Patient anxiety scores after low-dose ketamine or fentanyl for epidural catheter placement

The Effect of Preprocedural Low-Dose Ketamine for Pain and Anxiety in Patients during Thoracic Epidural Catheterization

Background and Objectives: Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods: Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results: During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K (p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point (p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points (p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements (p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K (p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K (p = 0.007). Conclusions: A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).

Use of EMLA cream for skin anesthesia and epidural insertion in the patients with cesarean delivery: A prospective double-blind randomized clinical trial

Background:

Pain relief of epidural anesthesia in cesarean delivery is difficult. EMLA, a eutectic mixture of lidocaine and prilocaine, is effective for pain reduction during venipuncture and superficial surgery. However, its effectiveness during epidural insertion is not well elucidated. The aim of this randomized, double-blind study was to evaluate the efficacy of EMLA for epidural insertion in elective cesarean delivery.

Methods:

With Institutional Review Board approval and written patients’ informed consent, forty-two ASA physical status 2 patients (aged 23–45) scheduled for elective cesarean section were included in this study. The patients were randomized to applied ELMA (EMLA group) or placebo cream (Placebo group) about one hour prior to anesthesia. Pain during skin infiltration with 1% mepivacaine and subsequent insertion of Tuohy needle was assessed immediately after each procedure. The presence of patient's response with physical withdrawal on both procedures was recorded. Statistical analysis was performed using Mann–Whitney U test and Fisher's exact test. A value of P < 0.05 was considered significant.

Results:

Median VAS values on skin infiltration and on insertion of Tuohy needle did not differ between groups. The incidence of patient's response with physical withdrawal on skin infiltration was not different between groups. However, that on insertion of Tuohy needle was significantly lower in EMLA group than in Placebo group (0%, 21%).

Conclusions:

EMLA cream could not reduce the pain during epidural insertion.

The interactive effects of ketamine and magnesium upon depressive-like pathology

Approximately one-third of patients with major depressive disorders (MDDs) are resistant to current treatment methods, and the majority of cases relapse at some point during therapy. This has resulted in novel treatments being adopted, including subanesthetic doses of ketamine, which affects aberrant neuroplastic circuits, glutamatergic signaling, and the production of brain-derived neurotrophic factor. Ketamine rapidly relieves depressive symptoms in treatment-resistant major depressive disorder patients with effects that last for up to 2 weeks even after a single administration. However, it is also a drug with an abusive potential and can have marked side effects. Hence, this study aimed at enhancing the antidepressant-like effects of ketamine (allowing for lower dosing regimens) by coadministering magnesium hydroaspartate (Mg(2+) normally affects the same receptors as ketamine) and also assessed whether an Mg(2+)-deficient diet would modify the impact of ketamine. It was found that a single 15 mg/kg dose of ketamine did indeed induce rapid antidepressant-like effects in the forced swim test but did not affect brain levels of the brain-derived neurotrophic factor. Contrary to our hypothesis, magnesium administration or deficiency did not influence the impact of ketamine on these outcomes. Thus, these data do not support the use of magnesium as an adjunct agent and instead suggest that further research involving other antidepressant and animal models is required to confirm the present findings.

Parecoxib Possesses Anxiolytic Properties in Patients Undergoing Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind, Placebo-Controlled, Clinical Study

Introduction

Intravenous administration of parecoxib could provide significant pain relief in surgical operations that require additional forms of analgesia. However, very little is known about its effects on the anxiety levels of patients before a surgical procedure. The aim of this prospective study was to investigate whether intravenous parecoxib, pre-emptively administered, has an effect on anxiety levels experienced post-surgically after total knee arthroplasty (TKA) and if it influences the reported pain of the procedure itself.

Methods

A total of 90 patients who underwent TKA under spinal anesthesia were included in the study. Prior to TKA, all patients received continuous femoral nerve block (CFNB) and were randomized into two groups: Group D consisted of 45 patients who received the drug parecoxib intravenously in addition to CFNB, whereas Group P consisted of 45 patients who received a placebo drug (N/S 0.9 %) intravenously instead of parecoxib. All patients were asked to fill in the questionnaires STAI1 and STAI2 in order to evaluate anxiety levels pre- and post-surgically, respectively. One of the main aims was to distinguish personality-trait anxiety from state anxiety, i.e., anxiety experience due to the actual perioperative events and the actual pain endured.

Results

The group receiving parecoxib had statistically significant lower anxiety levels both for personality trait anxiety and state anxiety, as compared to the placebo group.

Conclusions

Based on our findings, parecoxib had both analgesic and anxiolytic effects in patients undergoing TKA with CFNB.

Trial Registration

Current Controlled Trials: NCT02185924.

Nociception-specific blink reflex: pharmacology in healthy volunteers

BACKGROUND

The physiology and pharmacology of activation or perception of activation of pain-coding trigeminovascular afferents in humans is fundamental to understanding the biology of headache and developing new treatments.

METHODS

The blink reflex was elicited using a concentric electrode and recorded in four separate sessions, at baseline and two minutes after administration of ramped doses of diazepam (final dose 0.07 mg/kg), fentanyl (final dose 1.11 μg/kg), ketamine (final dose 0.084 mg/kg) and 0.9 % saline solution. The AUC (area under the curve, μV*ms) and the latency (ms) of the ipsi- and contralateral R2 component of the blink reflex were calculated by PC-based offline analysis. Immediately after each block of blink reflex recordings certain psychometric parameters were assessed.

RESULTS

There was an effect due to DRUG on the ipsilateral (F 3,60 = 7.3, P < 0.001) AUC as well as on the contralateral (F 3,60 = 6.02, P < 0.001) AUC across the study. A significant decrement in comparison to placebo was observed only for diazepam, affecting the ipsilateral AUC. The scores of alertness, calmness, contentedness, reaction time and precision were not affected by the DRUG across the sessions.

CONCLUSION

Previous studies suggest central, rather than peripheral changes in nociceptive trigeminal transmission in migraine. This study demonstrates a robust effect of benzodiazepine receptor modulation of the nociception specific blink reflex (nBR) without any μ-opiate or glutamate NMDA receptor component. The nociception specific blink reflex offers a reproducible, quantifiable method of assessment of trigeminal nociceptive system in humans that can be used to dissect pharmacology relevant to primary headache disorders.

Comparison of predicted and perceived pain from epidural and spinal puncture in patients undergoing elective caesarean section

The intensity of pain expected by patients before an epidural and/or a spinal puncture is uncertain. The main purpose of this study was to identify and compare the intensity of pain predicted and perceived by patients having an epidural and a spinal procedure. After screening for relevant exclusion criteria, 50 women who were undergoing elective caesarean section under combined spinal-epidural anaesthesia (double-segment technique) were enrolled in the study. Infiltration anaesthesia prior to needle insertion was performed for the epidural but not the spinal puncture. Pain assessments, using a 100 mm visual analogue pain scale, were made before (predicted pain) and after (perceived pain) the epidural and the spinal puncture. Predicted pain for epidural and spinal insertion (epidural 60.6 +/- 20.5 mm, spinal: 55.1 +/- 24 mm) was significantly higher than the pain perceived (epidural 36.3 +/- 20 mm, spinal 46.1 +/- 23.2 mm) (epidural P < 0.001, spinal P = 0.031). Patients who were scheduled for an elective caesarean section under combined spinal-epidural anaesthesia predicted 1.2- to 1.7-fold stronger pain intensity than they perceived during the procedure. Patients should be informed that a regional anaesthetic, especially epidural, procedure is often less painful than the patient's expectation.

Predominant effects of midazolam for conscious sedation: benefits beyond the early postoperative period

PURPOSE

Conscious sedation with intravenous sedative-hypnotic drugs has the advantage of relaxing patients before invasive procedures. Preoperative anxiety has been suggested to correlate with postoperative comfortableness. In this study, we chose midazolam and droperidol as well-established intravenous sedative-hypnotic drugs. We evaluated the preoperative anxiolytic effect on postoperative memories and emotions up to the first postoperative morning.

METHODS

In a prospective, double blind study, 120 patients requiring epidural anesthesia were randomly assigned to one of three groups to receive saline, midazolam (0.04 mg/kg), or droperidol (0.1 mg/kg). Cardiovascular and respiratory measurements, observer's assessment of alertness/sedation scale, level of anxiety and discomfort of the patients, pain during the infiltration of local anesthetics, and incidence of adverse effects were recorded. Amnesia, anxiety, and discomfort during the epidural procedure were re-assessed between 12 and 20 h postsurgery.

RESULTS

Patients who received sedatives were significantly more sedated (P < 0.0001), but the pain score was significantly higher in the droperidol group (P = 0.0007) at epidural catheterization. On the first postoperative morning, patients receiving midazolam had a significantly lower pain score (P < 0.0001) with less anxiety and discomfort. Patients in both the midazolam and droperidol groups showed a significant decrease in blood pressure (P < 0.0167), but no respiratory impairment. No adverse effects were experienced throughout the study period.

CONCLUSION

Conscious sedation with intravenous midazolam 0.04 mg/kg significantly decreased the anxiety and discomfort scores of the patients on the day following surgery but had no effect on these immediately following the epidural catheterization procedure.

Comparisons of two different doses of fentanyl for procedural analgesia during epidural catheter placement: a double-blind prospective, randomized, placebo-controlled study

The purpose of this study was to investigate the effect of fentanyl on analgesic properties and respiratory responses during an epidural procedure. Sixty patients premedicated with oral brotizolam 0.25 mg were allocated to receive procedural analgesia with saline or 25 or 50 μg of fentanyl. Five minutes after administration, an epidural procedure was started. Pain assessments were made immediately after the epidural catheter placement using a visual analog scale. The lowest SpO₂ levels during the procedure were recorded to evaluate respiratory depression, and cardiovascular complications were also recorded. The pain scores were significantly lower in the 25 and 50 μg fentanyl groups than in the placebo group (P < 0.01). There was no difference in pain assessment between the 25 and 50 μg fentanyl groups. The lowest SpO₂ value of the 50 μg fentanyl group was significantly lower than those of the other groups (P < 0.001). Seven of 20 cases in the 50 μg fentanyl group needed oxygen administration because of a decreased SpO₂ value (<94%). No cardiovascular complications were observed in any group during the entire study period. Thus, intravenous fentanyl at a dose of 25 μg provides effective procedural analgesia without the risk of hypoxemia during an epidural procedure in a patient with preanesthetic medication.

Anxiolytic- and antidepressant-like properties of ketamine in behavioral and neurophysiological animal models

Ketamine, a dissociative anesthetic agent, appears to have rapid antidepressant effects at sub-anesthetic doses in clinically depressed patients. Although promising, these results need to be replicated in double-blind placebo-controlled studies, a strategy thwarted by the psychoactive effects of ketamine, which are obvious to both patients and clinicians. Alternatively, demonstrations of the psychotherapeutic effects of ketamine in animal models are also complicated by ketamine's side-effects on general activity, which have not been routinely measured or taken into account in experimental studies. In this study we found that ketamine decreased "behavioral despair" in the forced swim test, a widely used rats model of antidepressant drug action. This effect was not confounded by side-effects on general activity, and was comparable to that of a standard antidepressant drug, fluoxetine. Interestingly, ketamine also produced anxiolytic-like effects in the elevated-plus-maze. Importantly, the effective dose of ketamine in the plus-maze did not affect general locomotion measures, in either the plus-maze or in the open field test. While the selective N-methyl-d-aspartic acid (NMDA) receptor antagonist MK-801 also produced antidepressant-like and anxiolytic-like effects, these were mostly confounded by changes in general activity. Finally, in a neurophysiological model of anxiolytic drug action, ketamine reduced the frequency of reticularly-activated theta oscillations in the hippocampus, similar to the proven anxiolytic drug diazepam. This particular neurophysiological signature is common to all known classes of anxiolytic drugs (i.e. benzodiazepines, 5-HT1A agonists, antidepressants) and provides strong converging evidence for the anxiolytic-like effects of ketamine. Further studies are needed to understand the underlying pharmacological mechanisms of ketamine's effects in these experiments, since it is not clear they were mimicked by the selective NMDA antagonist MK-801.

A randomized, double-blind, placebo-controlled study of preemptively administered intravenous parecoxib: effect on anxiety levels and procedural pain during epidural catheter placement for surgical operations or for chronic pain therapy

BACKGROUND

The effect of parecoxib, when used perioperatively or during interventional techniques, is well demonstrated in the literature. Little is known about its effects on anxiety levels before the analgesic technique application. The aim of this prospective, randomized, double-blind, placebo-controlled, clinical study is to investigate whether parecoxib, preemptively administrated, has an effect on anxiety levels reported prior to an epidural puncture, and if it influences the reported pain of the interventional technique itself.

MATERIAL AND METHODS

The study protocol involved 110 patients, scheduled for epidural catheter placement for chronic pain therapy--Group I, as well as 112 patients scheduled for orthopedic operations under epidural anesthesia--Group II. Patients in each group were randomly allocated into two subgroups in relation to parecoxib/placebo administration before epidural catheter placement: Group Ia, parecoxib 40 mg i.v. (n = 54), Group Ib, placebo (n = 56), Group IIa, parecoxib 40 mg i.v. (n = 57), Group IIb, placebo (n = 55). Patients were given a self-administered inventory to measure the anxiety level of the presurgical/preprocedural state (State-Trait Spielberger Anxiety Inventory) and anxiety levels were recorded 1 hour before epidural puncture, 20 minutes postdosing, and 1 hour after epidural catheter placement. Anxiety levels were also measured and recorded using visual analog scale (VAS). One hour after epidural puncture, reported procedural pain was recorded (VAS). One hour and 6 hours postepidural, patients' satisfaction was also recorded, on a 4-point scale.

RESULTS

All four subgroups were similar regarding demographic, operative/procedural data, and coexisting diseases. Preprocedural anxiety levels were significantly decreased with parecoxib administration in comparison with placebo in both groups (P < 0.05). Reported VAS regarding pain from epidural puncture was lower in Groups IA and Ib. Patients' satisfaction was greater with parecoxib in comparison with placebo.

CONCLUSION

The levels of anxiety have been investigated in several medical procedures and early, in the study of pain. The higher the expectation of pain and the anxiety are, the higher the intensity of the pain. Parecoxib seems to exert positive influence on pain and anxiety levels of interventional procedure. Further studies are needed to elucidate the actual mechanisms that are involved.

Self-reports of anxiety in burn-injured hospitalized adults during routine wound care

The purpose of this investigation was to examine the amount of anxiety patients believed tolerable and the amount of anxiety experienced during routine burn wound care. Participants included 47 hospitalized adults who provided data for four consecutive assessment periods. Patients (mean TBSA, 16%; range, 2-70%) were primarily Caucasian (87%) and had an average hospital stays of 23 days (range, 11-130). Reports of what level of anxiety they would be able to tolerate and what level of anxiety had been experienced were assessed using 10-point Graphic Rating Scales. The use of anxiolytic was recorded, and patient suggestions for reducing anxiety were obtained. The single most commonly endorsed anxiety treatment goal was 0, although 53% consistently chose a treatment goal other than 0 (range, 1-6). Two repeated-measure analyses of variance indicated that the amount of anxiety patients could tolerate and the amount they reported experiencing did not change over the course of time. Paired t-tests revealed that patients routinely reported more anxiety than they considered tolerable. Analyses of anxiety reports of patients treated with anxiolytics (n = 6) vs patients receiving no anxiolytics (n = 41) revealed inconsistent differences in actual anxiety and treatment goals across time. In general, patient suggestions for lessening anxiety included requests for education, communication, additional medications, and manipulation of the hospital environment. Anxiety for burn-injured, hospitalized adults remains a concern. Our findings are consistent with the literature indicating that adult patients hospitalized for burn wound care report appreciable anxiety, over and above what they consider "tolerable." Continued research is needed and should include investigations into the relationship between pain and anxiety during routine wound care.