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