Medical

Communication

Biosci. Biotech. Res. Comm. 10(4): 775-782 (2017)

Comparing the analgesic effect of intranasal fentanyl

and ketamine in children

Golikhatir Iraj

, Montazer Seyed Hossein

*, Aghilli Elham

, Aminiahidashti Hamed

, Bozorgi

Farzad

, Jahanian Fatemeh

and Hosseininejad Seyed Mohammad

Assistant Professor, Department of Emergency Medicine, Mazandaran University of Medical Science, Sari, Iran

Emergency Medicine Resident, Mazandaran University of Medical Science, Sari, Iran

ABSTRACT

Introduction: Pain control is one of the treatment priorities and the most important children’s rights because children

experience painful events since birth and during childhood due to common childhood illnesses or accidents. The aim

of this study was to compare the analgesic effect of intranasal ketamine and fentanyl in children. Method: The present

research is a double blind randomized clinical trial conducted on 80 children aged 3-13 years who were admitted to

the Emergency Department of Sari Imam Hospital. The patients who met the inclusion criteria were randomly divided

into two groups using random number generator and 40 patients were considered per group. Data were analyzed

using SPSS, Mann-Whitney-U test and wilcoxon paired test. Findings: The  ndings showed that the analgesic effect

of ketamine and fentanyl are similar among the studied children and there is no signi cant difference. In ketamine

group there was signi cant difference between the mean of pain, systolic blood pressure, diastolic blood pressure,

heart rate and respiratory rate variables before and after taking ketamine, according to Willcoxon statistics and sig.

smaller than 0.05. In fentanyl Group, there was signi cant difference between the mean of pain, systolic blood pres-

sure, heart rate and respiratory rate variables before and after taking fentanyl, according to Willcoxon statistics and

sig. smaller than 0.05. There was no signi cant difference between ketamine and fentanyl analgesic effect in terms

of parental satisfaction and there was also no signi cant difference between medical team’s level of satisfaction with

ketamine and fentanyl analgesic effect. Conclusion: Considering that the analgesic effect of intranasal ketamine and

fentanyl on the pain control among the studied children is similar, their prescription is recommended. It is also rec-

ommended to simultaneously measure children’s level of anxiety and effect of these drugs on their anxiety because

children have different experiences of pain and anxiety affects measuring pain severity in future studies.

KEY WORDS: ANALGESIC, INTRANASAL, FENTANYL, KETAMINE, CHILDREN

775

ARTICLE INFORMATION:

*Corresponding Author: igk_47@yahoo.com

Received 1

Oct, 2017

Accepted after revision 21

Dec, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at:

http//www.bbrc.in/

DOI: 10.21786/bbrc/10.4/24

776 COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Golikhatir Iraj et al.

INTRODUCTION

Pain is one of the most common symptoms in patients

admitted to the emergency room. Achieving desired anal-

gesia and sedation before the procedures has become an

elusive goal in many cases (Murphy et al., (2014).Inter-

national Association of pain de ned it as an unpleasant

feeling and emotional experience associated with acute

or potential tissue damage (Hazinski 2013). Children

are usually brought to the emergency department due

to painful diseases and injuries. Other diagnostic and

painful or unpleasant therapeutic procedures may be

required during the visits (Atkinson et al., (2009). Pain

in children is more dif cult than adults either in the

evaluation or treatment process. This dif culty becomes

more obvious when Intravenous analgesic is considered

(Moore et al. (2010). Creating a practical approach to

sedation and analgesia may vary in different parts of the

world (Shahryariet al 2010 Majidi et al., 2017).

Many studies have been conducted on the analge-

sic effects of ketamine in the world. Many studies con-

ducted on intranasal, oral and rectal administration of

ketamine have shown that topical application of this

drug is also possible. Many empirical evidence suggest

that NMDA receptors exist in the central nervous sys-

tem and peripheral nerves. Moreover, empirical studies

have noted that the peripheral administration of NMDA

receptor antagonists show analgesic effects of this drug

(Hadayi M, Rezaeian M. (2011, Brian et al 2015).

Fentanyl is a potent opioid agonist that can be used

in different ways. Fentanyl is the oldest synthetic opioid

agonist and mainly exerts its effect on the hair receptor

(Brian et al., (2015). Intravenous administration is the

main method of medications to children but it is also

stressful and painful and we sometimes need to spend

a lot of time. Intramuscular injection is similar to the

intravenous injection with the exception that longer

period of time is required for the drug to exert its effect.

According to the foregoing, intranasal and buccal meth-

ods seem to be more appropriate methods (Banks, et al.

(2004). However, between these two methods, using buc-

cal method requires need more interaction between the

child and the therapist and even in voluntary cases of

drug use, 56% of the drug remains in the mouth. Nasal

cavity holds a rich vascular network and since this vas-

cular bed is easily accessible, it is easy to be managed.

Onset and peak effect usually occurs after 3-5 minutes

and within 10-15 minutes (Veldhorst, 2013).

Studies have shown that a wide range of intrana-

sal ketamine doses has been used in clinical practice

and further research is proposed to determine the opti-

mal dose of intranasal ketamine for analgesia (Marcia

et al. (2013). So far, various medications are presented

and provided for this purpose. But ketamine, which is a

receptor agonist has gained much popularity in this  eld

(Majidi et al., 2017).

Fentanyl is a short-acting strong industrial drug and

is now widely used for pain relief. Few studies have com-

pared the effects of intranasal fentanyl and ketamine.

Graudins et al., (2015) conducted a study in American

Academy of Emergency Medicine (AAEM) and compared

the effect of intranasal fentanyl and ketamine in children

3 to 13 years who suffered from organ damage and had

pain severity of at least 6 out of 10. The 40 children were

assigned in each group in this comparison. As a result,

a reduced pain which was reported in both groups was

similar, but ketamine showed more side effects. Level of

satisfaction with and side effects of ketamine and fenta-

nyl was respectively 83%, 78% and 82%, 40%. Prior to

this study, there was no study on intranasal fentanyl and

ketamine for pain control in children.

In a study in 2013 in the Department of Emergency

Medicine of British Columbia Hospital, Andolfatto

investigated the intranasal ketamine effect in reducing

pain in patients admitted to the emergency department.

This study was performed in patients older than 6 years.

A total of 40 patients were enrolled in the study and the

mean change in pain was 34mm within 30 minutes and

the average time for this reduction in pain was about

9.5 minutes. There were no reports of serious side effects

during this time and all reported side effects were tran-

sient, requiring no intervention.

Murphy et al. (2014) conducted a study in the Depart-

ment of Emergency Medicine at University College Dub-

lin and studied intranasal fentanyl consumption for

the treatment of acute pain in children. Patients were

randomly selected and intranasal fentanyl was admin-

istrated for pain control and its ef cacy was compared

with intravenous medications. Side effects and level

of satisfaction were also investigated. This study was

carried out on children aged less than 21 years who

weighed more than 10 kg with severe pain . Severity of

pain was assessed every 5 minutes to 30 minutes and

then at 30.60 and 120 minutes. A total of 30 patients

were enrolled and the pain severity was dropped by

about 13mm after 120 minutes. There were no severe

side effects, for which intervention was needed. Also,

small sample size of some studies caused the results

not to be generalized to the entire population (Yeaman

et al., (2013). Also, different doses of these two drugs

were used in studies on the effects of intranasal keta-

mine or fentanyl in pain control among children (Saun-

ders et al., 2010).

In our country, no comparison has been made in this

way. Since there has been no similar study in this regard

so far in the country, similar studies conducted abroad

are few and the results of these few studies cannot gen-

eralized to all areas yet. On the other hand, taking into

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN 777

Golikhatir Iraj et al.

account the speed and ease of use of the intranasal drug,

we decided to compare the effect of intranasal fentanyl

and ketamine as well as their effects and complications

in pain management. The present study also aimed to

achieve acceptable outcome with regard to recommend-

ing the use of these two drugs in the emergency depart-

ment by measuring satisfaction of parents and medical

team.

MATERIAL AND METHODS

This study is a double blind randomized clinical trial

that was conducted on 80 children aged 3-13 years’ old

who were taken to Sari Imam Hospital. Individuals who

were enrolled in the study were selected among all chil-

dren aged 3-13 years who were admitted to emergency

due to the trauma and needed remedial measures and

painful procedures such as healing wounds with moder-

ate to severe pain during procedure. The number of sam-

ples was considered 40 individuals for each group based

on statistical formulas. Patients who met the inclusion

criteria were randomly assigned in two groups using

random number generator so that the number of chil-

dren had relatively equal distribution at the end, allow-

ing evaluation of the results for both age groups. A total

of 40 patients were considered in each group. One group

received Ketamine and the other one was given fentanyl.

Among pain severity assessment scales, which are used

at early age, FPS-R scale is a scale that is translated into

30 languages and can be used for free (Julie 2013).

VAS scale is also a measure commonly used in the

age of 6 years, the patient shows the location of his/her

pain on a horizontal line. Left and right sides of the line

show point of no pain and unbearable pain, respectively.

Pain score range is between the pain score in the left side

and is expressed in millimeters. Based on the pain scales

pain severity of 6 and higher shows moderate to severe

pain. At the beginning of the project and during the pro-

cedure, FPS-R and VAS scales were respectively used to

assess pain in children aged 3-6 and over 6 years. Even-

tually, after summarizing the pain assessment results

and the effect of the drugs on it, qualitative evaluation

of the results was performed.

According to ASA physical status classi cation

standards, all ASA I and II class children were enrolled

in the study. Also according to method of drug use,

all children with severe colds, respiratory infections or

major nasal damage, and all those with taking painkill-

ers before referral, given the confounding effect on the

evaluation of results, and contraindications for drugs,

suspected cases of increased ICP, severe respiratory dis-

eases or a history of seizure disorders were excluded.

Also, after obtaining permission from the Medical Ethics

Committee, registering the present trial in the Iranian

database of clinical trials and providing adequate expla-

nations on how to do pain management technique as

well as obtaining consent letter from children’s parents,

patients were enrolled.

However, patients were not deprived of any treat-

ment due to participation in this research and it does

not cause any harm to them .Lidocaine was used for

local anesthesia during the procedure. Both drugs pro-

duced by Rotemxmedica-Germany company, Ketamine

and fentanyl were prepared by Saha Halal Pharmaceuti-

cal Company and Drug Administration of Mazandaran

University of Medical Sciences, respectively. After the

initial assessment and recording pain levels and vital

signs at admission in the  rst questionnaire then in the

second questionnaire during the procedure, the follow-

ing standard recording and monitoring were performed:

pulse rate (PR), respiratory rate (RR), blood pressure (BP),

blood oxygen saturation (SpO2) and temperature body

temperature (T).

Drugs were already drawn into 1cc syringes, to have

equal volume of drugs, appropriate to 10 kg weight. The

syringe were named A and B and were given to the head

of the pharmaceutical ward who was unaware of their

contents. The drugs were later administrated to patients

in a double-blind, randomized manner during the pro-

ject. One group received 1 mg / kg intranasal ketamine

and 1mcg/kg intranasal fentanyl was administrated to

another group. The procedure was started 5 minutes

after administration is starting considering the time

required for onset of action. The pain severity and vital

signs were examined at 5, 15, 20, 30, 45 and 60 minutes

in the studied patients, if necessary, an additional 1.4

dose was prescribed for pain control to at 15 minutes.

In case of spo2 less than 92% for more than 10 seconds

or apnea more than 20 seconds, jaw thrust maneuver

and mask ventilation was started. Nausea and vomiting

was measured by observing and questioning the patient

and parents. Other side effects, including dizziness, and

derealization were recorded by observing and question-

ing and each of them underwent treatment and moni-

toring based on the severity and type. Information was

recorded by an individual (emergency resident or medi-

cine specialists) who was unaware of the groups. Data

analysis was carried out using SPSS v.16 and Mann-

Whitney-U test and Willcoxon paired test.

RESULTS AND DISCUSSION

The mean ± standard deviation of pain before tak-

ing Ketamine and fentanyl were respectively, 8.9, 8.93

and 0.93, 0.92 and there was no signi cant difference

between Ketamine and fentanyl groups in terms of pain

before taking these drugs based on Mann-Whitney U

z-statistic and sig. value of greater than 0.05. Thus, chil-

778 COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

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Table 1. Comparison of pre- to post-intervention change in pain intensity in both groups

based on Mann-Whitney-U test

Variable Group Average Number

Standard

Deviation

Mann- Whitney

Z statistics

Sig.

Pre medication

pain

Ketamine 40 8.90 0.93

0.14- 0.900

Fentanyl 40 8.93 0.92

Post medication

pain

Ketamine 40 2.68 0.86

0.00 0.001

Fentanyl 40 2.68 0.86

Table 2. Comparison of variable blood pressure, heart rate and oxygen saturation before

taking the drug among children in groups based on Mann-Whitney U test

Variable Group Number Average

Standard

deviation

Mann-Whitney

Z statistics

Sig.

Pre- systolic blood

pressure

Ketamine 40 107.63 5.43

1.86- 0.062

Fentanyl 40 107.38 4.86

Pre diastolic blood

pressure

Ketamine 40 66.38 5.06

0.64- 0.52

Fentanyl 40 65.63 4.83

Pre-heart rate

Ketamine 40 108.30 7.05

0.07 0.95

Fentanyl 40 108.35 7.49

Pre-RR

Ketamine 40 18.40 1.82

0.76- 0.45

Fentanyl 40 18.80 2.02

Pre- oxygen

saturation

Ketamine 40 99.50 0.96

0.05- 0.96

Fentanyl 40 99.55 0.85

dren in both groups were not statistically different in

terms of the premedication pain and are homogeneous.

The mean ± standard deviation of pain after taking Ket-

amine and fentanyl were respectively, 2.68, 2.68 and 0.86,

0.86 and there was no signi cant difference between Keta-

mine and fentanyl groups in terms of pain after taking

these drugs based on Mann-Whitney U z-statistic and sig.

value of greater than 0.05. Thus, children in both groups

were not statistically different in terms of the post-medi-

cation pain and are homogeneous. In other words, it can

be said that the analgesic effect of these drugs is similar in

children is not signi cantly different (Table 1).

According to U Mann Whitney Test, mean ± SD of

systolic blood pressure before taking ketamine and fen-

tanyl were 107.63, 107.38 and 5.43, 4.86, respectively.

Based on U Mann Whitney Test z-statistic and sig. value

of greater than 0.05, there is no difference between

the two groups of children in terms of blood pressure

before using the drug. According to U Mann Whitney

Test, mean ± SD of diastolic blood pressure before taking

ketamine and fentanyl were 66.38, 65.63 and 5.06, 4.83,

respectively. Based on U Mann Whitney Test z-statistic

and sig. value of greater than 0.05, there is no difference

between the two groups of children in terms of dias-

tolic blood pressure before using the drug. Mean ± SD

of heart rate before taking ketamine and fentanyl were

108.30, 108.35 and 7.05, 7.49, respectively. Based on U

Mann Whitney Test z-statistic and sig. value of greater

than 0.05, there is no difference between the two groups

of children in terms of heart rate before using the drug.

Mean ± SD of respiratory rate before taking ketamine

and fentanyl were 18.4,18.8 and 1.82,2.02, respectively

and based on U Mann Whitney Test z-statistic and sig.

value of greater than 0.05, there is no difference between

the two groups of children in terms of respiratory rate

before using the drug.

Mean ± SD of oxygen saturation before taking ket-

amine and fentanyl were 99.5, 99.55 and 0.96,0.85,

respectively and based on U Mann Whitney Test z-sta-

tistic and sig. value of greater than 0.05, there is no

difference between the two groups of children in terms

of oxygen saturation before using the drug. Thus, we

conclude that children in two groups are homogeneous

in terms of the above variables and there is no signi -

cant difference between them before treatment (Table 2).

Based on U Mann Whitney Test, mean ± SD of sys-

tolic blood pressure after taking ketamine and fenta-

nyl were 103.75,103.25 and 4.63,5.13, respectively and

based on U Mann Whitney Test z-statistic and sig. value

of greater than 0.05, there is no difference between the

two groups of children in terms of systolic blood pres-

sure after using the drug.

Mean ± SD of diastolic blood pressure after taking

ketamine and fentanyl were 64,65 and 4.56,4.24, respec-

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN 779

Golikhatir Iraj

Table 3. Comparison of blood pressure, heart rate and oxygen saturation variables after drug

consumption among children in both groups based on Mann-Whitney-U test

Variable Group Number Average

Standard

deviation

Mann-Whitney

Z statistics

Sig.

Post- systolic blood

pressure

Ketamine 40 103.75 4.63

0.69- 0.4896

Fentanyl 40 103.25 5.13

Post diastolic blood

pressure

Ketamine 40 0.64 4.56

1.21- 0.2268

Fentanyl 40 0.65 4.24

Post –heart rate

Ketamine 40 102.15 5.57

1.54- 0.1242

Fentanyl 40 0.100 5.83

Post-RR

Ketamine 40 17.45 1.50

0.52- 0.6063

Fentanyl 40 17.60 1.45

Post –oxygen

saturation

Ketamine 40 99.70 0.72

1.11- 0.2666

Fentanyl 40 99.50 0.88

Table 4. Comparison of variables between children groups treated with ketamine based on Willcoxon

paired test

Ketamine

Drug type Average Number

Standard

deviation

Willcoxon

statistics

Sig.

Pre medication pain 8.90 40 0.93

5.630- 0.00009

Post-medicationpain 2.68 40 0.86

Pre medication systolicblood pressure 107.63 40 5.43

3.489- 0.0005

Post medication systolicbloodpressure 103.75 40 4.63

Pre-medicationdiastolicbloodpressure 66.38 40 5.06

2.747- 0.0060

Post-medicationdiastolicbloodpressure 0.64 40 4.56

Pre-medicationHeart ratePre 108.30 40 7.05

5.191- 0.00009

Post-medicationheart rate 102.15 40 5.57

Pre-medicationRR 18.40 40 1.82

4.359- 0.00009

Post-medicationRR 17.45 40 1.50

Pre- medication oxygen saturation 99.50 40 0.96 1.232-

0.2180

Post- medication oxygen saturation 99.70 40 0.72

tively and based on U Mann Whitney Test z-statistic and

sig. value of greater than 0.05, there is no difference

between the two groups of children in terms of diastolic

blood pressure after using the drug.

Mean ± SD of heart rate after taking ketamine and fen-

tanyl were 102.15,100 and 5.57,5.83, respectively and based

on U Mann Whitney Test z-statistic and sig. value of greater

than 0.05, there is no difference between the two groups of

children in terms of heart rate after using the drug.

Mean ± SD of respiratory rate after taking ketamine

and fentanyl were 17.45,17.60 and 1.5,1.45, respectively

and based on U Mann Whitney Test z-statistic and sig.

value of greater than 0.05, there is no difference between

the two groups of children in terms of respiratory rate

after using the drug.

Mean ± SD of oxygen saturation after taking ketamine

and fentanyl were 99.70,99.50 and 0.72,0.88, respectively

and based on U Mann Whitney Test z-statistic and sig.

value of greater than 0.05, there is no difference between

the two groups of children in terms of oxygen saturation

after using the drug. Thus, we conclude that there is no

statistically signi cant difference between children in the

two groups after taking the drugs and the effect of these

drugs on children is similar in this study (Table 3).

Now, after examining the mean differences between

studied variables in two groups of children, we inves-

tigate the differences between these variables in each

group before and after drug use in this section. Accord-

ing to Willcoxon statistics and sig. value of smaller than

0.05, there was statistically signi cant difference in

the ketamine group among mean values of pain, sys-

tolic blood pressure, diastolic blood pressure, heart rate

and respiratory rate before and after taking ketamine.

In other words, ketamine is effective in reducing blood

pressure (systolic and diastolic), heart rate and respira-

tory rate except for oxygen saturation variable (Table 4).

780 COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

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Table 5. Comparison of variables between children groups treated with fentanyl based on Willcoxon

paired test

Fentanyl

Drug type Average Number

Standard

deviation

Willcoxon

statistics

Sig.

Pre-medication pain 8.93 40 0.92 5.630-

0.00009

Post-medication pain 2.68 40 0.86

Pre-medication systolic blood pressure 109.88 40 4.87 3.489-

0.0005

Post-medication systolic blood pressure 103.25 40 5.13

Pre-medication diastolic blood pressure 65.63 40 4.83 2.747-

0.0060

Post-medication diastolic blood pressure 0.65 40 4.24

Pre-medication Heart Pre rate 108.35 40 7.49 5.191-

0.00009

Post- medication heart rate 0.100 40 5.83

Pre- medication RR 18.80 40 2.02 4.359 -

0.00009

Post-medication RR 17.60 40 1.45

Pre-medication oxygen saturation 99.55 40

0.85

1.232-

0.2180

Post-medication oxygen saturation 99.50 40 0.88

Table 6. Comparison of parents and the medical team satisfaction with analgesic effect of

Ketamine and fentanyl based on the Mann-Whitney U test

Variable Group Number Average

Standard

deviation

Mann Whitney

Z statistics

Sig.

Parental satisfaction

Ketamine 40 73.75 7.40

0.991 0.322

Fatanyl 40 75.25 6.79

Medical Team

Satisfaction

Ketamine 40 74.75 5.06

0.890- 0.374

Fantanyl 40 75.75 5.01

According to Willcoxon statistics and sig. value of

smaller than 0.05, there was statistically signi cant dif-

ference in the fentanyl group among mean values of

pain, systolic blood pressure, heart rate and respiratory

rate before and after taking fentanyl. In other words,

fentanyl is effective in reducing blood pressure (systolic

and diastolic), heart rate and respiratory rate except for

diastolic blood pressure and oxygen saturation variable

(Table 5)

Based on the Mann-Whitney test, mean ± SD of par-

ents’ satisfaction with analgesic effect of ketamine and

fentanyl were respectively 73.75, 75.25 and 7.40 6.79;

so based on the Mann-Whitney z-statistic and sig. value

of more than 0.05, there is no signi cant difference

between parental satisfaction with the ketamine and

fentanyl analgesic effect.

Mean ± SD of medical team satisfaction with anal-

gesic effect of ketamine and fentanyl were respectively

74.75, 75.75 and 5.06, 5.01; so based on the Mann-

Whitney z-statistic and sig. value of more than 0.05,

there is no signi cant difference between medical team

satisfaction with the ketamine and fentanyl analgesic

effect (Table 6).

The results showed that there is no signi cant dif-

ference between analgesic effects of these two drugs

in studied children. These results are consistent with

results obtained by Gradyns (2015) in America where

the level of pain reduction was similar in both groups.

The result of the current study are also consistent with

the results of the study conducted by Yeamen et al.,

(2013) who examined the effects of fentanyl and keta-

mine on pain and pain caused by intraoperative ulcer

and concluded that both fentanyl and ketamine are

effective in pain relief and analgesia compared with

placebo, but are not signi cantly different from each

other: but the results of this study are inconsistent with

results of the study conducted by (Julie 2013) in Iran,

in which the difference between ketamine and fenta-

nyl is relatively low and negligible and this effect has

been reported to be due to the analgesic properties of

ketamine.

The results of studies on the effects of fentanyl and

ketamine are different, which could be due to different

injury, choice of different patients, lack of blinding in the

studies and type of the study design. The results showed

that except for the oxygen saturation variable, ketamine

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARING THE ANALGESIC EFFECT OF INTRANASAL FENTANYL AND KETAMINE IN CHILDREN 781

Golikhatir Iraj

was effective in reducing blood pressure (systolic and

diastolic), heart rate and respiratory rate and fentanyl

was also effective in reducing systolic blood pressure,

heart rate and respiratory rate except for diastolic blood

pressure and oxygen saturation variables. Very limited

side effects were observed that were not tested due to

being limited. Five derealization cases in the ketamine

Group and three vomiting and three nausea cases in the

fentanyl Group were reported. The results of the present

study are consistent with the results of the study con-

ducted by Gradyns (2015) who showed that ketamine

has more side effects.

In a study on changes in respiratory rate, Javaher-

forooshet al., (2006)showed that ketamine and fentanyl

lead to the highest and lowest respiratory rates, which

may be due to the respiratory stimulant and respiratory

depression effects of ketamine and fentanyl, respec-

tively. In a study, (Tsze et al., (2012) showed that keta-

mine was well tolerated in pediatric pain management

and one case led to vomiting. The results showed that

the difference between the satisfaction of parents and

the medical team of ketamine and fentanyl analgesic

effect is not signi cant. Parents’ average satisfaction

with the analgesic effect of ketamine in children is

73.75% and medical team’s average satisfaction with

the analgesic effect of fentanyl was equal to 74.75%.

The same amount for ketamine and fentanyl was 83%

and 82%, respectively in a study conducted by Gradyns

et al. (2015).

In a study on the effects of intranasal fentanyl for

pain relief in children with musculoskeletal trauma,

Saunders et al. (2010) reported satisfaction percentage

of 79% and 74% respectively for parents and the medi-

cal team. One of the limitations of this study include

that patients might have usednarcotic or any other

analgesic drug for pain relief prior to admission to the

emergency center. So, this issue could affect the out-

come of the research and that’s why this issue should

be considered in future studies and prevents the entry

of similar cases to the study. Considering the small

number of similar studies, further studies are needed

to prove the effectiveness and compare the intrana-

sal effect of these drugs. Another limitation was that

pain was different for children because they had dif-

ferent experiences of pain and assess pain in children

were not easy. Therefore, it is recommended to consider

larger sample size in next studies and level of anxi-

ety in children and the effect of these drugs on anxi-

ety be measured simultaneously because children have

different experiences of pain and anxiety is effective

in measuring the severity of pain. Also, ketamine and

fentanyl analgesic effects and side effects and different

methods of administration should be investigated in

future studies.

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