Low-dose Ketamine vs Morphine for Vaso-occlusive Crisis in Sicklers

Condition(s) targeted: Sickle Cell Crisis; Acute Pain

Intervention: Low dose ketamine (Drug); Morphine (Drug)

Phase: Phase 4

Status: Recruiting

Sponsored by: Makerere University

Official(s) and/or principal investigator(s):
Felix A. Lubega, MBChB, Principal Investigator, Affiliation: Makerere University, College of Health Sciences, Department of Anesthesia and Critical Care
Tonny S. Luggya, MMed, Study Chair, Affiliation: Makerere University, College of Health Sciences, Department of Anaesthesia and Critical care
Deogratias Munube, MMed, Study Director, Affiliation: Makerere University, College of Health Sciences, Department of Child Health and Pediatrics
Fred Bulamba, MBChB, Study Director, Affiliation: Makerere University, College of Health Sciences, Department of Anaesthesia and Critical care

Overall contact:
Felix A. Lubega, MBChB, Phone: +256777756571, Email: falubega@chs.mak.ac.ug

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.

Official title: Low-dose Ketamine Versus Morphine for Severe Painful Sickle Cell Crises in Children at Mulago Hospital: A Randomised Controlled Trial

Study design: Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Treatment

Primary outcome: Maximal change in NRS pain scores as a percentage of baseline NRS pain score.

Secondary outcome:

Time to maximal analgesic effect and duration of action of ketamine

Incidence of side effects, including outlying vital signs

Incidence of treatment failure with ketamine.

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 5minutes. 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.

Minimum age: 7 Years. Maximum age: 18 Years. Gender(s): Both.

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

Felix A. Lubega, MBChB, Phone: +256777756571, Email: falubega@chs.mak.ac.ug

Sickle Cell clinic, Mulago Hospital Complex, Kampala 256, Uganda; Recruiting
Felix A Lubega, MBChB, Phone: +256777756571, Email: falubega@chs.mak.ac.ug
Sureshi M De Silva, MD, Phone: +256785786044, Email: mith.desilva@gmail.com

Related publications:

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.

Starting date: June 2015
Last updated: July 31, 2015