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Vadivelu N, Schermer E, Kodumudi V, Belani K, Urman RD, Kaye AD. Role of ketamine for analgesia in adults and children. J Anaesthesiol Clin Pharmacol 2016; 32:298-306. [PMID: 27625475 PMCID: PMC5009833 DOI: 10.4103/0970-9185.168149] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Ketamine an N-methyl-D-aspartate (NMDA) receptor blocking agent and a dissociative anesthetic with neurostimulatory side effects. In recent years, multiple research trials as well as systematic reviews and meta-analyses suggest the usefulness of ketamine as a strong analgesic used in subanesthetic intravenous doses, and also as a sedative. In addition, ketamine was noted to possess properties of anti-tolerance, anti-hyperalgesia and anti-allodynia most likely secondary to inhibition of the NMDA receptors. Tolerance, hyperalgesia and allodynia phenomena are the main components of opioid resistance, and pathological pain is often seen in the clinical conditions involving neuropathic pain, opioid-induced hyperalgesia, and central sensitization with allodynia or hyperalgesia. All these conditions are challenging to treat. In low doses, ketamine does not have major adverse dysphoric effects and also has the favorable effects of reduced incidence of opioid-induced nausea and vomiting. Therefore, ketamine can be a useful adjunct for pain control after surgery. Additional studies are required to determine the role of ketamine in the immediate postoperative period after surgical interventions known to produce severe pain and in the prevention and treatment of chronic pain.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Erika Schermer
- Program of Applied Translational Research, Yale University, New Haven, CT 06510, USA
| | - Vijay Kodumudi
- University of Connecticut, College of Liberal Arts and Sciences, Storrs, CT, USA
| | - Kumar Belani
- Department of Anesthesiology, University of Minnesota Children's Hospital, Minneapolis, MN 55454, USA
| | - Richard D Urman
- Department of Anesthesiology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan David Kaye
- Department of Anesthesiology and Pharmacology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Abstract
This review has been amended to include further information on Menigaux 2000 pre pre and Menigaux 2000 post included studies. At July 2014, this review is out of date and has been withdrawn. This review is correct as of the date of publication. The latest version is available in the ‘Other versions’ tab on The Cochrane Library, and may still be useful to readers. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Rae F Bell
- Haukeland University HospitalCentre for Pain Management and Palliative Care & Regional Centre for Excellence in Palliative CareBergenNorwayN‐5021
| | - Jørgen B Dahl
- Rigshospitalet and Copenhagen UniversityDepartment of Anaesthesia 4231Centre of Head and OrthopaedicsBlegdamsvej 9CopenhagenDenmark2100
| | - R Andrew Moore
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Pain Research UnitChurchill HospitalOxfordOxfordshireUKOX3 7LE
| | - Eija A Kalso
- Helsinki University Central HospitalDepartment of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain MedicineHelsinkiFinland
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Mihaljevic S, Mihaljevic L, Cacic M. [Sympathetic activity of S-(+)-ketamine low doses in the epidural space]. Rev Bras Anestesiol 2014; 64:227-35. [PMID: 25096766 DOI: 10.1016/j.bjan.2013.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 03/22/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p<0.05 has been taken as a limit of statistical significance. CONCLUSIONS Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25mg of S-(+)-ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.
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Affiliation(s)
- Slobodan Mihaljevic
- Hospital de Clínicas de Zagreb, Faculdade de Medicina da Universidade de Zagreb, Klinički Bolnički Centar, Zagreb, Croácia.
| | - Ljiljana Mihaljevic
- Hospital de Clínicas de Zagreb, Faculdade de Medicina da Universidade de Zagreb, Klinički Bolnički Centar, Zagreb, Croácia
| | - Marko Cacic
- Hospital de Clínicas de Zagreb, Faculdade de Medicina da Universidade de Zagreb, Klinički Bolnički Centar, Zagreb, Croácia
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Does the addition of tramadol and ketamine to ropivacaine prolong the axillary brachial plexus block? BIOMED RESEARCH INTERNATIONAL 2014; 2014:686287. [PMID: 24883319 PMCID: PMC4032708 DOI: 10.1155/2014/686287] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 02/06/2023]
Abstract
Background and Objectives. A prospective, randomized, controlled, double-blind clinical trial to assess the effect of tramadol and ketamine, 50 mg, added to ropivacaine in brachial plexus anesthesia. Methods. Thirty-six ASA physical statuses I and II patients, between 18 and 60 years of age, scheduled for forearm and hand surgery under axillary brachial plexus block, were allocated to 3 groups. Group R received 0.375% ropivacaine in 40 mL, group RT received 0.375% ropivacaine in 40 mL with 50 mg tramadol, and group RK received 0.375% ropivacaine in 40 mL with 50 mg ketamine for axillary brachial plexus block. The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events (nausea, vomiting, and feeling uncomfortable) were recorded. Results. The onset time of sensorial block was the fastest in ropivacaine + tramadol group. Duration of sensorial and motor block was the shortest in the ropivacaine + tramadol group. Duration of analgesia was significantly longer in ropivacaine + tramadol group. Conclusion. We conclude that when added to brachial plexus analgesia at a dose of 50 mg, tramadol extends the onset and duration time of the block and improves the quality of postoperative analgesia without any side effects.
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Erol İM, Özdoğan L, Örnek D, Taşpınar V, Kalaycı D, Barçın S, Şahin F, Erk G, Dikmen B. Effect of Ketamine on the Quality of Anesthesia and Postoperative Analgesia in Epidural Anesthesia. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jecm.2014.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mihaljevic S, Mihaljevic L, Cacic M. Sympathetic activity of S-(+)-ketamine low doses in the epidural space. Braz J Anesthesiol 2013; 64:227-35. [PMID: 24998105 DOI: 10.1016/j.bjane.2013.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 03/22/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p<0.05 has been taken as a limit of statistical significance. CONCLUSIONS Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25mg of S-(+)-ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.
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Affiliation(s)
- Slobodan Mihaljevic
- Clinic Hospital Zagreb, University of Zagreb School of Medicine, Klinički Bolnički Centar, Zagreb, Croatia.
| | - Ljiljana Mihaljevic
- Clinic Hospital Zagreb, University of Zagreb School of Medicine, Klinički Bolnički Centar, Zagreb, Croatia
| | - Marko Cacic
- Clinic Hospital Zagreb, University of Zagreb School of Medicine, Klinički Bolnički Centar, Zagreb, Croatia
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Sethi M, Sethi N, Jain P, Sood J. Role of epidural ketamine for postoperative analgesia after upper abdominal surgery. Indian J Anaesth 2011; 55:141-5. [PMID: 21712870 PMCID: PMC3106386 DOI: 10.4103/0019-5049.79894] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ketamine, a N-methyl-D-aspartate receptor antagonist inhibits central sensitization due to peripheral nociception thus potentiating the analgesic effect of morphine. The purpose of our study was to evaluate the effect of adding small-dose ketamine in a multimodal regimen of postoperative patient-controlled epidural analgesia (PCEA). One hundred patients of American Society of Anesthesiologists physical status I-II, undergoing major upper abdominal surgery were randomly allocated to two groups. Group I received PCEA device containing bupivacaine hydrochloride 0.0625% and morphine sulphate (preservative free) 0.05mg/ml. Group II received PCEA device containing bupivacaine hydrochloride 0.0625%, morphine sulphate (preservative free) 0.05 mg/ml and ketamine hydrochloride (preservative free) 0.2 mg/ml. The mean morphine consumption in group I after 1stand 2ndpostoperative day was 8.38±2.85 and 7.64±1.95 mg, respectively, compared to 6.81±1.35 and 6.25±1.22 mg (P<0.05) in group II. Although group II consumed significantly less morphine, pain relief at rest and at movement after 6, 12, 24 and 48 hours, postoperatively was significantly better in group II (P<0.05) than in group I. These findings suggest that adding small-dose ketamine to a multimodal PCEA regimen provides better postoperative analgesia and reduces morphine consumption.
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Affiliation(s)
- Mamta Sethi
- Department of Anaesthesia, Max Superspeciality Hospital, Saket, New Delhi, India
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8
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Abstract
Both, acute and chronic pain should be treated using appropriate pain management as they may cause several negative reactions and jeopardise the health or at least the quality of life of the patients. Nowadays there are many analgesics and treatment tools available to provide sufficient pain relief for almost all patients. Unfortunately there are still patients suffering from pain due to inadequate or/and inconsequent pain therapy.
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Affiliation(s)
- A Spacek
- Department of Anaesthesiology and Intensive Care (A), Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Guedes AGP, Pluhar GE, Daubs BM, Rudé EP. Effects of preoperative epidural administration of racemic ketamine for analgesia in sheep undergoing surgery. Am J Vet Res 2006; 67:222-9. [PMID: 16454625 DOI: 10.2460/ajvr.67.2.222] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the effects of preoperative epidural administration of racemic ketamine to provide analgesia in sheep undergoing experimental hind limb orthopedic surgery. ANIMALS 12 adult sheep (weight range, 51.4 to 67.2 kg). PROCEDURE Sheep were anesthetized with guaifenesin, thiopental, and isoflurane; after induction of anesthesia, sheep received a lumbosacral epidural injection of ketamine (1 mg/kg; n = 6) or saline (0.9% NaCl) solution (1 mL/7 kg; 6 [control group]). Respiratory and cardiovascular variables were recorded before and at intervals during and for 6 hours after anesthesia. During that 6-hour postoperative period, analgesia was evaluated subjectively with a numeric ranking scale that included assessments of comfort, posture, movement, and response to wound palpation; buprenorphine was administered when a score > 3 (maximum score, 10) was achieved. Rectal temperature, heart and respiratory rates, and lameness were evaluated daily for 2 weeks after surgery. RESULTS At all evaluations, cardiovascular and respiratory variables were comparable between the 2 groups. Compared with control sheep, time to first administration of rescue analgesic was significantly longer and total dose of buprenorphine administered during the 6- hour postoperative period was significantly decreased for ketamine-treated sheep. During the second week following surgery, ketamine-treated sheep had significantly less lameness than control sheep. CONCLUSIONS AND CLINICAL RELEVANCE In sheep undergoing hind limb surgery, preoperative epidural administration of ketamine appears to provide analgesia in the immediate postoperative period and has residual analgesic effects, which may contribute to more rapid return of normal function in surgically treated limbs.
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Affiliation(s)
- Alonso G P Guedes
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN 55108-1016, USA
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Abstract
BACKGROUND Postoperative pain management is often limited by adverse effects such as nausea and vomiting. Adjuvant treatment with an inexpensive opioid-sparing drug such as ketamine may be of value in giving better analgesia with fewer adverse effects. OBJECTIVES To evaluate the effectiveness and tolerability of ketamine administered perioperatively in the treatment of acute postoperative pain in adults. SEARCH STRATEGY Studies were identified from MEDLINE (1966-2004), EMBASE (1980-2004), the Cochrane Library (2004) and by handsearching reference lists from review articles and trials. The manufacturer of ketamine (Pfizer) provided search results from their in-house database, PARDLARS. SELECTION CRITERIA Randomised controlled trials (RCTs) of adult patients undergoing surgery, being treated with perioperative ketamine or placebo. Studies where ketamine was administered in addition to a basic analgesic (such as morphine or NSAID) in one study group, and compared with a group receiving the same basic analgesic (but without ketamine) in another group, were also included. DATA COLLECTION AND ANALYSIS Two independent reviewers identified fifty five RCTs for potential inclusion. Quality and validity assessment was performed by two independent reviewers. In the case of discrepancy, a third reviewer was consulted. Patient reported pain intensity and pain relief was assessed using visual analogue scales or verbal rating scales and adverse effects data were collated. MAIN RESULTS Thirty-seven trials were included (2240 participants). Eighteen trials were excluded.Twenty-seven of the 37 trials found that perioperative subanaesthetic doses of ketamine reduced rescue analgesic requirements or pain intensity, or both. Quantitative analysis showed that treatment with ketamine reduced 24 hour PCA morphine consumption and postoperative nausea or vomiting (PONV). Adverse effects were mild or absent. AUTHORS' CONCLUSIONS Ketamine in subanaesthetic dose (that is a dose which is below that required to produce anaesthesia) is effective in reducing morphine requirements in the first 24 hours after surgery. Ketamine also reduces postoperative nausea and vomiting. Adverse effects are mild or absent.
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Affiliation(s)
- R F Bell
- Haukeland University Hospital/ University of Bergen, Pain Clinic/Dept. of Surgical Sciences, Bergen, Norway, N-5021.
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Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005; 49:1405-28. [PMID: 16223384 DOI: 10.1111/j.1399-6576.2005.00814.x] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Post-operative pain management is usually limited by adverse effects such as nausea and vomiting. Adjuvant treatment with an inexpensive opioid-sparing drug such as ketamine may be of value in giving better analgesia with fewer adverse effects. The objective of this systematic review was to evaluate the effectiveness and tolerability of ketamine administered peri-operatively in the treatment of acute post-operative pain in adults. METHODS Studies were identified from MEDLINE (1966-2004), EMBASE (1980-2004), the Cochrane Library (2004) and by hand searching reference lists from review articles and trials. The manufacturer of ketamine (Pfizer AS, Lysaker, Norway) provided search results from their in-house database, PARDLARS. Randomized and controlled trials (RCTs) of adult patients undergoing surgery, being treated with peri-operative ketamine, placebo or an active control were considered for inclusion. RESULTS Eighteen trials were excluded. Thirty-seven trials were included. Twenty-seven out of 37 trials found that peri-operative ketamine reduced rescue analgesic requirements or pain intensity, or both. Quantitative analysis showed that treatment with ketamine reduced 24-h patient-controlled analgesia (PCA) morphine consumption and post-operative nausea and vomiting (PONV). Adverse effects were mild or absent. CONCLUSION In the first 24 h after surgery, ketamine reduces morphine requirements. Ketamine also reduces PONV. Adverse effects are mild or absent. These data should be interpreted with caution as the retrieved studies were heterogenous and the result of the meta-analysis can not be translated into any specific administration regimen with ketamine.
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Affiliation(s)
- R F Bell
- Pain Clinic, Department of Anaesthesia and Intensive Care, Haukeland University Hospital and Department of Surgical Sciences, University of Bergen, Norway.
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Abstract
Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.
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Affiliation(s)
- Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA
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Jung JY, Bang KH, Kim SH, Kim YI. Influence of Ketamine on the Analgesic Effect of Epidural Bupivacaine and Fentanyl after a Transabdominal Hysterectomy. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.2.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jai Yun Jung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Kyung Ho Bang
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Sang Hyon Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Yong Ik Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Bucheon, Korea
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Joo JD, Jeon YS, Choi JW, In JH, Kim YS, Kang YJ, Kim DW, Lim YG, Kim GH. Dose-Related Prolongation of Ropivacaine Epidural Anesthesia by Epidural Ketamine. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yeon Su Jeon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Woo Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jang Hyeok In
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Shin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Jin Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Woo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Gul Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ghi Hyun Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Acosta ADP, Gomar C, Correa-Natalini C, Bopp S, Polydoro A, Sala-Blanch X. Analgesic effects of epidurally administered levogyral ketamine alone or in combination with morphine on intraoperative and postoperative pain in dogs undergoing ovariohysterectomy. Am J Vet Res 2005; 66:54-61. [PMID: 15691036 DOI: 10.2460/ajvr.2005.66.54] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the analgesic and adverse effects of epidurally administered levogyral (S[+]) ketamine alone or in combination with morphine on intraoperative and postoperative pain in dogs undergoing ovariohysterectomy. ANIMALS 30 dogs scheduled for ovariohysterectomy. PROCEDURE Dogs were randomly allocated to 1 of 3 groups. Dogs in group 1 received S(+) ketamine (1 mg/kg), dogs in group 2 received S(+) ketamine (0.5 mg/kg) and morphine (0.05 mg/kg), and dogs in group 3 received S(+) ketamine (1 mg/kg) and morphine (0.025 mg/kg). The skin was incised 15 minutes after epidural administration of analgesics. Heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), oxygen saturation as measured by pulse oximetry, and arterial blood gases were obtained before anesthesia, 15 minutes after epidural administration of analgesics, 15 and 30 minutes after initiation of surgery, and at the end of surgery. During the intraoperative period, an increase of > or =20% in baseline values for HR, RR, and SBP was considered a sign of intraoperative pain. Signs of pain and adverse effects were assessed at 2, 4, and 8 hours postoperatively. RESULTS There were no significant differences in intraoperative or postoperative measurements among the 3 groups. No dogs had intraoperative signs of pain. Mean postoperative pain assessment scores were <3.5 in all 3 groups. Salivation was the most frequent adverse effect in dogs in groups 1 and 3, and sedation occurred more frequently in dogs in groups 2 and 3. CONCLUSIONS AND CLINICAL RELEVANCE All 3 analgesic regimens provided good respiratory and cardiovascular stability intraoperatively and adequate postoperative analgesia with minimal adverse effects.
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Affiliation(s)
- Alinne Dalla-Porta Acosta
- Departamento de Anestesiología and the Hospital Clínico, University of Barcelona, 08036 Barcelona, Spain
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Elia N, Tramèr MR. Ketamine and postoperative pain – a quantitative systematic review of randomised trials. Pain 2005; 113:61-70. [PMID: 15621365 DOI: 10.1016/j.pain.2004.09.036] [Citation(s) in RCA: 324] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2004] [Revised: 09/10/2004] [Accepted: 09/28/2004] [Indexed: 01/28/2023]
Abstract
Ketamine, an N-methyl-D-aspartate receptor antagonist, is known to be analgesic and to induce psychomimetic effects. Benefits and risks of ketamine for the control of postoperative pain are not well understood. We systematically searched for randomised comparisons of ketamine with inactive controls in surgical patients, reporting on pain outcomes, opioid sparing, and adverse effects. Data were combined using a fixed effect model. Fifty-three trials (2839 patients) from 25 countries reported on a large variety of different ketamine regimens and surgical settings. Sixteen studies tested prophylactic intravenous ketamine (median dose 0.4 mg/kg, range (0.1-1.6)) in 850 adults. Weighted mean difference (WMD) for postoperative pain intensity (0-10 cm visual analogue scale) was -0.89 cm at 6 h, -0.42 at 12 h, -0.35 at 24 h and -0.27 at 48 h. Cumulative morphine consumption at 24 h was significantly decreased with ketamine (WMD -15.7 mg). There was no difference in morphine-related adverse effects. The other 37 trials tested in adults or children, prophylactic or therapeutic ketamine orally, intramuscularly, subcutaneously, intra-articulary, caudally, epidurally, transdermally, peripherally or added to a PCA device; meta-analyses were deemed inappropriate. The highest risk of hallucinations was in awake or sedated patients receiving ketamine without benzodiazepine; compared with controls, the odds ratio (OR) was 2.32 (95%CI, 1.09-4.92), number-needed-to-harm (NNH) 21. In patients undergoing general anaesthesia, the incidence of hallucinations was low and independent of benzodiazepine premedication; OR 1.49 (95%CI 0.18-12.6), NNH 286. Despite many published randomised trials, the role of ketamine, as a component of perioperative analgesia, remains unclear.
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Affiliation(s)
- Nadia Elia
- EBCAP Institute (Evidence-Based Critical care, Anaesthesia and Pain treatment), Division of Anaesthesiology, Geneva University Hospitals, 24 Rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.
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Abstract
Interest in the use of regional anaesthesia, particularly peripheral nerve blocks (PNBs) and continuous PNBs, has increased in recent years. Accompanying this resurgence in interest has been the development of new local anaesthetics and additives designed to enhance block duration and quality. This manuscript provides a literature-based review on accepted uses of local anaesthetics and adjuncts for a variety of regional anaesthesia techniques. A brief review of local anaesthetic pharmacodynamics describes the action of these drugs in preventing nerve depolarisation, thus blocking nerve impulses. Toxic adverse effects of local anaesthetics, specifically CNS and cardiac manifestations of excessive local anaesthetic blood concentrations and the direct neurotoxic properties of local anaesthetics, are discussed generally and specifically for many commonly used local anaesthetics. Clinically useful ester and amide local anaesthetics are evaluated individually in terms of their physical properties and toxic potential. How these properties impact on the clinical uses of each local anaesthetic is explored. Particular emphasis is placed on the long-acting local anaesthetic toxic potential of racemic bupivacaine compared with levobupivacaine and ropivacaine, which are both levorotatory stereoisomers. Guidelines for using ropivacaine and mepivacaine, based on the authors' experience using advanced regional anaesthesia in a busy practice, is provided. Finally, epinephrine (adrenaline), clonidine and other local anaesthetic additives and their rationale for use is covered along with other future possibilities.
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Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as Adjuvant Analgesic to Opioids: A Quantitative and Qualitative Systematic Review. Anesth Analg 2004; 99:482-95, table of contents. [PMID: 15271729 DOI: 10.1213/01.ane.0000118109.12855.07] [Citation(s) in RCA: 279] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Animal studies on ketamine and opioid tolerance have shown promising results. Clinical trials have been contradictory. We performed a systematic review of randomized, double-blind clinical trials of ketamine added to opioid analgesia. Thirty-seven trials with 51 treatment arms and 2385 patients were included. Studies were divided into 5 subgroups: IV ketamine as single dose (n = 11), continuous infusion (n = 11), patient-controlled analgesia (PCA) (n = 6), epidural ketamine with opioids (n = 8), and studies in children (n = 4). Outcome measures included pain scores, time to first request for analgesia, supplemental analgesics, and adverse events. Efficacy was estimated by statistical significance (P < 0.05) of outcome measures as reported in studies and also by calculation of weighted mean difference for pain scores during the first 24 h after surgery. As compared to morphine alone, IV PCA with ketamine and morphine did not improve analgesia. Intravenous infusion of ketamine decreased IV and epidural opioid requirements in 6 of 11 studies. A single bolus dose of ketamine decreased opioid requirements in 7 of 11 studies. Five of 8 trials with epidural ketamine showed beneficial effects. Adverse effects were not increased with small dose ketamine. We conclude that small dose ketamine is a safe and useful adjuvant to standard practice opioid-analgesia.
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MESH Headings
- Adult
- Analgesia, Epidural
- Analgesia, Patient-Controlled
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthetics, Dissociative/administration & dosage
- Anesthetics, Dissociative/adverse effects
- Anesthetics, Dissociative/therapeutic use
- Child
- Double-Blind Method
- Drug Therapy, Combination
- Humans
- Infusions, Intravenous
- Ketamine/administration & dosage
- Ketamine/adverse effects
- Ketamine/therapeutic use
- Pain/drug therapy
- Pain Measurement
- Postoperative Nausea and Vomiting/epidemiology
- Randomized Controlled Trials as Topic
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology, Critical Care & Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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McCartney CJL, Sinha A, Katz J. A Qualitative Systematic Review of the Role of N-Methyl-d-Aspartate Receptor Antagonists in Preventive Analgesia. Anesth Analg 2004; 98:1385-400, table of contents. [PMID: 15105220 DOI: 10.1213/01.ane.0000108501.57073.38] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED We evaluated in a qualitative systematic review the effect of N-methyl-D-aspartate (NMDA) receptor antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Randomized trials examining the use of an NMDA antagonist in the perioperative period were sought by using a MEDLINE (1966-2003) and EMBASE (1985-2003) search. Reference sections of relevant articles were reviewed, and additional articles were obtained if they evaluated postoperative analgesia after the administration of NMDA antagonists. The primary outcome was a reduction in pain, analgesic consumption, or both in a time period beyond five half-lives of the drug under examination. Secondary outcomes included time to first analgesic request and adverse effects. Forty articles met the inclusion criteria (24 ketamine, 12 dextromethorphan, and 4 magnesium). The evidence in favor of preventive analgesia was strongest in the case of dextromethorphan and ketamine, with 67% and 58%, respectively, of studies demonstrating a reduction in pain, analgesic consumption, or both beyond the clinical duration of action of the drug concerned. None of the four studies examining magnesium demonstrated preventive analgesia. IMPLICATIONS We evaluated, in a qualitative systematic review, the effect of N-methyl D-aspartate antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Dextromethorphan and ketamine were found to have significant immediate and preventive analgesic benefit in 67% and 58% of studies, respectively.
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Affiliation(s)
- Colin J L McCartney
- Department of Anesthesia and Pain Management, Toronto Western Hospital and University of Toronto, Ontario, Canada.
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids and compounds derived from them, including further products of oxidation, condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2001 to June 2002 is reviewed, with 581 references cited.
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Sato E, Takano Y, Kuno Y, Takano M, Sato I. Involvement of spinal tyrosine kinase in inflammatory and N-methyl-D-aspartate-induced hyperalgesia in rats. Eur J Pharmacol 2003; 468:191-8. [PMID: 12754057 DOI: 10.1016/s0014-2999(03)01718-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Phosphorylation of a subunit of N-methyl-D-aspartate (NMDA) receptor by protein tyrosine kinase (PTK) Src or Trk is known to enhance its channel activity. We examined whether a spinally administered selective PTK inhibitor, lavendustin A, which has high affinity for Src and Trk tyrosine kinases, could influence the development and maintenance of inflammatory hyperalgesia or NMDA-induced hyperalgesia. Inflammation was induced by injection of a mixture of carrageenan and kaolin into the tail base of rats. In another group of rats, hyperalgesia was induced by intrathecal administration of NMDA. Intrathecal administration of lavendustin A (1.0 microg) or NMDA receptor antagonist, (+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cycloheptane-5,10-iminemaleate, MK-801 (3.0 microg) before injection of a mixture of carrageenan and kaolin or after the development of inflammation inhibited carrageenan-kaolin-induced mechanical hyperalgesia. Intrathecal injection of 1.0 microg NMDA produced thermal and mechanical hyperalgesia. Co-administration of 1.0 microg lavendustin A with NMDA significantly reduced the duration of spontaneous pain behaviour and inhibited NMDA-induced hyperalgesia. Lavendustin A itself did not cause any sedation, motor impairment or analgesia. Our results suggest that inhibition of PTK could be therapeutically effective as an analgesic in some NMDA receptor-mediated hyperalgesic states.
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Affiliation(s)
- Eiru Sato
- Department of Anesthesiology, Koshigaya Hospital, Dokkyo University, School of Medicine, 2-1-50 Minami-Koshigaya, Saitama 343-8555, Koshigaya City, Japan.
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Ozbek H, Bilen A, Ozcengiz D, Günes Y, Ozalevli M, Akman H. The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children. Paediatr Anaesth 2002; 12:610-6. [PMID: 12358657 DOI: 10.1046/j.1460-9592.2002.00913.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Our aim was to compare the effect of single dose caudal ketamine, alfentanil or a mixture of both drugs in the treatment of pain after hypospadias repair surgery in children. METHODS The group comprised 109 boys, ASA I-II, aged 1-9 years, who were undergoing hypospadias repair surgery as day cases. The children were randomly divided into three groups for postoperative analgesia: group 1, only alfentanil (20 microg x kg(-10) was given caudally; group 2, ketamine (0.5 mg x kg(-1)) alone; and group 3, alfentanil (20 microg x kg(-1))-ketamine (0.5 mg x kg(-1)) was given caudally. The analgesic effect of caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using a five-point sedation score. The first analgesic requirement time and the number of supplementary analgesics required by each child in a 24-h period were also recorded. RESULTS No statistical differences were found in demographic characteristics, haemodynamic and respiratory parameters, objective pain scores, postoperative sedation scores and duration of surgery among the groups. The median time to first analgesia was significantly shorter in group 1 than in groups 2 and 3 (P=0.009, P=0.001). Significantly more patients in group 1 required additional postoperative analgesia (paracetamol 15 mg x kg(-1)) compared with groups 2 and 3 (P < 0.001). CONCLUSIONS Caudal administration of ketamine 0.5 mg.kg-1 with or without alfentanil in children produced satisfactory postoperative analgesia without respiratory depression or other side-effects.
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Affiliation(s)
- Hayri Ozbek
- Department of Anesthesiology, Cukurova University Faculty of Medicine, Adana, Turkey.
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Abstract
PURPOSE OF REVIEW The controversy over preemptive analgesia continues unabated, with studies both supporting and refuting its efficacy. The timing of an analgesic intervention and presence of a placebo control may have significant impact on the interpretation of results and may have led to the premature conclusion that preemptive analgesia is of limited clinical utility. A review of the recent literature using strict definitions of preemptive and preventive analgesia is required in order to clarify the broader issue of the benefits of perioperative analgesia. RECENT FINDINGS A total of 27 studies, published from April 2001 to April 2002, were found to evaluate preemptive (n = 12) or preventive analgesia (n = 15). Evidence for a benefit of preventive analgesia was strong, with 60% of studies finding reduced pain or analgesic consumption beyond the clinical duration of action of the analgesic intervention. Evidence for a benefit of preemptive analgesia was equivocal, with 41.7% of studies demonstrating that preincisional treatment reduces pain or analgesic consumption to a greater extent than does postincisional treatment. SUMMARY Studies that used a preventive design had a greater likelihood of finding a beneficial effect. The application of preventive perioperative analgesia (not necessarily preincisional) is associated with a significant reduction in pain beyond the clinical duration of action of the analgesic agent, in particular for the N-methyl-D-aspartate antagonists. The classical definition of preemptive analgesia should be abandoned in favor of preventive analgesia. This will broaden the scope of inquiry from a narrow focus on preincisional versus postincisional interventions to one that aims to minimize postoperative pain and analgesic requirements by reducing peripheral and central sensitization arising from noxious preoperative, intraoperative and postoperative inputs.
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Affiliation(s)
- Joel Katz
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Current awareness in pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:169-74. [PMID: 12004884 DOI: 10.1002/pds.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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