*Department of Emergency Medicine,University of Ottawa,Ottawa,ON.
CJEM. 2018 Jan;20(1):36-45. doi: 10.1017/cem.2017.48. Epub 2017 Jun 28.
The aim of the study is to determine the performance of low-dose ketamine (LDK) as an analgesic for acute pain management in adult patients in the emergency department (ED).
We systematically reviewed electronic databases, grey literature, conference abstracts, and clinical trial registries. Two independent reviewers identified eligible studies. These selections were subsequently reviewed by one reviewer who identified the final eligible studies, using refined inclusion and exclusion criteria. Our outcome measures included the analgesic effect of LDK, need for rescue analgesia, and neuropsychological adverse events secondary to LDK use. We assessed inter-rater agreement using kappa statistics and proposed a treatment recommendation using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) software. Heterogeneity among studies precluded meta-analysis.
Our electronic search identified 1,408 records; 44 were selected for full evaluation (kappa=0.70), and 8 were included after the final review. All six randomized controlled trials and two observational studies were set in the ED where LDK was administered to adult patients ( >18 years old) exclusively for pain management. All studies had an overall low risk of bias. There was extensive variation in the dose and route of LDK used (0.1-0.7 mg/kg SC/IV/IM), administration protocols, and use of adjunct analgesia. Overall, most studies reported a significant analgesic effect of LDK with occasional need for rescue analgesia and mild-to-moderate adverse events (dizziness, dysphoria, and confusion).
There are moderate to low quality data supporting LDK as an alternative analgesic in the ED with the potential for minimal requirement of rescue analgesia and self-limited neuropsychological adverse events.
本研究旨在确定小剂量氯胺酮（LDK）作为急诊科成人急性疼痛管理的镇痛剂的效果。
我们系统地检索了电子数据库、灰色文献、会议摘要和临床试验注册处。两名独立的审查员确定了合格的研究。随后，由一名审查员对这些选择进行了审查，该审查员使用经过改进的纳入和排除标准确定了最终合格的研究。我们的结局指标包括 LDK 的镇痛效果、需要抢救性镇痛以及 LDK 使用引起的神经心理不良事件。我们使用kappa 统计评估了组内一致性，并使用 GRADE（推荐评估、制定与评价）软件提出了治疗建议。由于研究之间存在异质性，因此无法进行荟萃分析。
我们的电子搜索确定了 1408 条记录；对 44 条记录进行了全面评估（kappa=0.70），并在最终审查后纳入了 8 条记录。所有六项随机对照试验和两项观察性研究均在急诊科进行，仅将 LDK 用于治疗成年患者（>18 岁）的疼痛管理。所有研究的总体偏倚风险较低。LDK 的剂量和给药途径（0.1-0.7 mg/kg SC/IV/IM）、给药方案以及辅助镇痛的使用存在广泛差异。总体而言，大多数研究报告 LDK 具有显著的镇痛效果，偶尔需要抢救性镇痛和轻度至中度不良事件（头晕、烦躁不安和意识混乱）。
有中等至低质量的数据支持 LDK 作为急诊科的替代镇痛剂，其潜在的抢救性镇痛需求和自限性神经心理不良事件较少。
