Clinical trial NCT02434939: Low-dose Ketamine vs Morphine for Vaso-occlusive Crisis in Sicklers
Official title: Low-dose Ketamine Versus Morphine for Severe Painful Sickle Cell Crises in Children at Mulago Hospital: A Randomised Controlled Trial
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE4
Conditions: Sickle Cell Crisis
Acute Pain
Lead sponsor: Makerere University
Sponsor class: OTHER
First posted: 2015-05-06
Enrollment: 240
Sex: ALL
Minimum age (years): 7
Maximum age (years): 18
Standard ages: CHILD
ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This clinical trial will inform of the role of Low dose ketamine in the acute treatment of severe painful sickle cell crisis in children in a day-case sickle cell centre. The primary aim is to determine whether Low dose ketamine is non inferior to morphine in the management of acute painful sickle cell crises. The specific objectives will be to determine the maximal change in NRS pain score following administration of ketamine and to examine the safety profile of ketamine compared to morphine in this population.

The investigators hypothesize that low dose ketamine will result in similar effective pain control as morphine alone and will not be associated with an increase in adverse events.

Detailed description: Acute pain episodes associated with sickle cell disease (SCD) are very difficult to manage effectively. Opioid, phobia, tolerance, availability and side effects have been major roadblocks in our ability to provide these patients with adequate pain relief.

Ketamine is cheap, widely safe, readily available drug in low-middle income setting, with analgesic effects at sub-anesthetic doses and has a wide range of use including surgery (opioid sparing drug), burns (change of dressing ) and cancer related pain. However literature concerning its use in sickle cell crises is still limited in our setting.

This is a double-blinded, randomized control, study comparing low-dose ketamine (LDK) to morphine for acute pain control in children with sickle cell crises. A sample of 240 children will be enrolled from a population of patients with Sickle Cell Anemia aged 7-18 who present to the Mulago Referral Hospital Sickle Cell Clinic with acute painful Vaso-occlusive Crisis (VOC). To take part in the study, a patient must have a pain score of 7 and above as assessment by the treating physician in addition to the patient meeting all other study criteria.

After enrollment, the consented patient's weight in kg will be determined at the holding area with a standardized calibrated weighing scale (SECA - From National Medical Stores, Uganda) before transfer to the treatment room.

Baseline clinical parameters which include pulse rate, respiratory rate, blood pressure, temperature, oxygen saturation, level of consciousness, Numerical Rating Scale (NRS) Pain score (with 0 being no pain and 10 being the worst pain possible) and sites of VOC pain will be noted.

This will be followed by placement of a peripheral intravenous cannula, G22-G20 (this is part of standard care) with subsequent fluid load of 15mls per kg of crystalloid, repeated if required. Other non analgesic therapies will be prescribed by the primary care provider and started concurrently.

The recruited patients will then be randomized and allocated to receive Ketamine at 1mg/kg (study drug) or morphine at 0.1mg/kg (active control) through an intravenous infusion using a syringe pump(Agilia, Fresenius Kabi) over 10 minutes.

The vital signs and NRS and Ramsay sedation scores (RSS) will be reassessed and recorded at 5, 10 and 20 minutes after the end of the drug infusion. However, patient monitoring will be continuous. At 20 minutes, patients with NRS of 5 and more will be given a second dose without crossing over. Monitoring will be continued as above. If the NRS is less than 5, they will continue to be reassessed every 20 minutes (vital signs, NRS, RSS and adverse events) until either inpatient admission to the ward or up to 120 minutes after which they will be cared for by the ward team..

If they require a third dose of pain medication at any time during the study, this will be deemed as treatment failure and the treating pediatrician will be contacted to provide further pain control.

Any Ketamine (even for morphine) side effects as listed in the risks and safety section will monitored for among the study subjects and will treated by the study team.

Eligibility criteria: Inclusion Criteria:

* Children aged 7-18 years
* sickle cell anemia patient with severe acute painful crisis
* Parental consent and child assent where applicable

Exclusion Criteria:

* Oxygen saturations below 90% on initial assessment
* Altered conscious and mental state that hinders communication
* Current enrollment in another clinical trial involving an investigational drug.
* History of a stroke
* Hypertension,
* Increased intracranial pressure.
* Glaucoma,
* Failed/ Difficult IV access

Primary outcomes:
measure: Maximal Change in NRS Pain Scores as a Percentage of Baseline NRS Pain Score.
timeFrame: 5, 10, 20,25,30, 40,45,50 60, 80, 100, 120 minutes post drug adminstration
Secondary outcomes:
measure: Time to Maximal Analgesic Effect and Duration of Action of Ketamine
timeFrame: 5, 10, 20, 40, 60, 80, 100, 120 minutes post drug administration
measure: Incidence of Side Effects, Including Outlying Vital Signs
timeFrame: 5, 10, 20, 40, 60, 80, 100, 120 minutes post drug administration
measure: Incidence of Treatment Failure by Treatment Group.
timeFrame: 120 minutes
Other outcomes:
Locations:
city: Kampala
country: Uganda
facility: Sickle Cell clinic, Mulago Hospital Complex
Study officials:
affiliation: Makerere University, College of Health Sciences, Department of Anesthesia and Critical Care
name: Felix A. Lubega, MBChB
role: PRINCIPAL_INVESTIGATOR
affiliation: Makerere University, College of Health Sciences, Department of Anaesthesia and Critical care
name: Tonny S. Luggya, MMed
role: STUDY_CHAIR
affiliation: Makerere University, College of Health Sciences, Department of Child Health and Pediatrics
name: Deogratias Munube, MMed
role: STUDY_DIRECTOR
affiliation: Makerere University, College of Health Sciences, Department of Anaesthesia and Critical care
name: Fred Bulamba, MBChB
role: STUDY_DIRECTOR
affiliation: University of Sydney, Department of Peadiatrics
name: Mithrika S De Silva, MD
role: STUDY_DIRECTOR
References:
citation: Marcus RJ, Victoria BA, Rushman SC, Thompson JP. Comparison of ketamine and morphine for analgesia after tonsillectomy in children. Br J Anaesth. 2000 Jun;84(6):739-42. doi: 10.1093/oxfordjournals.bja.a013585.
citation: Lubega FA, DeSilva MS, Munube D, Nkwine R, Tumukunde J, Agaba PK, Nabukenya MT, Bulamba F, Luggya TS. Low dose ketamine versus morphine for acute severe vaso occlusive pain in children: a randomized controlled trial. Scand J Pain. 2018 Jan 26;18(1):19-27. doi: 10.1515/sjpain-2017-0140.