Intranasal Ketamine for Procedural Sedation

Study Overview
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Brief Summary
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This study will examine the effectiveness of intranasal (IN) ketamine compared to standard intravenous (IV) ketamine administration for simple reductions of orthopaedic injuries in the paediatric population. The aim is to assess if IN administration is equivalent to the current standard of care, IV. The population to be studied is children 4-17 years of age who require a simple orthopaedic reduction. Following a double dummy approach to overcome the difficulty in masking interventions, each participant will receive both IV and IN interventions, only one of which will be the real drug. Procedural sedation and analgesia (PSA) will be assessed using the Dartmouth Operative Conditions Scale (DOCS).

Detailed Description
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Randomization and concealment of allocation will be pharmacy-controlled using a computerized central randomization service. The treating physician, bedside nurse, research assistant, and participant will be blinded to the intervention. Eligible participants will be randomized in a 1:1 allocation ratio with a stratified block design of four or six to either (1) IN ketamine (each single dose, 10 mg/kg prepared in 0.9% NS in 3 mL syringe and atomizer, to a maximum of 8 mL) PLUS IV 0.9% NS 0.02 mL/kg or (2) IV ketamine (single dose, 1 mg/kg, to a maximum 80 mg) PLUS intranasal 0.9% NS 0.10 mL/kg divided to both nares. Due to the perceptible differences in interventional routes, each participant will receive both IV and IN interventions using this double-dummy approach. For IN dose volumes less than or equal to 0.5 mL, the entire dose will be delivered into 1 nostril and for doses greater than 0.5 mL, the dose will be divided equally between both nares. Adjunctive sedation will be given as needed in the form of IV ketamine, any dose, for participants who are adequately sedated 1 minute after IV administration at the discretion of the treating physician. Inadequate sedation in this context refers to one of the following: participant's vocalizations are consistent with pain OR participant withdraws or localizes due to pain. Eligible participants will be identified by the treating physician after viewing the radiographs and performing a clinical assessment. The physician will then inform a research assistant (RA) that the participant is eligible. The RA will then seek informed consent and explain the protocol to the family. Baseline demographic information will be obtained. Informed consent for PSA and a pre-anesthetic assessment will be performed by the treating physician in accordance with the usual standard of care. The RA will record a continuous video of the participant's entire body and monitor using an iPad starting immediately after the IV intervention until the participant is awake and able to tolerate oral fluids. DOCS scores will be obtained by two trained outcome assessors every 30 seconds for the entire duration of the video. The outcome assessors will also score the entire video for emergence delirium using the Paediatric Anesthesia Emergence Delirium (PAED) scale every 5 minutes beginning at the completion of fracture reduction until the participant is awake and drinking. Participants will receive standard monitoring of oxygen saturation, blood pressure, respiratory rate, apnea, heart rate, and rash by the attending nurse and physician every 5 minutes as per the usual standard of care. The usual standard of care also includes monitoring post-anesthetic for the presence of known idiosyncratic effects of ketamine that include vomiting, seizure, headache, emergence reaction, and hypersensitivity. The RA will obtain this information from the nursing record at discharge and based on consensus-based Canadian recommendations. Immediately prior to discharge, the RA will also record the duration of stay in the ED, parental, patient, and physician satisfaction with PSA using a 5-item Likert scale, and nasal irritation

Official Title
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Intranasal Ketamine Versus Intravenous Ketamine for Procedural Sedation in Children: a Multi-centre Randomized Controlled Non-inferiority Trial

Conditions
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Bone Fractures, Dislocations

Intervention / Treatment
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* Drug: IN ketamine
* Drug: IV ketamine
* Drug: IN saline 0.9%
* Drug: IV saline 0.9%


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 4 -17 years Up to 80 kg Presenting the paediatric emergency department Require a closed reduction by procedural sedation and analgesia Acute (=< 48 hours) distal radius and/or ulna fracture that is angulated with or without displacement No more than 0.5 cm shortening in either the radius or ulna (not both) Exclusion Criteria: Previous hypersensitivity reaction to ketamine Globe rupture Traumatic brain injury with intracranial hemorrhage History of uncontrolled hypertension Nasal bone deformity Duration of reduction expected to be greater than 20 minutes Poor English or French fluency in the absence of a native language interpreter American Society of Anesthesiologists (ASA) class of 3 or greater Previous sedation with ketamine within 24 hours Previous diagnosis of schizophrenia or psychosis based on DSM-V criteria Pregnancy Neuro-cognitive impairment that precludes informed consent, assent, or ability to self-report pain and satisfaction Multi-limb trauma Hemodynamic compromise Glasgow coma score < 15 Fracture is comminuted Fracture is associated with a dislocation Hematoma block at index visit Unilateral or bilateral nasal obstruction (due to infectious or allergic rhinitis, nasal polyps, septal hematoma, or septal deviation)

Ages Eligible for Study
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Minimum Age: 4 Years
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: IN ketamine and IV saline<br>Ketamine, single dose, 10 mg/kg (0.1 mL/kg) of 100 mg/mL solution delivered intranasally using an atomizer and divided to both nares to a maximum of 800 mg (8 mL) AND 0.9% normal saline (NS) 0.02 to 0.03 mL/kg delivered intravenously to a maximum of 2.4 mL | Drug: IN ketamine<br>* Intranasal ketamine 100 mg/mL solution (10 mg/kg, maximum 800 mg)<br>* Other names: ketamine hydrochloride;Drug: IV saline 0.9%<br>* Intravenous 0.9% normal saline<br>|
| Active Comparator: IV ketamine and IN saline<br>Ketamine, single dose, 1 to 1.5 mg/kg (0.02 to 0.03 mL/kg) of 50 mg/mL solution delivered intravenously, to a maximum of 120 mg (2.4 mL) AND 0.9% normal saline (NS) 0.1 mL/kg delivered intranasally using an atomizer and divided to both nares, to a maximum of 8 mL | Drug: IV ketamine<br>* Intravenous ketamine 50 mg/mL solution (1 to 1.5 mg/kg, maximum 120 mg)<br>* Other names: ketamine hydrochloride;Drug: IN saline 0.9%<br>* Intranasal 0.9% normal saline<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adequacy of sedation | Proportion with DOCS score -2 to +2 for duration of fracture reduction | Duration of fracture reduction | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Depth of sedation | Score using Pediatric Sedation State Scale | Duration of fracture reduction | 
| Onset of adequate sedation | Time interval from first IN sprays to first DOCS score between -2 and +2 in minutes | Within 1 hour following intervention | 
| Duration of sedation | Duration of time between the first DOCS score -2 to +2 to last DOCS score between -2 and +2 post-fracture reduction | Within 2 hours following intervention | 
| Proportion of time participant adequately sedated during fracture reduction | Proportion of time DOCS score is -2 to +2 during fracture reduction. | Within 2 hours following intervention | 
| Adverse events | The proportion of participants with adverse effects between groups will be compared. The list of adverse effects was chosen based on known adverse effects associated with ketamine and consensus-based recommendations for reporting for procedural sedation and analgesia in children. | Within 2 hours following intervention | 
| Length of stay due to PSA | Time interval from the first pair of IN sprays to discharge | Within 3 hours of intervention | 
| Duration of procedure | Time of the first pair of IN sprays to the end of cast or splint application | Within 3 hours of intervention | 
| Caregiver satisfaction | Obtained when patient is awake and drinking using a Visual Analog Scale; Parents not wishing to remain in proximity of child for sedation may opt out | Within 2 hours of intervention | 
| Participant satisfaction | Obtained when patient is awake and drinking using a Visual Analog Scale; Satisfaction will only be assessed in children at least eight years of age as the VAS has not been validated in younger children. | Within 2 hours of intervention | 
| Physician satisfaction | Obtained immediately prior to discharge using a Visual Analog Scale | Within 2 hours of intervention | 
| Nurse satisfaction | Obtained immediately prior to discharge using a Visual Analog Scale | Within 2 hours of intervention | 
| Requirement for additional sedative medication | Number of doses and type of adjunctive sedative medication required; Deemed inadequate if additional sedative medication given (for IN ketamine group only) | Within 2 hours of intervention | 
| Analgesic medication | Number of doses and type of analgesic medication required | Within 2 hours of intervention | 
| Pain | Pain scores will be recorded using the FPS-R on arrival and when the child is awake and drinking | Within 2 hours of intervention | 
| Emergence delirium | The proportion of children experiencing emergence delirium will be compared using the Paediatric Anesthesia Emergence Delirium (PAED) scale scored from the video every 5 minutes by an outcome assessor starting when fracture reduction is complete to when awake and drinking | 20 to 80 minutes post-IV intervention | 
| Nasal irritation | Measured using the Faces Pain Scale - Revised when awake and drinking | Within 2 hours following intervention | 
| Successful sedation | Successful sedation - Based on the definition of Bhatt et al., this will be defined as no unpleasant patient recall of the procedure, no resistance or restraint required during the procedure, no permanent sedation-related complication or no sedation-related event requiring abandonment of the procedure. Defined as: no unpleasant patient recall of the procedure, no resistance or restraint required during the procedure, no permanent sedation-related complication or no sedation-related event requiring abandonment of the procedure. Defined as no unpleasant recall of procedure, no resistance or restraint, no permanent sedation related complication, no sedation-related event requiring abandonment of procedure | Within 2 hours following intervention | 
| Adjunctive IV therapy | Other reasons for IV insertion (analgesia, anxiolysis, fluids, etc.) | Within 2 hours following intervention | 
| Number of IN sprays received / Intended number of sprays | Number of IN sprays received / Intended number of sprays | Within 2 hours following intervention | 
| Number of IV attempts | Number of IV attempts and time to IV insertion Number of IV attempts | Within 2 hours following intervention | 
| Time to IV insertion | Time from first breakage of skin to establishment of successful flow with a flush | Within 2 hours following intervention |