Download Evidence Based Medicine Lecture

Evidence Based
Medicine Lecture
Jawad Shahid
88 year old male
 PMH: Afib on Coumadin, CKD, HTN, DMII,
LBO s/p ileostomy
 CC: Sent from NH for SOB
 Additional information:
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 SOB started day before after taking Benadryl
 NH concerned about allergic reaction
 Patient has osteoarthiritis of knees, but complains
of L knee pain > R knee pain
The Case
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Temp
◦ Oral: 36.8
◦ Rectal: 39.9
BP: 149/64
 RR: 30
 HR: 96
 O2 Sat: 96% RA
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Vital
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Gen: Mild distress
Skin: Ecchymosis on R hip
CV: RRR, no MRG, No edema, S1, S2
Lungs: Tachypneic, labored breathing, no
wheezes, rales/rhonchi appreciated L > R
MSK: Venous stasis, 1+ pitting edema b/l;
L suprapatellar effusion
Neuro: Alert and Oriented x 3
Physical
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Pneumonia
Sepsis
Decompensated Heart Failure
Pulmonary Embolism
CAD
Pleural Effusions
Pericardial effusion
Tamponade
Differential Diagnosis
Few B-lines on Lung Ultrasound
 Normal contractility, no pericardial
effusion, no D-sign
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Bedside Ultrasound
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Chem
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Na: 130
K: 3.6
Cl: 83
HCO3: 25
Glucose: 210
BUN: 124
Cr: 3.78 (1.58 on 1/3/15)
GFR: 13
Ca: 9.5
Labs
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CBC
 WBC: 19.09
 H/H: 8.9/27
 Plt: 297
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Coags
◦ PT: 46.1
◦ INR: 4.0
◦ aPTT: 42.8
Labs
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Lactate: 3.5 (POC)
Troponin: 0.08
BNP: 5354
D-Dimer: 258
CRP: 5.3
UA: Negative
ESR: 63
Labs
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Chest X-ray
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Pelvis Xray
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Left Knee Xray:
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Right Femur Xray: no fractures
 Blunting of L costrophrenic sulcus; nonspecific; maybe
related to effusion
◦ Negative for fractures
◦ Osteoarthrosis
◦ Osteoarthorsis
Imaging
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CT Chest
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No evidence of pneumonia
Trace right pleural effusion
Heterogenous thyroid gland
CAD
Imaging
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The patient is still tachypneic
RR of 30s throughout stay in ED
BiPAP placed
Still tachypneic
Patient continuing to complain of severe L
knee pain
ABG
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pH: 7.66
PCO2: 17
PO2: 92
HCO3: 21
The Course
Is Pain Causing His Symptoms?
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08:55
09:16
09:53
11:51
14:03
14:58
17:08
18:00
- Tylenol 1g IV (for fever)
- Fentanyl 50 mg IV
– Fentanyl 50mg IV
– Fentanyl 50mg IV
– Morphine 2mg IV
– Morphine 5mg IV
– Ketamine 14mg IV
– Dilaudid 0.5mg IV
Pain Medications Patient Received
Just Tap it
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Fluid type: Synovial
Color: Red
Appearance: Bloody
WBC: 37777
RBC: 8888
Neutrophils: 97%
Mononuclears: 3%
Arthrocentesis
Synovial Fluid
Abx given earlier in his stay (Vanco and
Zosyn)
 Ortho consulted
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◦ Planned for OR washout
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MICU consulted
◦ Patient admitted to ICR
The Closer
What is today’s topic?
Low-Dose Ketamine as Analgesia
Most common complaint in the ED
 Acute vs Chronic
 Inadequate Pain Control
 Opioid Dependence
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Pain
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Mechanism: noncompetitive NMDA receptor
antagonist that blocks glutamate
Uses:
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Onset of Action
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Duration
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RSI (1-1.5 mg/kg)
Delayed Sequence Intubation
Procedural Sedation
Analgesia (0.1 – 0.3 mg/kg)
◦ IV: 30 seconds
◦ IM: 3-4 minutes
◦ IV: 5-10 minutes
◦ IM: 12-25 minutes
Ketamine
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High Dose
◦ Dissociative
◦ Cataleptic Type State
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Low Dose
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Analgesic
Amnestic
Opioid Sparing
Improved Perception of pain
Protection of Airway reflexes, Spontaneous
Respiration, Cardiopulmonary Stability
Studied in Surgical and Anesthesia Literature
Ketamine
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Emergence Phenomenon
Transient Apnea
Larynospasm
Emesis
Catecholamine-mediated HTN and
Tachycardia
Increased ICP and IOP
Ketamine Side Effects
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Giving LDK (0.1-0.3) mg/kg IV or IM
◦ IV: 5-20mg (93%)
◦ IM: 10-25mg (7%)
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Broad Inclusion Criteria
Chronic and Acute Pain Patients
Side Effects
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Minor
Major
SBP
HR
530 patients enrolled
Methods
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No change in SBP or HR
◦ At triage
 Mean SBP: 141
 Mean HR: 93
◦ 1 hour after LDK administration
 Mean SBP: 138
 Mean HR: 86
Results
6% of 530 patients
 7 had transient hypoxia (Sat 86-92%)
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◦ 1 required 2L NC
5 had emesis
 18 had psychomimetic or dysphoria
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◦ 3 required Ativan
◦ Most improved without intervention
Adverse Events
It’s safe!
ANNALS OF EMERGENCY
MEDICINE
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LDK vs Morphine
◦ LDK: 0.3mg/kg
◦ Morphine: 0.1mg/kg
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Patient Groups
◦ LDK: 45 patients
◦ Morphine 45 patients
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Randomized Control Trial
Medication given at time 0
Pain Scores, Vital Signs, Adverse Effects
monitored at 15, 30, 60, 90, 120 minutes
Fentanyl (1mcg/kg) as rescue dose
Method
Acute Pain (within 7 days)
 18-55 years old
 Abdominal, flank, back, or MSK pain
 Rate of Pain: 5+
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Inclusion Criteria
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Pregnancy
Breast-feeding
AMS
Allergies to Morphine or Ketamine
46kg < Weight < 115kg
Unstable Vital Signs
Acute Head or Eye Injury
Seizures, Intracranial HTN, Chronic Pain
Renal/Hepatic Insufficiency
EtOH or Drug Abuse
Psychiatric Illness
Recent Opioid Use
Exclusion Criteria
Results
Results
AMERICAN JOURNAL OF
EMERGENCY MEDICINE
Results
Results
SOCIETY FOR ACADEMIC
EMERGENCY MEDICINE
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Group 1 (n =20)
◦ Morphine
◦ Normal Saline Placebo
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Group 2 (n = 20)
◦ Morphine
◦ Ketamine 0.15 mg/kg
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Group 3 (n = 20)
◦ Morphine
◦ Ketamine 0.30 mg/kg
METHODS
Group 1 = Group 2
 Group 3 > Group 1
 Rescue Analgesia
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◦ 7 in Group 1
◦ 4 in Group 2
◦ 4 in Group 3
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Ketamine viable adjunct to morphine
Results
Prospective, Nonrandomized, Nonblinded
Study
 Time 0
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◦ 15mg IV of Ketamine
◦ 20mg IV infusion of Ketamine in 250cc NS
 Delivered over 60 minutes
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Time 20, 40, 60 minutes
◦ More pain medicine?
◦ If yes, 4mg IV Morphine or 0.5-2mg of Dilaudid
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38 patients enrolled
Methods
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10 minutes
◦ 18% complete resolution
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30 minutes
◦ 40% complete resolution
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60 minutes
◦ Infusion stopped
◦ 65% complete resolution
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120 minutes
◦ 68% complete resolution
Results
Ketamine = Morphine
 Ketamine has higher adverse event profile
 Inadequate dosing of Opioids
 Fear of using Opioids
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Take Home Points
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http://www.uptodate.com.proxy.library.stonybrook.edu/contents/ketamine-druginformation?source=search_result&search=ketamine&selectedTitle=1~142#F18569
http://www.uptodate.com.proxy.library.stonybrook.edu/contents/synovial-fluidanalysis?source=search_result&search=synovial+fluid+analysis&selectedTitle=1~41
Rosen’s Emergency Medicine
Ahern TL, Herring AA, Anderson ES, Madia VA, Fahimi J, Frazee BW. The first 500: initial experience with
widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015
Feb;33(2):197-201. doi: 10.1016/j.ajem.2014.11.010. Epub 2014 Nov 15. PubMed PMID: 25488336
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. PubMed PMID: 25817884.
Ahern TL, Herring AA, Miller S, Frazee BW. Low-Dose Ketamine Infusion for Emergency Department
Patients with Severe Pain. Pain Med. 2015 Jul;16(7):1402-9. doi: 10.1111/pme.12705. Epub 2015 Feb 3.
PubMed PMID: 25643741.
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. PubMed PMID: 25624076.
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. PubMed PMID:
25377395.
References