University of Oulu

Sandberg M, Hyldmo PK, Kongstad P, et al, Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm, BMJ Open 2020; 10: e038134. doi: 10.1136/bmjopen-2020-038134

Ketamine for the treatment of prehospital acute pain : a systematic review of benefit and harm

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Author: Sandberg, Mårten1,2; Hyldmo, Per Kristian3,4,5; Kongstad, Poul6;
Organizations: 1Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
2Faculty of Medicine, University of Oslo, Oslo, Norway
3Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
4Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
5Trauma Unit, Sørlandet Hospital, Kristiansand, Norway
6Department of Prehospital Care and Disaster Medicine, Region of Skåne, Lund, Sweden
7Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
8Department of Anaesthesiology, Regional Hospital of Horsens, Horsens, Denmark
9Centre for Prehospital Emergency Care, Oulu University Hospital, Oulu, Finland
10Anaesthesia Research group, MRC, Oulu University Hospital and University of Oulu, Oulu, Finland
11Department of Anaesthesiology and Intensive Care, Linköping University Hospital, Linköping, Sweden
12Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
13Landspitalinn University Hospital, Reykjavik, Iceland
14Danish Air Ambulance, Aarhus, Denmark
15Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
16Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
17Centre for Prehospital Emergency Medicine, Kuopio University Hospital, Kuopio, Finland
18University of Eastern Finland, Kuopio, Finland
19Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.2 MB)
Persistent link:
Language: English
Published: BMJ, 2020
Publish Date: 2021-02-03


Background: Few publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug) in adult prehospital patients with acute pain.

Methods: A systematic review of clinical trials assessing prehospital administration of ketamine in analgesic doses compared with other analgesic drugs or no analgesic treatment in adults. We searched PubMed, EMBASE, Cochrane Library and Epistemonikos from inception until 15 February 2020, including relevant articles in English and Nordic languages. We used the Cochrane and Grading of Recommendations Assessment, Development and Evaluation methodologies and exclusively assessed patient-centred outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias.

Results: We included eight studies (2760 patients). Ketamine was compared with various opioids given alone, and intranasal ketamine given with nitrous oxide was compared with nitrous oxide given alone. Four randomised controlled trials (RCTs) and one cluster randomised trial included 699 patients. One prospective cohort included 27 patients and two retrospective cohorts included 2034 patients. Five of the eight studies had high risks of bias. Pain score with ketamine is probably lower than after opioids as demonstrated in a cluster-RCT (308 patients) and a retrospective cohort (158 patients) study, Δvisual analogue scale −0.4 (−0.8 to 0.0) and Δnumeric pain rating scale −3.0 (−3.86 to −2.14), respectively. Ketamine probably leads to less nausea and vomiting (risk ratio (RR) 0.24 (0.11 to 0.52)) but more agitation (RR 7.81 (1.85 to 33)) than opioids.

Conclusions: This systematic literature review finds that ketamine probably reduces pain more than opioids and with less nausea and vomiting but higher risk of agitation. Risk of bias in included studies is high.

Other: Scandinavian society of anaesthesiology and intensive care medicine funded meetings and software. The Norwegian Air Ambulance Foundation funded publication. Otherwise this research received no grant from any agency in the public, commercial or not-for-profit sectors.

PROSPERO registration number: CRD42018114399.

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Series: BMJ open
ISSN: 2044-6055
ISSN-E: 2044-6055
ISSN-L: 2044-6055
Volume: 10
Issue: 11
Article number: e038134
DOI: 10.1136/bmjopen-2020-038134
Type of Publication: A1 Journal article – refereed
Field of Science: 3126 Surgery, anesthesiology, intensive care, radiology
Funding: SSAI funded meetings and software costs. The Norwegian Air Ambulance Foundation funded publication costs. Otherwise this research received no further grant from any funding agency in the public, commercial or not-for-profit sectors.
Copyright information: © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.