Effect of Perioperative Ketamine on Postoperative Mood and Depression: A Review of the Literature

Single low-dose ketamine infusion for women with prenatal depressive symptoms undergoing cesarean delivery: A pilot randomized trial

Background

Ketamine is approved for antidepressant therapy, but evidence regarding its use in women with perinatal depression is lacking. Herein, we investigated the effects of low-dose ketamine in women with prenatal depressive symptoms and tested the feasibility of a future large randomized trial.

Methods

This was a randomized, double-blind, placebo-controlled pilot trial. Sixty-six women with prenatal depressive symptoms who were scheduled for elective cesarean delivery were randomized to receive either low-dose ketamine (0.5 mg/kg) or placebo (normal saline). The study drugs were intravenously infused over a 40-minute period after clamping the umbilical cord. The primary outcome was depression score assessed with the Edinburgh Postnatal Depression Scale at 48 h postpartum. Among other and safety outcomes, occurrence of nausea or vomiting was observed, pain intensity was assessed with the numeric rating scale. The feasibility of implementing the protocol was also evaluated.

Results

A total of 64 parturients were included in the intention-to-treat analysis. The depression score at 48 h did not differ between groups: median 9 (interquartile range 6 to 13) with ketamine vs. 8 (6 to 10) with placebo; median difference 1, 95% CI -1 to 3; P = 0.608. The pain intensity at 4 h postpartum was less severe in the ketamine group (median difference -1, 95% CI -1 to 0, P = 0.002). Among safety outcomes, intraoperative nausea or vomiting was less common in patients given ketamine (0.0% [0/33] with ketamine vs. 21.2% [7/33] with placebo, P = 0.011). Recruitment was satisfactory and the protocol was acceptable to participants and clinicians.

Conclusions

A single low-dose ketamine infusion did not decrease the depression score at 2 days, but reduced intraoperative nausea and vomiting and lowered pain intensity at 4 h after cesarean delivery among women with prenatal depressive symptoms. The study protocol is feasible for a large randomized trial.

Clinical Trial Registration

The study was registered with ClinicalTrials.gov (identifier: NCT03336541; 08/11/2017).

Anesthesia and the neurobiology of fear and posttraumatic stress disorder

PURPOSE OF REVIEW

Dysfunction of fear memory systems underlie a cluster of clinically important and highly prevalent psychological morbidities seen in perioperative and critical care patients, most archetypally posttraumatic stress disorder (PTSD). Several sedative-hypnotics and analgesics are known to modulate fear systems, and it is theoretically plausible that clinical decisions of the anesthesiologist could impact psychological outcomes. This review aims to provide a focused synthesis of relevant literature from multiple fields of research.

RECENT FINDINGS

There is evidence in some contexts that unconscious fear memory systems are less sensitive to anesthetics than are conscious memory systems. Opiates may suppress the activation of fear systems and have benefit in the prevention of PTSD following trauma. There is inconsistent evidence that the use of propofol and benzodiazepines for sedation following trauma may potentiate the development of PTSD relative to other drugs. The benefits of ketamine seen in the treatment of major depression are not clearly replicated in PTSD-cluster psychopathologies, and its effects on fear processes are complex.

SUMMARY

There are multiple theoretical mechanisms by which anesthetic drugs can modulate fear systems and clinically important fear-based psychopathologies. The current state of research provides some evidence to support further hypothesis investigation. However, the absence of effectiveness studies and the inconsistent signals from smaller studies provide insufficient evidence to currently offer firm clinical guidance.

When Experiencing a Surgery: Gastrointestinal Cancer Patients’ Longitudinal Trajectories in Psychological Stress and Their Association with Quality of Recovery

Objective

Surgical treatment, particularly for gastrointestinal cancer, is a burdensome prospect for many patients. Psychological stress is a common complaint; however, little is known about its patterns in perioperative patients. This study aimed to identify distinct trajectories of perioperative stress and explore antecedent factors and hospitalization outcomes among different trajectories in patients with gastrointestinal cancer.

Methods

A longitudinal study was conducted on 203 patients with gastrointestinal surgical cancer at a specialized oncology hospital in China. Psychological stress was assessed at five perioperative time points (1–3 days before surgery; 1–3 days, 4–6 days, 7–9 days after surgery, and before discharge). A growth mixture model was used to analyze the potential stress trajectories. Multinomial logistic regression was used to identify the characteristics associated with different trajectories.

Results

Three stress trajectories were identified: recovery class (RC, 60.6%), chronic class (CC, 29.5%), and deterioration class (DC, 9.9%). Compared with CC, RC exhibited a shorter length of stay and better recovery quality, and was related to employment, low illness perception, and positive coping; DC reported lower recovery quality from 7 to 9 days after surgery to discharge and was associated with poor education level, history of surgery, stoma, smoking, and preoperative insomnia.

Conclusions

Most surgical patients were insulated from stress due to psychosocial resources, and thus displayed good recovery. However, many patients had moderate stress that did not improve or worsen over the perioperative period, which still needs to be screened and provided with early stress management.

S-ketamine as an adjuvant in patient-controlled intravenous analgesia for preventing postpartum depression: a randomized controlled trial

Background

Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD. However, whether S-ketamine in patient-controlled intravenous analgesia (PCIA) can reduce the incidence of PPD is unknown. This study assessed the effect of S-ketamine as an adjuvant in PCIA for preventing PPD in women undergoing cesarean delivery.

Methods

A total of 375 parturients scheduled to undergo cesarean section and then receive PCIA were recruited from a single center and were randomly assigned to control (C) group (sufentanil 2 μg/kg + tropisetron 10 mg) or S-ketamine (S) group (S-ketamine 0.5 mg/kg + sufentanil 2 μg/kg + tropisetron 10 mg). The primary outcome was the incidence of PPD measured by the Edinburgh postnatal depression scale (EPDS) after surgery. The secondary outcomes were EPDS scores, visual analog scale (VAS) scores, Ramsay sedation scale (RSS) scores, and the rate of adverse events, including headache, nausea, dizziness, drowsiness, and vomit.

Results

A total of 275 puerperal women were included in the study. The rate of depression in parturient on postoperative days 3, 14, 28 in the C group and S group were 17.6 and 8.2% (p < 0.05), 24.2 and 9.8% (p < 0.05), and 19.0 and 17.2% (p = 0.76) respectively. EPDS scores in the C group and S group on postoperative days 3,14, and 28 were 7.65 ± 3.14 and 6.00 ± 2.47 (p < 0.05), 7.62 ± 3.14 and 6.38 ± 2.67 (p < 0.05), and 7.35 ± 3.17 and 6.90 ± 2.78 (p = 0.15), respectively. The rate of adverse events in the C group and S group were headache 3.3 and 4.1% (p = 0.755), nausea 5.9 and 8.2% (p = 0.481), dizziness 9.2 and 12.3% (p = 0.434), drowsiness 6.5 and 10.7%(p = 0.274), and vomit 5.9 and 5.7% (p = 0.585).

Conclusions

S-ketamine (0.01 mg/kg/h) as an adjuvant in PCIA significantly reduces the incidence of PPD within 14 days and relieves pain within 48 h after cesarean delivery, without increasing the rate of adverse reactions.

Trial registration

Registered in the Chinese Clinical Trial Registry (ChiCTR2100050263) on August 24, 2021.