The Use of Ketamine in Acute Sickle Cell Pain Crisis
Date First Published:
January 31, 2020
Last Updated:
March 9, 2020
Report by:
Sara Alavian, Resident Doctor (McMaster University)
Search checked by:
Sonja Wakeling, McMaster University
Three-Part Question:
For [patients with acute sickle cell pain crisis], does [ketamine as an adjuvant to standard opioid therapy] [reduce the amount of opioids used]?
Clinical Scenario:
A 24 year old male presents to the ED in an acute sickle cell pain crisis. He is requiring increasing amounts of opioids to control his pain with little effect. You wonder if a subdissociative dose of ketamine may be effective to control his pain and reduce his overall opioid consumption.
Search Strategy:
Ovid MEDLINE(R) ALL 1946 to January 30, 2020
[exp Anemia, Sickle Cell/ or sickle cell.mp.] AND [ketamine.mp. or exp Ketamine/]
[exp Anemia, Sickle Cell/ or sickle cell.mp.] AND [ketamine.mp. or exp Ketamine/]
Outcome:
21 papers found of which the following were excluded: 9 irrelevant, 2 study protocols with no data, 4 case studies/series, and 3 review papers. A total of 3 papers were included.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Low-dose Ketamine for Children and Adolescents with Acute Sickle Cell Disease Related Pain: A Single Center Experience. Neri CM, Pestieau SR, Young H, Elmi A, Finkel JC, et al. 2014 USA | Children and adolescents | Retrospective case-crossover study | Mean total daily opioid dose (morphine equivalents) with ketamine + opioid patient controlled analgesia (PCA) vs opioid PCA only | Ketamine + opioid PCA: 0.04 mg/kg/hr vs Opioid PCA only: 0.032 mg/kg/hr (p=0.0038) | Non-randomized design results in potentially skewed case selection of those who received ketamine. Small number of participants. |
| Patient characteristics affect the response to ketamine and opioids during the treatment of vaso-occlusive episode-related pain in sickle cell disease Raissa Nobrega, Kathy A. Sheehy, Caroline Lippold, Amy L. Rice, Julia C. Finkel and Zenaide M.N. Quezado 2017 USA | Children and adolescents | Retrospective cohort study | Change in opioid consumption (morphine equivalents) from before starting ketamine infusion to the day after ketamine infusion discontinuation | Mean baseline opioid consumption: 3.36 mg/kg/day vs After ketamine discontinuation mean opioid consumption: 2.06 mg/kg/hr Change mean = -1.30 mg (p < 0.001) | Retrospective cohort study results in non-uniform treatment regimens. No control arm. |
| Ketamine and lidocaine infusions decrease opioid consumption during vaso-occlusive crisis in adolescents with sickle cell disease Latika Puri, Kyle J. Morgan, and Doralina L. Anghelescu 2019 USA | Children and adolescents | Retrospective case-crossover study | Total opioid consumption (morphine equivalents) with ketamine + opioid PCA vs opioid PCA only | Patient 1: Opioid PCA only = 0.48 mg/kg/day vs Ketamine + opioid PCA = 0.38–0.44 mg/kg/day Patient 3: Opioid PCA only = 0.73 mg/kg/day vs Ketamine + opioid PCA = 0.60 mg/kg/day Patient 4: Opioid PCA only = 0.34 mg/kg/day vs Ketamine + opioid PCA = 0.56 mg/kg/day | Some patients received both ketamine and lidocaine. No standardized dosing of ketamine. Didn't calculate p-values. Small number of patients. |
Author Commentary:
While there are several case reports and series published on this topic, only a few cohort studies with case controls demonstrate promising results. No randomized control trials have yet to be published looking at the use of ketamine as an adjunct to standard opioid therapy. In addition, the majority of studies appear to only involve children and adolescents.
Bottom Line:
More evidence is needed to support the use of ketamine as an adjunct to standard opioid therapy.
References:
- Neri CM, Pestieau SR, Young H, Elmi A, Finkel JC, et al.. Low-dose Ketamine for Children and Adolescents with Acute Sickle Cell Disease Related Pain: A Single Center Experience.
- Raissa Nobrega, Kathy A. Sheehy, Caroline Lippold, Amy L. Rice, Julia C. Finkel and Zenaide M.N. Quezado. Patient characteristics affect the response to ketamine and opioids during the treatment of vaso-occlusive episode-related pain in sickle cell disease
- Latika Puri, Kyle J. Morgan, and Doralina L. Anghelescu. Ketamine and lidocaine infusions decrease opioid consumption during vaso-occlusive crisis in adolescents with sickle cell disease