Efficacité et sécurité de la kétamine pour l'analgésie préhospitalière du blessé de guerre

 

Kétamine: Moins performant après !

Comparison of the effects of ketamine and morphine on performance of representative military tasks

Gaydos SJ et Al. J Emerg Med. 2015 Mar;48(3):313-24

 

BACKGROUND:

When providing care under combat or hostile conditions, it may be necessary for a casualty to remain engaged in military tasks after being wounded. Prehospital care under other remote, austere conditions may be similar, whereby an individual may be forced to continue purposeful actions despite traumatic injury. Given the adverse side-effect profile of intramuscular (i.m.) morphine, alternative analgesics and routes of administration are of interest. Ketamine may be of value in this capacity.

OBJECTIVES:

To delineate performance decrements in basic soldier tasks comparing the effects of the standard battlefield analgesic (10 mg i.m. morphine) with 25 mg i.m. ketamine.

METHODS:

Representative military skills and risk propensity were tested in 48 healthy volunteers without pain stimuli in a double-blind, placebo-controlled, crossover design.

RESULTS:

Overall, participants reported more symptoms associated with ketamine vs. morphine and placebo, chiefly dizziness, poor concentration, and feelings of happiness. Performance decrements on ketamine, when present, manifested as slower performance times rather than procedural errors.

CONCLUSIONS:

Participants were more symptomatic with ketamine, yet the soldier skills were largely resistant to performance decrements, suggesting that a trained task skill (autonomous phase) remains somewhat resilient to the drugged state at this dosage. The performance decrements with ketamine may represent the subjects' adoption of a cautious posture, as suggested by risk propensity testing whereby the subject is aware of impairment, trading speed for preservation of task accuracy. These results will help to inform the casualty care community regarding appropriate use of ketamine as an alternative or opioid-sparing battlefield analgesic.

Kétamine: Oui, à la bonne dose

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.

Beaudoin FL et Al. Acad Emerg Med. 2014 Nov;21(11):1193-202

OBJECTIVES:

Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.

METHODS:

A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration < 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured.

RESULTS:

Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p < 0.02). The SPIDs for the ketamine groups were similar (p < 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness.

CONCLUSIONS:

Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations.

 

Morphine mieux que kétamine ?

Comparison of the effects of ketamine and morphine on performance of representative military tasks.

Gaydos SJ et Al. J Emerg Med. 2015 Mar;48(3):313-24

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Même un militaire blessé peut avoir à recourir à son arme. L'administration d'antalgiques peut interférer avec son niveau de vigilance. La kétamine semble être sur ce point moins maniable que la morphine du moins dans ce travail américain qui fait appel à l'administration intramusculaire, voie qui n'est pas usuelle dans notre pratique.

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BACKGROUND:

When providing care under combat or hostile conditions, it may be necessary for a casualty to remain engaged in military tasks after being wounded. Prehospital care under other remote, austere conditions may be similar, whereby an individual may be forced to continue purposeful actions despite traumatic injury. Given the adverse side-effect profile of intramuscular (i.m.) morphine, alternative analgesics and routes of administration are of interest. Ketamine may be of value in this capacity.

OBJECTIVES:

To delineate performance decrements in basic soldier tasks comparing the effects of the standard battlefield analgesic (10 mg i.m. morphine) with 25 mg i.m. ketamine.

METHODS:

Representative military skills and risk propensity were tested in 48 healthy volunteers without pain stimuli in a double-blind, placebo-controlled, crossover design.

RESULTS:

Overall, participants reported more symptoms associated with ketamine vs. morphine and placebo, chiefly dizziness, poor concentration, and feelings of happiness. Performance decrements on ketamine, when present, manifested as slower performance times rather than procedural errors.

CONCLUSIONS:

Participants were more symptomatic with ketamine, yet the soldier skills were largely resistant to performance decrements, suggesting that a trained task skill (autonomous phase) remains somewhat resilient to the drugged state at this dosage. The performance decrements with ketamine may represent the subjects' adoption of a cautious posture, as suggested by risk propensity testing whereby the subject is aware of impairment, trading speed for preservation of task accuracy. These results will help to inform the casualty care community regarding appropriate use of ketamine as an alternative or opioid-sparing battlefield analgesic.

 

Douleur du combattant blessé

La prise en charge de la douleur à l'avant fait appel à l'association de mesures passant par les immobilisations, le recours à la morphine sous cutanée, le paracétamol et dès que possible certaines techniques d' ALR. Les US viennent de proposer l'évolution de leur vision des choses.

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La douleur: S'en occuper ACTIVEMENT

Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan

Buckenmaier III CC et All. Pain Med. 2009 Nov;10(8):1487-96.

Objective. Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. Painmanagement practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. An exploratory study was undertaken to examine pain and other outcomes during evacuation and at Landstuhl Regional Medical Center (LRMC), Germany. 

Design. A mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded U.S. soldiers evacuated from Iraq and Afghanistan to LRMC. Setting and Patients. A total of 110 wounded soldiers evacuated from Iraq and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0–10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann–Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.

Results. Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05).

Average percent pain relief achieved was 45.2%  26.6% during transport and 64.5%  23.5% while at LRMC (P < 0.001).

Participants with CPNB catheters placed at LRMC reported significantlyy less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs

Conclusions. Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes

Analgésie du combattant:Le point US

Pain Management Task Force - Final Report - May 2010

Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families

http://www.amedd.army.mil/reports/Pain_Management_Task_Fo...

Document SFMU: Analgésie et afflux de blessés en contexte de guerre

http://www.sfmu.org/urgences2011/donnees/articles/fs_conf...

Analgésie Sédation préhospitalière

http://www.sfmu.org/documents/consensus/rfe_sedation_anal...