Page 98 - JSOM Fall 2021

Use of the Intranasal Route for Administration of Ketamine
by Special Operations Medical Personnel
During Training Mishaps

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Romain Montagnon, MD *; Christophe Dubecq, MD ; Pierre Pasquier, MD, MSc 3

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Dear Editor, another dose of 25mg of ketamine IN. (R,S)-Ketamine is a
phenylcyclohexylamine derivative consisting of its two opti-
e read with great interest the study by Fisher et al. advo- cal enantiomers, (S)- and (R)-ketamine. Racemic mixture is
Wcating the use of ketamine by Special Operations med- usually used, but (R)-ketamine does not exhibit psychoactive
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ical personnel during training mishaps. We fully agree with effects. Currently, French military physicians have access to
the different points of the article highlighting the benefit of only a racemic mixture of ketamine.
the use of ketamine for analgesia in austere settings. Indeed,
the optimal management of analgesia is a key point in com- Moreover, a recent cross-sectional survey, investigating the use
bat casualty care. Among the various drugs available for of IN analgesia in military setting, aimed to evaluate the med-
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combat analgesia, ketamine appears as a suitable drug on the ical practice of the French Military Medical Service physicians
battlefield, well known by military physicians, reliable and ef- regarding the current understanding and use of IN analgesia.
fective in controlling casualties’ acute pain, with a large ther- The surveyed population involved physicians of the French
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apeutic window. Interestingly, in the study by Fisher et al., Military Medical Service. Of the 259 responses collected,
a total of eight patients (23.5%) received ketamine using the 77.6% of physicians reported being familiar with the IN route
intranasal (IN) route. Recent studies have shown a growing for analgesia. However, only 18.4% had already used it. The
interest in the IN route for administration of ketamine during most common drug used was ketamine (51%).
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analgesia procedures. The average bioavailability of ket-
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amine delivered via the IN route is 40%. Based on the French Finally, a ketamine pulverization device for IN analgesia is be-
Military Medical Service experience, recent analgesia proce- ing developed currently by the Central Pharmacy of the French
dures proposed to extend the use of IN route for analgesia Military Medical Service. Such a dedicated device, deployed
into combat zones. Military physicians from the First Special in all medical kits, could allow auto-administration of IN ket-
Operation Medical Unit (1 Antenne Médicale Spécialisée), amine for all servicemen and women, in addition to or instead
ère
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supporting the Groupe d’Intervention de la Gendarmerie Na- of the administration of a syrette of morphine. To conclude,
tionale, a French military tactical unit, use a dedicated analge- the IN route seems to allow rapid and effective pain control on
sia protocol for administering sufentanil and ketamine via the the battlefield, before obtaining intravenous (IV) or intraosse-
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IN route. Cazes et al. reported the case of a French soldier ous (IO) access, which currently remains the gold standard for
wounded in operations who received multimodal analgesic at analgesia. We believe that having been the subject of numerous
the point of care, including 50µg/kg IN sufentanil, and the au- ongoing studies in civilian and military settings, and illustrated

thors also highlighted the interest of the use of IN ketamine by Fisher et al.’s study, IN ketamine seems to be a promising
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on the battlefield. Sufentanil is more lipophilic than ketamine solution for analgesia procedures performed in remote and
and, consequently, is absorbed better by the nasal mucosa. The austere environments.
average bioavailability of sufentanil delivered via the IN route
is 78%. The current US military and civilian standards of Author Contributions
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analgesia do not include the use of IN sufentanil. However, All authors read and approved the final manuscript.
this analgesia option is under investigation in Europe although
there is with sparse information on efficacy and safety. 11–13 Financial Disclosure
Other French military medical teams reported the use of IN The authors have indicated they have no financial relation-
ketamine to manage acute pain during deployment in over- ships relevant to this article to disclose.
seas military operations. Dubecq et al. reported a cohort of References
73 combat casualties who received 0.5mg/kg IN ketamine, 1. Fisher AD, Schwartz DS, Petersen CD, et al. Ketamine adminis-
with high efficacy and rare side effects. Indeed, the authors tration by Special Operations medical personnel during training
reported only one case of psychodyslepsy, which ended after mishaps. J Spec Oper Med. 2020;20(3):81–86.
*Correspondence to r.montagnon@yahoo.fr
1 OF-1 Romain Montagnon is affiliated with the Emergency Department, Sainte Anne Military Training Hospital, French Military Health Service,
Toulon, France. OF-4 Christophe Dubecq is affiliated with Direction Interarmées du Service de Santé Réunion-Mayotte, Antenne Médicale de
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Saint Pierre, French Military Health Service, La Réunion, France. OF-5 Pierre Pasquier is affiliated with the Department of Anesthesiology and
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Intensive Care, Percy Military Training Hospital, French Military Health Service, Clamart, France; and the French Military Health Service, Val
de Grâce Military Academy, Paris, France.
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