PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay

PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay
PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay
In a 3page paper:

Restate your PICOT question and its significance to nursing practice.

Summarize the findings from the articles you selected for your literature review. Describe at least one nursing practice that is supported by the evidence in the articles. Justify your response with specific references to at least 2 of the articles.

Explain how the evidence-based practice that you identified contributes to better outcomes. In addition, identify potential negative outcomes that could result from failing to use the evidence-based practice. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.

Outline the strategy for disseminating the evidence-based practice that you identified throughout your practice setting. Explain how you would communicate the importance of the practice to your colleagues. Describe how you would move from disseminating the information to implementing the evidence-based practice within your organization. How would you address concerns and opposition to the change in practice?
1-   Ahern, T. L., Herring, A. A., Miller, S., & Frazier, B. W. (2015, July). Brief research report: Low-dose ketamine infusion for emergency department with severe pain. Pain , 16(7), 1402-1409. Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/delivery?sid=641349b8-3177-45ba-953c-c5a2d79612aa%40sessionmgr102&vid=3&ReturnUrl=https%3a%2f%2feds.b.ebscohost.com%2feds%2fpdfviewer%2fpdfviewer%3fvid%3d2%26sid%3d641349b8-3177-45ba-953c-c5a2d79612aa%2540sessionmgr102
2-  Boker, G., & Anderson, P. (2014, March 20). Ketamine: An update on its abuse. J Pharm Pract, 27(6), 582-586. http://dx.doi.org/10.1177/0897190014525754
3.-  Ku, J., & Lei, H. (2014, October 28). Ketamine: An update on its clinical uses and abuses. CNS Neuroscience & Therapeutics, 20, 1015-1020. http://dx.doi.org/10.1111/cns.12363
4-  Pourmand, A., Mazer-Amirshahi, M., Royall, C., Alhawas, R., & Shesser, R. (2017, March 2). American Journal of Emergency Medicine. Low dose ketamine use in the emergency department, a new direction in pain management, 35(6), 918-921. http://dx.doi.org/10.1016/j.ajem.2017.03.005
5-  Sassano-Higgins, S., Baron, D., Juarez, G., & Esmaili, N. (2016). A review of ketamine abuse and diversion. Depression and Anxiety, 33(8), 718-727. http://dx.doi.org/10.1002/da.22536
Literature Review
The literature review is intended to determine if ketamine would be a viable alternative pain management strategy to address pain control for opioid abusers in the Emergency Department (ED).  This literature review consists of 5 articles. The studies evaluated entailed use of a nonrandomized control trial and evidence from systematic or integrative reviews published by scholarly journals.  This literature review will synthesize the comparisons and contrasts of each article. The studies used different combined routes for administering ketamine primarily, as intravenously (IV).  Studies also yield in considerations of alternative routes of administration. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Comparison and Contrast
The 5 literature studies and reviews suggest, ketamine to have a correlation suggesting adequate pain management for different types of pain control.  In contrast, Boker and Anderson (2014) notes that although ketamine is an effective pain reliever it is subject to abuse.  Additionally, it alters brain function to include alterations in time, reaction, cognition, attention, memory and color perception.  Some studies have resulted in inappropriate prescribing patterns linked to knowledge deficits, safety perceptions, and inadequate pain assessment associated with under-treatment. Xu and Lei (2014) report ketamine abuse to be increasing and produce a dissociative state and hallucinations. This review confirms the alterations in the brain including; color perception, memory, attention, cognition, reaction time, and since of time, and can produce psychological addiction.  Addiction to prescription medication is considered a national wide occurrence and can be actively addressed through use of less addictive medications with comparable medications.  Sassano-Higgins et al (2016) reveal limited withdrawal symptoms reported for users of ketamine.  Pourmand et at (2017) reports the ED involvement in the opioid epidemic to be unclear although, opioids are prescribed often in the ED for pain control. This review suggests ketamine given in the ED to be a safe and effective alternative for pain control. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Patient side effects was of high importance of quality while performing the literature review. Side effects were revealed in multiple reviews. All 5 literatures state ketamine as a dissociative type of anesthetic. Ketamine is also considered a type of drug that has been used as a street drug.  Xu and Lei (2014); Boker and Anderson (2014); Sassano-Higgins et al (2016); and Pourmand et at (2017) reports the apprehension for over use of ketamine and have potential toxicity to the gastrointestinal tract and the urinary tracts.  Gastrointestinal issues revealed to have epigastric pain, hepatic dysfunction, colic like behaviors with a dilated common bile duct, abnormal liver function test, choledochal cysts.  Urinary tract side effects report ketamine users to present with dysuria, suprapubic pain, and painful hematuria. This can result in cystitis or renal failure. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
In contrast, Ahern et al (2015) reports ketamine to be safe and have limited to mild side effects during a 2-hour monitoring experimental trial. The conclusion is contradictory due to the trial also added narcotics subsequently to the ketamine for assistance in pain management during the experiment. This study is based on the research hypotheses that ketamine is an alternative for pain management.  This research would not benefit the opioid abuser’s due to the relevance of using a narcotic as an adjunct. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Pourmand et al (2017) encourages nurses should be cautious when administering LDK (Low Dose Ketamine) due to the lack of experience. Suggestions for ketamine to be administered under the supervision of pain specialist or anesthesiologist. Texas Board of Nursing considers ketamine to be safe for an RN to administer by an order from a pain specialist or anesthesiologist therefore contraindicating the use for ED. If the nurse is to provide ketamine as an analgesic ensure proper protocols are in place. Ketamine when in larger doses can result in respiratory depression.
Alternative Uses and Locations
The literature reviewed combined inconsistences for multiple uses on ketamine to be effective for the use of major depression, suicidal ideations, bipolar depression, and asthmaticus attacks and was not limited to only pain. The subjects that were treated for pain were located in numerous areas including ED, postoperative, perioperative, conscious sedation, and medical floors. The limitation was only one resource with patients presenting from the ED. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Although the reviewed literature portrays there is high potential for opioid pain medication to be abused and even turn addictive with ketamine presenting a viable non-addictive alternative, some of the information is not based on primary data and clinical trials therefore questioning the clinical significance.  Due to lack of resources, additional limitations in the study include absence of placebos and subjectivity of pain assessment tools.  Conducting a clinical trial using patients with opioid addiction and monitor for a new development of addiction for the use of ketamine would determine if ketamine would be an effective alternative.  There is need for more clinical trials on research and data to provide enough evidence to promote ketamine as a safe alternative for opioid abusers. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
PICOT Question
Pain control is a number one priority in the patient satisfaction scores for the Emergency Departments. With patient satisfaction survey scores driving how healthcare is being performed many physicians feel pressured to prescribe to customer satisfaction instead of medical necessity.  (Zgierska, Miller, Rabago, &, 2013) Prescribing opioids in this manner has caused an epidemic of opioid dependence. The deaths from narcotics are superseding the deaths from suicide and motor vehicle accidents. (Manchikanti et al., 2012) The government is now monitoring prescriptions of opioid prescribing and more patients are coming to the Emergency Department (ED) due to the need for pain control and due to opioid addiction.  Physicians are looking for a non-opioid pain relief.  Ketamine has started to appear in the emergency room for an alternative route for opioid abusers. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Alternative uses for non-opioid pain relief in the emergency rooms have incorporate low doses ketamine (LDK) to assist with acute pain, chronic pain, and refractory pain. Adverse effects to ketamine results in dizziness, nausea, vomiting, mild hallucinations or agitation.  (Pourmand, Mazer-Amirshahi, Royall, Alhawas, & Shesser, 2017) There are different types of psychological factors that can have detrimental effects on patients being given ketamine for pain control.  According to Bokor and Anderson, “ketamine can alter numerous functions in the brain including color perception, memory, attention, cognition, reaction time, and sense of time can produce psychological addiction” (Boker & Anderson, 2014) Ketamine is a scheduled class III drug which potentiates the likely increase for abuse and addiction. (American Addiction Centers, 2018). Knowledge of the side effects and levels of abuse the patient can develop from ketamine are concerning for another rising type of addiction to start in the medical field.  Currently ketamine is a recreational drug on the streets known as the “date rape drug”. (American Addiction Centers, 2018) The rationale to utilize ketamine instead of opioids is in need of recurring research to ensure safe prescribing for patients. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
In developing my clinical question, I utilized the formula of patient, intervention, comparison, and outcome. I then was able to develop the question, Is Ketamine a safe effective alternative to pain relief in the Emergency Department for opioid abusers?    The patient criteria of the question involve the group of opioid abuser.  The problem is the need for an alternate non-opioid pain management for patients who have history of opioid abuse.  The alternative needs to be a safe alternative to pain management and not just a cover up or another drug to start an addiction.   The intervention is giving low doses of ketamine for pain management to opioid abusers.  The comparison component is substituting opioids for low-dose ketamine.  The outcome component is highly important, are we managing patients pain safely or is being prescribed ketamine fueling another type of addiction.PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Deciding on the five questions I have developed involved understanding the reasoning, safety, and effects of giving ketamine. Patient safety is the number one priority. One correlation I perceived is are we going to be seeing more people returning to the ED for ketamine?  Is this going to be another type of addiction for opioid abuser? To understand and research the problem I have developed these five questions:

What is the mechanism of action for ketamine to provide pain relief?
What are side effects of ketamine?
Is ketamine addictive?
Should ketamine be given on a patient’s own pain scale rating?
When should ketamine be contraindicated?

Question one was developed with needing to know knowledge on how ketamine provides pain relief in the body.  This can be beneficial in knowing how the drug will affect the patient.  Question two is needing to be researched for patient safety.  Side effects can be synergistic to other diagnosis’s the patient may have. Question three is beneficial in understanding ketamine addiction could be a prevalence for patients with opioid abuse to also become addicted to ketamine.  Question 4 rational includes understanding the pain scale and when to give ketamine is being given for pain.  Should this be a common substitute for acute pain?  Should there be other factors to patient reaction when deciding when to give ketamine besides patient’s pain scale rating. Drug abusers will tell you they have a pain of 10 to try and ensure having opioids prescribed to them.  Question 5 is indicative to understanding if it is safe or not safe to given in situations when patients present with multiple diagnosis including history of addiction. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.
Keywords are important in researching the best evidence reviews and practice for developing an outcome to your PICO question.  Keywords that I chose to utilize for my database search includes; low dose ketamine, opioid abuse, pain management, adverse effects, drug seekers, analgesia, addiction, acute pain, emergency department, and subdissociative dose ketamine.  The keyword chosen correlates to the significance of the PICOT question.  The low dose ketamine and subdissociative dose ketamine is the dosage that would be given to patients who need acute pain management. Opioid abuse, drug seekers, and addiction are pertinent words to understand the reasoning for the need of an alternate solution to opioids.  Pain management, analgesia, acute pain is the types of pain or synonyms for the research of pain management in the Emergency Department for opioid abusers.  The keyword Emergency Department is important in understanding the location and setting where the patient is being given ketamine. Knowledge of adverse effects of ketamine can play an important role in understanding if the medication is safe to give in an ED setting.
Knowledge of ketamine can further inquire on the safety with administration of ketamine.  Correlating side effects, adverse effects, and mechanism of action will allow for a base understanding of the scientific purpose for treating pain with ketamine.  Further investigation and research needs to be applied in relevance to the later effects of using this type of drug for pain control. PICOT question and EBP – Opioids & Ketamine in Emergency Department (ED) Literature Review Essay.


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