30, and 60 minutes after treatment. The baseline pain levels in the ketamine and fentanyl groups were 75 and 72, respectively, and both groups of children had similar reductions in pain at each interval. At 15 minutes, the pain scores had decreased by 24 mm and 25 mm, respectively; at 30 minutes, they had decreased by 31 mm and 32 mm, respectively; and at 60 minutes, by 28 mm and 29 mm, respectively. Although each of these reductions are generally clinically meaningful, it still leaves the children, on average, in moderate pain. Overall, nearly one quarter of the children (11 ketamine-treated patients and 9 fentanyl-treated patients) needed rescue analgesia. Many more ketamine-treated children (77%) than fentanyl-treated children (31%) experienced adverse effects, all of which the researchers reported as minor (number needed to treat to harm = 3; 95% CI 2 - 4). Although sedation scores were similar in each group, drowsiness, dizziness, and dysgeusia were the most commonly reported adverse effects of the ketamine-treated kids.