Page 44 - JSOM Fall 2023

analgesic in military medicine due to its reliability and efficacy Author Contributions
23
on the battlefield. It stimulates the cardiovascular system via MR, CPJ, MG, DJ, PP, TS, AL, DC participated in study con-
sympathomimetic action while having little effect on ventila- cept and design. MR and DC participated in acquisition of
23
tion. Among military practitioners, ketamine-related psycho- data, MR, CPJ, DC in analysis of data, and AO, MR, CPJ,
dysleptic side effects are rumored to be reduced by midazolam. MG, DJ, DC in drafting of the manuscript. AO, DC, PP, TS,
However, this has never been proven. Some of our respondents AL revised the manuscript. All authors read and approved the
used midazolam as a single agent. Due to its hypnotic proper- final manuscript.
ties, it would seem more appropriate for sedation rather than
pain control. Ethics
Scientific and ethical approval was obtained from the French
Despite the large number of studies on sufentanil and fentanyl Military Health Service research division (project validation
in INA, particularly in prehospital care, these medications no. 2019PHJ20).
were less frequently used by our responding French military
physicians. Being more lipophilic than ketamine, these opioid References
molecules are more easily absorbed than the latter by the nasal 1. Benov A, Salas MM, Nakar H, et al. Battlefield pain management:
mucosa. However, their side effects, notably hypotension and A view of 17 years in Israel Defense Forces. J Trauma Acute Care
respiratory depression, are of serious concern when used in a Surg. 2017;83:150–155.
casualty with hemorrhagic shock. On the other hand, these 2. Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al. Pain fol-
lowing battlefield injury and evacuation: A survey of 110 casual-
major adverse effects can be rapidly reversed by IN adminis- ties from the Wars in Iraq and Afghanistan. Pain Med. 2009;10:
tration of naloxone. 24 1487–1496.
3. Travers S, Carfantan C, Luft A, et al. Five years of prolonged field
Several procedures were introduced to implement INA in care: prehospital challenges during recent French military opera-
French Armed Forces for combat settings in a similar manner to tions. Transfusion. 2019;59:1459–1466.
the U.S. TCCC. 21,25 Finally, a ketamine self-pulverization device 4. Grassin-Delyle S, Buenestado A, Naline E, et al. Intranasal drug
delivery: An efficient and non-invasive route for systemic admin-
for INA is under development by the French Military Health istration: Focus on opioids. Pharmacol Ther. 2012;134:366–379.
Service for all servicemembers, thus complementing the current 5. Jacques J.-M. Utilisation de la voie intranasale en médecine d’ur-
subcutaneously self-administered 10mg morphine syrette. It gence. Louvain Med. 2016;135:223–230.
will be essential to evaluate the impact of these improvements 6. Dale O. Intranasal administration of opioids/fentanyl physio-
on the level of knowledge and implementation of INA. logical and pharmacological aspects. Eur J Pain Suppl. 2010;4:
187–190.
7. Fantacci C, Fabrizio GC, Ferrara P, et al. Intranasal drug admin-
Our study was limited by the low response rate despite the istration for procedural sedation in children admitted to pediatric
three reminders as described. This low response rate might emergency room. Eur Rev Med Pharmacol Sci. 2018;22:217–222.
be the result of physicians deployed during the study period 8. Lemoel F. Gestion de la douleur traumatique en urgence par voie
(n = 92; 11.8%), an increase in administrative work result- intra nasale. Proceedings of the COPACAMU. 17–18 Mars 2016;
ing in less available time, and the clinical challenges of the Marseille, France.
COVID-19 epidemic. As a consequence, physicians interested 9. Carr D, Goudas L, Denman W, et al. Safety and efficacy of in-
in INA were probably overrepresented in our study. tranasal ketamine for the treatment of breakthrough pain in
patients with chronic pain: A randomized, double-blind, placebo-
controlled, crossover study. Pain. 2004;108:17–27.
Conclusion 10. Dubecq C, Taton P, Morand G. Intérêt de la kétamine intra nasale
dans le traitement de la douleur aiguë du blessé traumatique. Méd
Though a majority of French military physicians reported be- Armées. 2018;46:143–150.
ing familiar with INA, few had practical experience. Knowl- 11. Yanagihara Y, Ohtani M, Kariya S, et al. Plasma concentration
edge and use of this technique varied according to previous profiles of ketamine and norketamine after administration of var-
ious ketamine preparations to healthy japanese volunteers. Bio-
medical training and the type of military unit supported. Spe- pharm Drug Dispos. 2003;24:37–43.
cific training should, therefore, be recommended to spread 12. Weber F, Wulf H, Gruber M, et al. S-ketamine and S-norketamine
and standardize its use. This administration route seems to be plasma concentrations after nasal and IV administration in anes-
promising for military health practitioners, whose main mis- thetized children. Paediatr Anaesth. 2004;14:983–988.
sion is to provide medical support to troops whenever and 13. Andolfatto G, Innes K, Dick W, et al. Prehospital analgesia with
wherever necessary. However, implementation and follow-up intranasal ketamine (PAIN-K): A randomized double-blind trial
in adults. Ann Emerg Med. 2019;74:241–250.
studies are needed. 14. Stephen R, Lingenfelter E, Broadwater-Hollifield C, et al. Intra-
nasal sufentanil provides adequate analgesia for emergency depart-
Acknowledgments ment patients with extremity injuries. J Opioid Manag. 2012;8:
The authors would like to thank all participants for their time 237–241.
and interest. This work is dedicated to all deployed military 15. Sin B, Jeffrey I, Halpern Z, et al. Intranasal sufentanil versus intra-
healthcare personnel. venous morphine for acute pain in the emergency department: A
randomized pilot trial. J Emerg Med. 2019;56:301–307.
16. Lemoel F, Contenti J, Cibiera C, et al. Intranasal sufentanil given
Disclaimer in the emergency department triage zone for severe acute trau-
The opinions or assertions expressed herein are the private matic pain: A randomized double-blind controlled trial. Intern
views of the authors and are not to be considered as reflecting Emerg Med. 2019;14: 571–579.
the views of the French Military Health Service. 17. Blancher M, Maignan M, Clapé C, et al. Intranasal sufentanil ver-
sus intravenous morphine for acute severe trauma pain: A double-
blind randomized non-inferiority study. PLoS Med. 2019;16:
Disclosure e1002849.
The authors have indicated they have no financial relation- 18. Adelgais KM, Brent A, Wathen J, et al. Intranasal fentanyl and
ships relevant to this article to disclose. quality of pediatric acute care. J Emerg Med. 2017;53:607–615.

42 | JSOM Volume 22, Edition 3 / Fall 2023