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Kummer I, Lüthi A, Klingler G, Andereggen L, Urman RD, Luedi MM, Stieger A. Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy. Curr Pain Headache Rep 2024:10.1007/s11916-024-01276-w. [PMID: 38865074 DOI: 10.1007/s11916-024-01276-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE OF THE REVIEW Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality. RECENT FINDINGS Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.
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Affiliation(s)
- Isabelle Kummer
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
| | - Andreas Lüthi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Gabriela Klingler
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Stieger
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Ma X, Yan J, Jiang H. Application of Ketamine in Pain Management and the Underlying Mechanism. Pain Res Manag 2023; 2023:1928969. [PMID: 37622028 PMCID: PMC10447145 DOI: 10.1155/2023/1928969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
Since ketamine was approved by the FDA as an intravenous anesthetic, it has been in clinical use for more than 50 years. Apart from its anesthetic effects, ketamine is one of the few intravenous anesthetics with potent analgesic properties. As part of the effort to develop pain management, renewed interest has focused on the use of ketamine for the treatment of acute and chronic pain. Ketamine is commonly used to treat various kinds of chronic pain syndromes and is also applied to control perioperative pain and reduce the consumption of postoperative analgesics. However, its precise mechanisms of action remain mysterious for a large part. Despite extensive research in the field, the mechanism of ketamine is still unclear. Its analgesic effect appears to be largely mediated by blockade of NMDARs, but opioid, GABA, and monoaminergic system seem to partly participate in the pain transmission procedure. Its metabolites also have an analgesic effect, which may prolong pain relief. More recently, the antidepressant effect of ketamine has been considered to reduce pain-related aversion to relieve chronic pain. Overall, the analgesic mechanism of ketamine seems to be a complex combination of multiple factors. Due to its potent analgesic properties, ketamine is an analgesic with great clinical application prospects. Exploring the precise mechanism of action of ketamine will help guide clinical medication and confirm indications for ketamine analgesia. This review aims to list the application of ketamine in pain management and discuss its analgesic mechanism.
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Affiliation(s)
- Xiaofan Ma
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Yan
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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The effect of preemptive ketamine on postoperative analgesia in lower extremity surgery. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.862547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Varas V, Bertinelli P, Carrasco P, Souper N, Álvarez P, Danilla S, Egaña JI, Penna A, Sepúlveda S, Arancibia V, Álvarez MG, Vergara R. Intraoperative Ketamine and Magnesium Therapy to Control Postoperative Pain After Abdominoplasty and/or Liposuction: A Clinical Randomized Trial. J Pain Res 2020; 13:2937-2946. [PMID: 33235492 PMCID: PMC7678693 DOI: 10.2147/jpr.s276710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/02/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to compare the effects of ketamine and ketamine associated with magnesium on opioid consumption and pain scores in patients undergoing abdominoplasty and/or liposuction compared to standard treatment. Patients and Methods A total of 63 patients were included and randomized as follows: 21 patients in the Control group, 20 patients in the Ketamine group (Ket), and 22 patients in the Ketamine-magnesium group (KetMag). The KetMag group received an IV bolus of 0.3 mg/kg of ketamine and 50 mg/kg magnesium, followed by continuous infusion of ketamine (0.15 mg/kg/h) and magnesium (10 mg/kg/h) until extubation. The Ket group received the same bolus and infusion of ketamine, together with a bolus and continuous infusion of placebo instead of magnesium. The Control group received saline instead of ketamine and magnesium. The groups were compared in morphine consumption during the first 12h, body-postoperative pain and disability scale until the 90th day, the time until the first morphine request on the PCA pump, pain scores, and the adverse effects related to the use of study drugs. Results The KetMag group had a lower morphine consumption by almost 50% during the first 12h than the Control and the Ket groups. In addition, the KetMag group required the first dose of morphine later than the other two groups. There were no differences in the adverse effects of the proposed treatments. Finally, multiple linear regression and a nonlinear approach analysis indicated that the Control group experienced a higher degree of pain and increased morphine consumption per hour than Ket and KetMag groups. Conclusion Co-administration of intraoperative ketamine plus magnesium and ketamine alone are an effective and easy regime for reducing pain and opioid consumption in the postoperative period.
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Affiliation(s)
- Verónica Varas
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Paz Bertinelli
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Pablo Carrasco
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Nicole Souper
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Patricio Álvarez
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Stefan Danilla
- Department of Surgery, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - José Ignacio Egaña
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile.,Biomedical Neuroscience Institute (BNI), Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Sergio Sepúlveda
- Department of Surgery, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Virginia Arancibia
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - María Gabriela Álvarez
- Department of Anesthesia and Perioperative Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Rodrigo Vergara
- Departamento de Kinesiología, Facultad de Artes y Educación Física, Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile
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Effects of fentanyl-lidocaine-ketamine versus sufentanil-lidocaine-ketamine on the isoflurane requirements in dogs undergoing total ear canal ablation and lateral bulla osteotomy. Vet Anaesth Analg 2020; 47:595-603. [PMID: 32792272 DOI: 10.1016/j.vaa.2020.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 12/30/2019] [Accepted: 04/05/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the isoflurane-sparing effects of sufentanil-lidocaine-ketamine (SLK) and fentanyl-lidocaine-ketamine (FLK) infusions in dogs undergoing total ear canal ablation and lateral bulla osteotomy (TECA-LBO). STUDY DESIGN Randomized blinded clinical study. ANIMALS A group of 20 client-owned dogs undergoing TECA-LBO. METHODS Intravenous (IV) administration of lidocaine (3 mg kg-1) and ketamine (0.6 mg kg-1) with fentanyl (5.4 μg kg-1; n = 10; FLK group) or sufentanil (0.72 μg kg-1; n = 10; SLK group) was immediately followed by the corresponding constant rate infusion (CRI) (lidocaine 3 mg kg-1 hour-1; ketamine 0.6 mg kg-1 hour-1; either fentanyl 5.4 μg kg-1 hour-1 or sufentanil 0.72 μg kg-1 hour-1). Anaesthesia was induced with propofol 3-5 mg kg-1 IV and was maintained with isoflurane. End-tidal isoflurane concentration (Fe'Iso) was decreased in 0.2% steps every 15 minutes until spontaneous movements were observed (treated with propofol 1 mg kg-1 IV) or an increase of > 30% in heart rate or mean arterial pressure from baseline occurred (treated with rescue fentanyl or sufentanil). Quality of recovery and pain were assessed at extubation using the short-form Glasgow Composite Pain Scale (SF-GCPS), Colorado State University Canine Acute Pain scale (CSU-CAP), and visual analogue scale (VAS). Data were analysed with analysis of variance, t tests, Fisher test and Spearman coefficient (p < 0.05). RESULTS Fe'Iso decreased significantly in SLK group (45%; p = 0.0006) but not in FLK (15%; p = 0.1135) (p = 0.0136). SLK group had lower scores for recovery quality (p = 0.0204), SF-GCPS (p = 0.0071) and CSU-CAP (p = 0.0273) than FLK at extubation. Intraoperative rescue analgesia and VAS were not significantly different between groups. CONCLUSIONS AND CLINICAL RELEVANCE Compared with FLK infusion, CRI of SLK at these doses decreased isoflurane requirements, decreased pain scores and improved recovery quality at extubation in dogs undergoing TECA-LBO.
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Abstract
Pain management is complex regardless of whether the pain is acute or chronic in nature or non-cancer or cancer related. In addition, relatively few pain pharmacotherapy options with adequate efficacy and safety data currently exist. Consequently, interest in the role of NMDA receptor antagonists as a pharmacological pain management strategy has surfaced. This narrative review provides an overview of the NMDA receptor and elaborates on the pharmacotherapeutic profile and pain management literature findings for the following NMDA receptor antagonists: ketamine, memantine, dextromethorphan, and magnesium. The literature on this topic is characterized by small studies, many of which exhibit methodological flaws. To date, ketamine is the most studied NMDA receptor antagonist for both acute and chronic pain management. Although further research about NMDA receptor antagonists for analgesia is needed and the optimal dosage/administration regimens for these drugs have yet to be determined, ketamine appears to hold the most promise and may be of particular value in the perioperative pain management realm.
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Matsutani N, Seki N. Effect of preoperative pregabalin in video-assisted thoracoscopic surgery. J Thorac Dis 2019; 10:S4028-S4030. [PMID: 30631546 DOI: 10.21037/jtd.2018.09.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Noriyuki Matsutani
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, Kanagawa, Japan
| | - Nobuhiko Seki
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Brinck EC, Tiippana E, Heesen M, Bell RF, Straube S, Moore RA, Kontinen V. Perioperative intravenous ketamine for acute postoperative pain in adults. Cochrane Database Syst Rev 2018; 12:CD012033. [PMID: 30570761 PMCID: PMC6360925 DOI: 10.1002/14651858.cd012033.pub4] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inadequate pain management after surgery increases the risk of postoperative complications and may predispose for chronic postsurgical pain. Perioperative ketamine may enhance conventional analgesics in the acute postoperative setting. OBJECTIVES To evaluate the efficacy and safety of perioperative intravenous ketamine in adult patients when used for the treatment or prevention of acute pain following general anaesthesia. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to July 2018 and three trials registers (metaRegister of controlled trials, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP)) together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We sought randomised, double-blind, controlled trials of adults undergoing surgery under general anaesthesia and being treated with perioperative intravenous ketamine. Studies compared ketamine with placebo, or compared ketamine plus a basic analgesic, such as morphine or non-steroidal anti-inflammatory drug (NSAID), with a basic analgesic alone. DATA COLLECTION AND ANALYSIS Two review authors searched for studies, extracted efficacy and adverse event data, examined issues of study quality and potential bias, and performed analyses. Primary outcomes were opioid consumption and pain intensity at rest and during movement at 24 and 48 hours postoperatively. Secondary outcomes were time to first analgesic request, assessment of postoperative hyperalgesia, central nervous system (CNS) adverse effects, and postoperative nausea and vomiting. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS We included 130 studies with 8341 participants. Ketamine was given to 4588 participants and 3753 participants served as controls. Types of surgery included ear, nose or throat surgery, wisdom tooth extraction, thoracotomy, lumbar fusion surgery, microdiscectomy, hip joint replacement surgery, knee joint replacement surgery, anterior cruciate ligament repair, knee arthroscopy, mastectomy, haemorrhoidectomy, abdominal surgery, radical prostatectomy, thyroid surgery, elective caesarean section, and laparoscopic surgery. Racemic ketamine bolus doses were predominantly 0.25 mg to 1 mg, and infusions 2 to 5 µg/kg/minute; 10 studies used only S-ketamine and one only R-ketamine. Risk of bias was generally low or uncertain, except for study size; most had fewer than 50 participants per treatment arm, resulting in high heterogeneity, as expected, for most analyses. We did not stratify the main analysis by type of surgery or any other factor, such as dose or timing of ketamine administration, and used a non-stratified analysis.Perioperative intravenous ketamine reduced postoperative opioid consumption over 24 hours by 8 mg morphine equivalents (95% CI 6 to 9; 19% from 42 mg consumed by participants given placebo, moderate-quality evidence; 65 studies, 4004 participants). Over 48 hours, opioid consumption was 13 mg lower (95% CI 10 to 15; 19% from 67 mg with placebo, moderate-quality evidence; 37 studies, 2449 participants).Perioperative intravenous ketamine reduced pain at rest at 24 hours by 5/100 mm on a visual analogue scale (95% CI 4 to 7; 19% lower from 26/100 mm with placebo, high-quality evidence; 82 studies, 5004 participants), and at 48 hours by 5/100 mm (95% CI 3 to 7; 22% lower from 23/100 mm, high-quality evidence; 49 studies, 2962 participants). Pain during movement was reduced at 24 hours (6/100 mm, 14% lower from 42/100 mm, moderate-quality evidence; 29 studies, 1806 participants), and 48 hours (6/100 mm, 16% lower from 37 mm, low-quality evidence; 23 studies, 1353 participants).Results for primary outcomes were consistent when analysed by pain at rest or on movement, operation type, and timing of administration, or sensitivity to study size and pain intensity. No analysis by dose was possible. There was no difference when nitrous oxide was used. We downgraded the quality of the evidence once if numbers of participants were large but small-study effects were present, or twice if numbers were small and small-study effects likely but testing not possible.Ketamine increased the time for the first postoperative analgesic request by 54 minutes (95% CI 37 to 71 minutes), from a mean of 39 minutes with placebo (moderate-quality evidence; 31 studies, 1678 participants). Ketamine reduced the area of postoperative hyperalgesia by 7 cm² (95% CI -11.9 to -2.2), compared with placebo (very low-quality evidence; 7 studies 333 participants). We downgraded the quality of evidence because of small-study effects or because the number of participants was below 400.CNS adverse events occurred in 52 studies, while 53 studies reported of absence of CNS adverse events. Overall, 187/3614 (5%) participants receiving ketamine and 122/2924 (4%) receiving control treatment experienced an adverse event (RR 1.2, 95% CI 0.95 to 1.4; high-quality evidence; 105 studies, 6538 participants). Ketamine reduced postoperative nausea and vomiting from 27% with placebo to 23% with ketamine (RR 0.88, 95% CI 0.81 to 0.96; the number needed to treat to prevent one episode of postoperative nausea and vomiting with perioperative intravenous ketamine administration was 24 (95% CI 16 to 54; high-quality evidence; 95 studies, 5965 participants). AUTHORS' CONCLUSIONS Perioperative intravenous ketamine probably reduces postoperative analgesic consumption and pain intensity. Results were consistent in different operation types or timing of ketamine administration, with larger and smaller studies, and by higher and lower pain intensity. CNS adverse events were little different with ketamine or control. Perioperative intravenous ketamine probably reduces postoperative nausea and vomiting by a small extent, of arguable clinical relevance.
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Affiliation(s)
- Elina Cv Brinck
- Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Anesthesiology, Töölö Hospital, Helsinki University and Helsinki University Hospital, Topeliuksenkatu 5, Helsinki, Finland, PB 266 00029
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Kim JC, Byun S, Kim S, Lee SY, Lee JH, Ahn S. Effect of preoperative pregabalin as an adjunct to a multimodal analgesic regimen in video-assisted thoracoscopic surgery: A randomized controlled trial. Medicine (Baltimore) 2017; 96:e8644. [PMID: 29245223 PMCID: PMC5728838 DOI: 10.1097/md.0000000000008644] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Depending on the type of injury, the pain mechanisms are multifactorial. Preoperative pregabalin administrations as an adjunct to a multimodal postoperative pain management strategy have been tested in various surgical settings. The purpose of current study was to evaluate the effects of preoperative pregabalin administration on postoperative pain intensity and rescue analgesic requirement following video-assisted thoracoscopic surgery (VATS). METHODS Sixty adult patients undergoing VATS were randomly assigned either to receive pregabalin 150 mg (Pregabalin group) or placebo (Control group) 1 hour before anesthesia. Primary efficacy variable was pain intensity. Secondary efficacy variables were the requirement of rescue analgesics, total volume of intravenous patient-controlled analgesia (IV-PCA), and adverse effects induced by pregabalin or IV-PCA. RESULTS Pain intensity scores at post-anesthesia care unit (PACU), 6 and 24 hours were lower significantly in the Pregabalin group compared with the Control group (mean [SD]; 5.6 [2.0] vs 6.8 [1.8]; mean difference: 1.2, 95% CI of difference: 0.2166-2.1835, P = .018, mean [SD]; 3.8 [1.9] vs 5.6 [1.4]; mean difference: 1.8, 95% CI of difference: 1.0074-2.7260, P = .001 and mean [SD]; 2.6 [1.6] vs 3.5 [1.5]; mean difference: 0.9, 95% CI of difference: 0.0946-1.7054, P = .029, respectively]. Also, the frequency of additional rescue drug administered at PACU (median [interquartile range]; 2 [2-3] vs 1 [1-2], P = .027) was significantly less in the Pregabalin group. The incidences of adverse effects related to pregabalin or IV-PCA were not different between the groups. CONCLUSION A single administration of pregabalin 150 mg before VATS decreased postoperative pain scores and incidence of additional rescue analgesics in the immediate postoperative period without increased risk of adverse effects.
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Affiliation(s)
- Jong Chan Kim
- Department of Anesthesiology and Pain Medicine, Hando General Hospital, Ansan-si
| | - Sunghye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu
| | - Seongsu Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam-si, South Korea
| | - Seon-Yi Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam-si, South Korea
| | - Joo Hyung Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam-si, South Korea
| | - Sowoon Ahn
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam-si, South Korea
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Lee J, Park HP, Jeong MH, Son JD, Kim HC. Efficacy of ketamine for postoperative pain following robotic thyroidectomy: A prospective randomised study. J Int Med Res 2017; 46:1109-1120. [PMID: 29124992 PMCID: PMC5972244 DOI: 10.1177/0300060517734679] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective Although robotic thyroidectomy (RoT) is a minimally invasive surgery, percutaneous tunneling causes moderate to severe pain immediately postoperatively. We evaluated the efficacy of ketamine for postoperative pain management in patients following RoT. Methods Sixty-four patients scheduled for RoT were randomly divided into two groups. In the ketamine group (n = 32), ketamine was infused from induction of anaesthesia until the end of the procedure (0.15-mg/kg bolus with continuous infusion at 2 µg/kg/min). In the control group (n = 32), the same volume of saline was infused. Visual analogue scale (VAS) scores for acute and chronic pain, the incidence of hypoesthesia, postoperative analgesic requirements, and complications related to opioids or ketamine were compared between the two groups. Results The VAS pain scores were significantly lower in the ketamine group up to 24 h postoperatively. The VAS pain score when coughing was significantly higher in the control group than in the ketamine group at 24 h postoperatively. A significantly greater proportion of patients in the control group required rescue analgesics. Complications were comparable in both groups. Conclusions Ketamine infusion decreased pain scores for 24 h postoperatively and reduced analgesic requirements without serious complications in patients following RoT. Trial Registration: Clinicaltrials.gov Identifier: NCT01997801
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Affiliation(s)
- Jiwon Lee
- 1 Department of Anaesthesiology and Pain Medicine, Keimyung University Dongsan Medical Centre, Daegu, Korea
| | - Hee-Pyoung Park
- 2 Department of Anaesthesiology and Pain Medicine, Seoul National University, Seoul, Korea
| | - Mu-Hui Jeong
- 1 Department of Anaesthesiology and Pain Medicine, Keimyung University Dongsan Medical Centre, Daegu, Korea
| | - Je-Do Son
- 1 Department of Anaesthesiology and Pain Medicine, Keimyung University Dongsan Medical Centre, Daegu, Korea
| | - Hyun-Chang Kim
- 1 Department of Anaesthesiology and Pain Medicine, Keimyung University Dongsan Medical Centre, Daegu, Korea
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Moro ET, Feitosa IMPSS, de Oliveira RG, Saraiva GFP, Rosalino R, Marossi VP, Bloomstone JA, Navarro LHC. Ketamine does not enhance the quality of recovery following laparoscopic cholecystectomy: a randomized controlled trial. Acta Anaesthesiol Scand 2017. [PMID: 28620916 DOI: 10.1111/aas.12919] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Ketamine has been used as part of the multimodal analgesia technique in the acute perioperative period. The effect of perioperative intravenous small-dose ketamine on the quality of recovery from the patient point-of-view has not been assessed. We hypothesized that low-dose ketamine would enhance recovery following laparoscopic cholecystectomy under total intravenous anesthesia. METHODS One hundred thirty five patients undergoing laparoscopic cholecystectomy were enrolled in this randomized, double-blind placebo-controlled trial. Subjects were randomly assigned to one of three groups: saline, ketamine 0.2 mg/kg, or ketamine 0.4 mg/kg immediately following the induction of anesthesia and before skin incision. The primary endpoint was assessed using the Quality of Recovery Questionnaire (QoR-40), a 40-item quality of recovery scoring system. In addition, early clinical recovery variables, such as time to eye opening, occurrence of nausea and vomiting, pain score, analgesic use, and length of PACU stay were assessed. RESULTS No differences were detected in the total or individual dimension scores of the QoR-40 questionnaire. The incidence of nausea, vomiting, and other complications did not differ among the three groups. CONCLUSIONS Small doses of ketamine do not improve the quality of recovery after remifentanil-based anesthesia for laparoscopic cholecystectomy.
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Affiliation(s)
- E. T. Moro
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - I. M. P. S. S. Feitosa
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - R. G. de Oliveira
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - G. F. P. Saraiva
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - R. Rosalino
- School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - V. P. Marossi
- School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - J. A. Bloomstone
- Department of Anesthesiology; College of Medicine; University of Arizona; Phoenix AZ USA
| | - L. H. C. Navarro
- Department of Anesthesiology; Botucatu Medical School; São Paulo State University, UNESP; São Paulo Brazil
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Kaka U, Saifullah B, Abubakar AA, Goh YM, Fakurazi S, Kaka A, Behan AA, Ebrahimi M, Chen HC. Serum concentration of ketamine and antinociceptive effects of ketamine and ketamine-lidocaine infusions in conscious dogs. BMC Vet Res 2016; 12:198. [PMID: 27612660 PMCID: PMC5016942 DOI: 10.1186/s12917-016-0815-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 08/30/2016] [Indexed: 01/10/2023] Open
Abstract
Background Central sensitization is a potential severe consequence of invasive surgical procedures. It results in postoperative and potentially chronic pain enhancement. It results in postoperative pain enhancement; clinically manifested as hyperalgesia and allodynia. N-methyl-D-aspartate (NMDA) receptor plays a crucial role in the mechanism of central sensitisation. Ketamine is most commonly used NMDA-antagonist in human and veterinary practice. However, the antinociceptive serum concentration of ketamine is not yet properly established in dogs. Six dogs were used in a crossover design, with one week washout period. Treatments consisted of: 1) 0.5 mg/kg ketamine followed by continuous rate infusion (CRI) of 30 μg/kg/min; 2) 0.5 mg/kg ketamine followed by CRI of 30 μg/kg/min and lidocaine (2 mg/kg followed by CRI of 100 μg/kg/min); and 3) 0.5 mg/kg ketamine followed by CRI of 50 μg/kg/min. The infusion was administered up to 120 min. Nociceptive thresholds and ketamine serum concentrations were measured before drug administration, and at 5, 10, 20, 40, 60, 90, 120, 140 and 160 min after the start of infusion. Results Maximum concentration recorded was 435.34 ± 26.18 ng/mL, 582.34 ± 227.46 ng/mL and 733.77 ± 133.6 ng/mL for K30, KL30 and K50, respectively. The concentration at 120 min was 250.87 ± 39.87, 221.73 ± 91.03 and 343.67 ± 63.21 ng/mL at 120 min in K30, KL30 and K50, respectively. All the three infusion regimes maintained serum concentrations above 200 ng/mL. The thresholds returned towards baseline values within 20 min, after cessation of infusion. Conclusion Serum concentration to produce mechanical antinociceptive effects in dogs is between 100 and 200 ng/mL. All the three infusion regimes in this study provided antinociceptive effects throughout the infusions. In this study, we found that the serum concentration of ketamine to produce mechanical antinociceptive effects in dogs is above 200 ng/mL. All three infusion regimes provided antinociceptive effects throughout the infusions without causing harmful effects. Further studies are recommended in a clinical setting.
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Affiliation(s)
- Ubedullah Kaka
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.,Department of Surgery and Obstetrics, Faculty of Animal Husbandry & Veterinary Sciences, Sindh Agriculture University Tandojam, Sindh, 70060, Pakistan
| | - Bullo Saifullah
- Material Synthesis and characterization laboratory, Institute of Advanced technology, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Adamu Abdul Abubakar
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Yong Meng Goh
- Department of Veterinary Preclinical Sciences, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.,Institutes of Tropical Agriculture, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Sharida Fakurazi
- Laboratory of Vaccines and Immunotherapeutics, Institute of Bioscience, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.,Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Asmatullah Kaka
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.,Faculty of Animal Husbandry & Veterinary Sciences, Sindh Agriculture University Tandojam, Sindh, 70060, Pakistan
| | - Atique Ahmed Behan
- Department of Animal Sciences, Faculty of Agriculture, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.,Faculty of Animal Husbandry & Veterinary Sciences, Sindh Agriculture University Tandojam, Sindh, 70060, Pakistan
| | - Mahdi Ebrahimi
- Department of Veterinary Preclinical Sciences, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Hui Cheng Chen
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
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13
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Shen Y, Xu L, Liu M, Lei Y, Gu X, Ma Z. The effects of an intraperitoneal single low dose of ketamine in attenuating the postoperative skin/muscle incision and retraction-induced pain related to the inhibition of N-methyl-d-aspartate receptors in the spinal cord. Neurosci Lett 2016; 616:211-7. [DOI: 10.1016/j.neulet.2015.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/18/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
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Analgesic efficacy of preemptive pregabalin administration in arthroscopic shoulder surgery: a randomized controlled trial. Can J Anaesth 2015; 63:283-9. [DOI: 10.1007/s12630-015-0510-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/20/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022] Open
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Haliloglu M, Ozdemir M, Uzture N, Cenksoy PO, Bakan N. Perioperative low-dose ketamine improves postoperative analgesia following Cesarean delivery with general anesthesia. J Matern Fetal Neonatal Med 2015; 29:962-6. [PMID: 25845277 DOI: 10.3109/14767058.2015.1027190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In this study, the effect of perioperative uses of low dose ketamine on post-operative wound pain and analgesic consumption in patients undergoing elective Cesarean section was evaluated. METHODS In randomized, double blind clinical trial, 52 women with American Society of Anesthesiologists (ASA) class I-II identification undergoing elective Cesarean section in general anesthesia were enrolled. In the ketamine group (group K), a ketamine bolus of 0.5 mg kg(-1) IV was administered at the time of induction of general anesthesia. After induction, a ketamine infusion of 0.25 mg kg(-1) h(-1) was started and discontinued at the end of surgery. Patients allocated to the control group (group C) were given identical volumes of saline. The cumulative dose of morphine consumption after surgery was measured as the primary outcome of this study. Secondary outcomes were pain control assessed by numeric rating scale (NRS) and need for rescue analgesia and incidence of side effects. RESULTS The mean 24-h morphine consumption was lower in group K (p = 0,001). At 15 min postoperatively, NRS values were lower in group K than group C (p = 0,001). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (p > 0.05). CONCLUSIONS Perioperative uses of low dose ketamine decreased post-operative opioid requirements, which was observed long after the normal expected duration of ketamine.
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Affiliation(s)
- Murat Haliloglu
- a Department of Anaesthesiology and Reanimation , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Mehtap Ozdemir
- b Department of Anaesthesiology and Reanimation , Umraniye education and Research Hospital , İstanbul , Turkey , and
| | - Neslihan Uzture
- a Department of Anaesthesiology and Reanimation , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Pinar Ozcan Cenksoy
- c Department of Obstetrics and Gynecology , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Nurten Bakan
- b Department of Anaesthesiology and Reanimation , Umraniye education and Research Hospital , İstanbul , Turkey , and
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Motov S, Rockoff B, Cohen V, Pushkar I, Likourezos A, McKay C, Soleyman-Zomalan E, Homel P, Terentiev V, Fromm C. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2015; 66:222-229.e1. [DOI: 10.1016/j.annemergmed.2015.03.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/20/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
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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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Jouguelet-Lacoste J, La Colla L, Schilling D, Chelly JE. The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. PAIN MEDICINE 2015; 16:383-403. [DOI: 10.1111/pme.12619] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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19
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Nistal-Nuño B, Freire-Vila E, Castro-Seoane F, Camba-Rodriguez M. Preoperative low-dose ketamine has no preemptive analgesic effect in opioid-naïve patients undergoing colon surgery when nitrous oxide is used - a randomized study. F1000Res 2014; 3:226. [PMID: 25671084 PMCID: PMC4309164 DOI: 10.12688/f1000research.5258.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The analgesic properties of ketamine are associated with its non-competitive antagonism of the N-methyl-D-aspartate receptor; these receptors exhibit an excitatory function on pain transmission and this binding seems to inhibit or reverse the central sensitization of pain. In the literature, the value of this anesthetic for preemptive analgesia in the control of postoperative pain is uncertain. The objective of this study was to ascertain whether preoperative low-dose ketamine reduces postoperative pain and morphine consumption in adults undergoing colon surgery. METHODS In a double-blind, randomized trial, 48 patients were studied. Patients in the ketamine group received 0.5 mg/kg intravenous ketamine before surgical incision, while the control group received normal saline. The postoperative analgesia was achieved with a continuous infusion of morphine at 0.015 mg∙kg-¹∙h-¹ with the possibility of 0.02 mg/kg bolus every 10 min. Pain was assessed using the Visual Analog Scale (VAS), morphine consumption, and hemodynamic parameters at 0, 1, 2, 4, 8, 12, 16, and 24 hours postoperatively. We quantified times to rescue analgesic (Paracetamol), adverse effects and patient satisfaction. RESULTS No significant differences were observed in VAS scores between groups (P>0.05), except at 4 hours postoperatively (P=0.040). There were no differences in cumulative consumption of morphine at any time point (P>0.05). We found no significant differences in incremental postoperative doses of morphine consumption in bolus, except at 12 h (P =0.013) and 24 h (P =0.002). The time to first required rescue analgesia was 70 ± 15.491 min in the ketamine group and 44 ± 19.494 min in the control (P>0.05). There were no differences in hemodynamic parameters or patient satisfaction (P>0.05). CONCLUSIONS Preoperative low-dose-ketamine did not show a preemptive analgesic effect or efficacy as an adjuvant for decreasing opioid requirements for postoperative pain in patients receiving intravenous analgesia with morphine after colon surgery.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anesthesiology, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Enrique Freire-Vila
- Department of Anesthesiology, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Francisco Castro-Seoane
- Department of Anesthesiology, Complexo Hospitalario Arquitecto Marcide - Profesor Novoa Santos, Ferrol, Spain
| | - Manuel Camba-Rodriguez
- Department of Anesthesiology, Complexo Hospitalario Arquitecto Marcide - Profesor Novoa Santos, Ferrol, Spain
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Megahed NAE, Ellakany M, Elatter AMI, Moustafa Teima MAA. Comparison between analgesic effect of bupivacaine thoracic epidural and ketamine infusion plus wound infiltration with local anesthetics in open cholecystectomy. Anesth Essays Res 2014; 8:162-7. [PMID: 25886220 PMCID: PMC4173628 DOI: 10.4103/0259-1162.134492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neuraxial blocks result in sympathetic block, sensory analgesia and motor block. Continuous epidural anesthesia through a catheter offers several options for perioperative analgesia. Local anesthetic boluses or infusions can provide profound analgesia. Although the role of low-dose ketamine (<2 mg/kg intramuscular, <1 mg/kg intravenous [IV] or ≤ 20 μg/kg/min by IV infusion) in the treatment of post-operative pain is controversial, perioperative administration of a small dose of ketamine may be valuable to a multimodal analgesic regimen. A local anesthetic can be used for wound infiltration intra-operative to minimized the surgical pain. PATIENTS AND METHODS A prospective randomized study was performed in which 40 patients scheduled for elective open cholecystectomy under general anesthesia admitted to the Medical Research Institute were included and further subdivided into two groups, group A, received thoracic epidural catheter at T7-8, activation was done 20 min before induction of anesthesia with plain bupivacaine at a concentration of 0.25% at a volume of 1 ml/segment aiming to block sensory supply from T4-L2, then received continuous thoracic epidural infusion intra and postoperatively with plain bupivacaine at a concentration of 0.125% at a rate of 5 ml/h for 24 h, group B received 0.3 mg/kg bolus of ketamine at the time of induction then 0.1 mg/kg/h ketamine IV infusion during surgery followed by wound infiltration with 15 ml of plain bupivacaine 0.5% at the time of skin closure. RESULTS Bupivacaine thoracic epidural analgesia had better control on heart rate and mean arterial blood pressure than ketamine infusion plus wound infiltration with local anesthetic in patients undergoing open cholecystectomy. CONCLUSION Thoracic epidural analgesia had better control on hemodynamic changes intra-and postoperatively than ketamine infusion with local wound infiltration in open cholecystectomy.
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Affiliation(s)
| | - Mohamed Ellakany
- Department of Anesthesia, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg 2014; 259:413-31. [PMID: 24253135 DOI: 10.1097/sla.0000000000000349] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines. BACKGROUND ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy. METHODS We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated. RESULTS Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery. CONCLUSIONS ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.
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Singh H, Kundra S, Singh RM, Grewal A, Kaul TK, Sood D. Preemptive analgesia with Ketamine for Laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol 2013; 29:478-84. [PMID: 24249984 PMCID: PMC3819841 DOI: 10.4103/0970-9185.119141] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The aim of preemptive analgesia is to reduce central sensitization that arises from noxious inputs across the entire perioperative period. N-methyl d-aspartate receptor antagonists have the potential for attenuating central sensitization and preventing central neuroplasticity. MATERIALS AND METHODS Patients undergoing laparoscopic cholecystectomy were randomized into four groups of 20 patients each, who were administered the study drug intravenously 30 min before incision. Groups A, B, and C received ketamine in a dose of 1.00, 0.75 and 0.50 mg/kg, respectively, whereas group D received isotonic saline. Anesthetic and surgical techniques were standardized. Postoperatively, the degree of pain at rest, movement, and deep breathing using visual analogue scale, time of request for first analgesic, total opioid consumption, and postoperative nausea and vomiting were recorded in postanesthesia care unit for 24 h. RESULTS Pain scores were highest in Group D at 0 h. Groups A, B, and C had significantly decreased postoperative pain scores at 0, 0.5, 3, 4, 5, 6, and 12 h. Postoperative analgesic consumption was significantly less in groups A, B, and C as compared with group D. There was no significant difference in the pain scores among groups A, B, and C. Group A had a significantly higher heart rate and blood pressure than groups B and C at 0 and 0.5 h along with 10% incidence of hallucinations. CONCLUSION Preemptive ketamine has a definitive role in reducing postoperative pain and analgesic requirement in patients undergoing laparoscopic cholecystectomy. The lower dose of 0.5 mg/kg being devoid of any adverse effects and hemodynamic changes is an optimal dose for preemptive analgesia in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Harsimran Singh
- Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Addition of ketamine to propofol-alfentanil anesthesia may reduce postoperative pain in laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2013; 23:197-202. [PMID: 23579518 DOI: 10.1097/sle.0b013e3182827f09] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether intravenous anesthesia supplemented with ketamine reduces postoperative pain after elective laparoscopic cholecystectomy. MATERIALS AND METHODS Forty patients were enrolled and randomized 1:1 into one of 2 groups: the propofol group (received propofol and alfentanil supplemented with saline) and the ketamine group (received propofol and alfentanil with ketamine). The study was double-blind. The number and amount of the intraoperative additional alfentanil doses were recorded. Pain assessments and cumulative analgesic consumption at postanesthesia care unit (PACU) admission, PACU discharge, postoperative 24th hour, and hospital discharge were recorded. RESULTS The visual analog scale scores at PACU admission, PACU discharge, postoperative 24th hour, and hospital discharge were significantly lower in the ketamine group than the propofol group. The pain visual analog scale ≥ 75 at the postoperative 24th hour for the propofol group was also significantly lower (P<0.035) than that of the ketamine group. The difference in analgesic consumption between groups was statistically significant (P<0.001). CONCLUSIONS Our study showed that ketamine supplemented with propofol and alfentanil produced better analgesia intraoperatively and postoperatively and decreased analgesic consumption compared with the propofol group after laparoscopic cholecystectomy.
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Behdad S, Hajiesmaeili MR, Abbasi HR, Ayatollahi V, Khadiv Z, Sedaghat A. Analgesic Effects of Intravenous Ketamine during Spinal Anesthesia in Pregnant Women Undergone Caesarean Section; A Randomized Clinical Trial. Anesth Pain Med 2013; 3:230-3. [PMID: 24282773 PMCID: PMC3833040 DOI: 10.5812/aapm.7034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 10/11/2012] [Accepted: 06/20/2013] [Indexed: 12/04/2022] Open
Abstract
Background Suitable analgesia after cesarean section helps mothers to be more comfortable and increases their mobility and ability to take better care of their infants. Objectives Pain relief properties of ketamine prescription were assessed in women with elective cesarean section who underwent spinal anesthesia with low dose intravenous ketamine and midazolam and intravenous midazolam alone. Patients and Methods Sixty pregnant women scheduled for spinal anesthesia for cesarean section were randomized into two study groups. Ketamine (30 mg) + midazolam (1 mg = 2CC) or 1mg midazolam (2CC) alone, was given immediately after spinal anesthesia. Pain scores at first, second and third hours after CS operation, analgesic requirement and drug adverse effects were recorded in all patients. Results Ketamine group had significant pain relief properties in compare with control group in first hours after cesarean section (0.78 ± 1.09 vs. 1.72 ± 1.22, VAS score, P = 0.00). Total dose of meperidine consumption in women of ketamine group was significantly lower than women of control group (54.17 ± 12.86 vs. 74.44 ± 33.82 mg, P = 0.02). There were no significant drug side effects in participated patients. Conclusions Intravenous low-dose ketamine combined with midazolam for sedation during spinal anesthesia for elective Caesarean section provides more effective and long lasting pain relief than control group.
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Affiliation(s)
- Shekoufeh Behdad
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Mohammad Reza Hajiesmaeili
- Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of medical sciences (IUMS), Tehran, Iran
- Corresponding author: Mohammad Reza Hajiesmaeili, Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of Medical Sciences (IUMS), Tehran, Iran. Tel: +98-2166509059, Fax: +98-2166509059, E-mail:
| | - Hamid Reza Abbasi
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Vida Ayatollahi
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Zahra Khadiv
- Pain Research Center, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Alireza Sedaghat
- Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of medical sciences (IUMS), Tehran, Iran
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Galinski SF, Pereira JA, Maestre Y, Francés S, Escolano F, Puig MM. The combination of intravenous dexamethasone and ketamine does not improve postoperative analgesia when compared to each drug individually. ACTA ACUST UNITED AC 2013. [DOI: 10.1179/016911107x376936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Khajavi M, Emami A, Etezadi F, Safari S, Sharifi A, Shariat Moharari R. Conscious Sedation and Analgesia in Colonoscopy: Ketamine/Propofol Combination has Superior Patient Satisfaction Versus Fentanyl/Propofol. Anesth Pain Med 2013; 3:208-13. [PMID: 24223364 PMCID: PMC3821150 DOI: 10.5812/aapm.9653] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 02/01/2013] [Accepted: 02/10/2013] [Indexed: 01/08/2023] Open
Abstract
Background Colonoscopy is performed without preparing sedation in many countries. However,
according to the current literature patients are more satisfied when appropriate
sedation is prepared for them. Objectives We hypothesize that propofol-ketamine may prepare more patient satisfaction compared to
propofol-fentanyl combination. Patients and Methods Sixty adult patients older than 18 with ASA physical status of I, II or III were
enrolled in the present study after providing the informed consent. They were
prospectively randomized into two equal groups: 1- Group PF: was scheduled to receive IV
bolus dose of fentanyl 1µg/kg and propofol 0.5mg/kg. 2- Group PK: was scheduled to
receive IV bolus dose of ketamine 0.5mg/kg and propofol 0.5mg/kg. As a primary goal,
patient’s satisfaction was assessed by the use a Likert five-item scoring system
in the recovery. Comparisons of hemodynamic parameters (mean heart rate, mean systolic
blood pressure, mean diastolic blood pressure), mean Spo2 values during the procedure
and side effects such as nausea, vomiting, and psychological reactions during the
recovery period were our secondary goals. Level of sedation during the colonoscopy was
assessed with the Observer’s Assessment of Alertness/Sedation score (OAA/S). Results Mean satisfaction scores in the group PK were significantly higher than the group PF (P
= 0.005) while the level of sedation during the procedure was similar (P = 0.17).
Hemodynamic parameters and SpO2 values were not significantly different (P > 0.05).
Incidence of nausea and vomiting was the same in both groups. Conclusions IV bolus injection of propofol-ketamine can lead to more patients’ satisfaction
than the other protocols during colonoscopy.
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Affiliation(s)
- Mohammadreza Khajavi
- Department of Anesthesiology, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
| | - Azra Emami
- Department of Anesthesiology, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
| | - Farhad Etezadi
- Department of Anesthesiology, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
- Corresponding author: Farhad Etezadi, Department of
Anesthesiology, Sina Hospital, Hassan Abad Sq., Tehran University of Medical Sciences,
Tehran, Iran. Tel: +98-2122048483, Fax: +98-2166348553, E-mail:
| | - Saeid Safari
- Department of Anesthesiology, Rasoul Akram Medical center,
Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Alireza Sharifi
- Department of Gastroenterology, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
| | - Reza Shariat Moharari
- Department of Anesthesiology, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
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Han SY, Jin HC, Yang WD, Lee JH, Cho SH, Chae WS, Lee JS, Kim YI. The Effect of Low-dose Ketamine on Post-caesarean Delivery Analgesia after Spinal Anesthesia. Korean J Pain 2013; 26:270-6. [PMID: 23862001 PMCID: PMC3710941 DOI: 10.3344/kjp.2013.26.3.270] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/07/2013] [Accepted: 03/07/2013] [Indexed: 11/05/2022] Open
Abstract
Background Ketamine, an N-methyl-D-aspartate receptor antagonist, might play a role in postoperative analgesia, but its effect on postoperative pain after caesarean section varies with study design. We investigated whether the preemptive administration of low-dose intravenous ketamine decreases postoperative opioid requirement and postoperative pain in parturients receiving intravenous fentanyl with patient-controlled analgesia (PCA) following caesarean section. Methods Spinal anesthesia was performed in 40 parturients scheduled for elective caesarean section. Patients in the ketamine group received a 0.5 mg/kg ketamine bolus intravenously followed by 0.25 mg/kg/h continuous infusion during the operation. The control group received the same volume of normal saline. Immediately after surgery, the patients were connected to a PCA device set to deliver 25-µg fentanyl as an intravenous bolus with a 15-min lockout interval and no continuous dose. Postoperative pain was assessed using the cumulative dose of fentanyl and visual analog scale (VAS) scores at 2, 6, 24, and 48 h postoperatively. Results Significantly less fentanyl was used in the ketamine group 2 h after surgery (P = 0.033), but the difference was not significant at 6, 12, and 24 h postoperatively. No significant differences were observed between the VAS scores of the two groups at 2, 6, 12, and 24 h postoperatively. Conclusions Intraoperative low-dose ketamine did not have a preemptive analgesic effect and was not effective as an adjuvant to decrease opioid requirement or postoperative pain score in parturients receiving intravenous PCA with fentanyl after caesarean section.
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Affiliation(s)
- Seung Yeup Han
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Shariat Moharari R, Lajevardi M, Khajavi M, Najafi A, Shariat Moharari G, Etezadi F. Effects of Intra-Operative Ketamine Administration on Postoperative Catheter-Related Bladder Discomfort: A Double-Blind Clinical Trial. Pain Pract 2013; 14:146-50. [DOI: 10.1111/papr.12055] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 01/27/2013] [Indexed: 01/12/2023]
Affiliation(s)
| | - Mahbod Lajevardi
- Sina Hospital; Tehran University of Medical Sciences; Tehran Iran
| | | | - Atabak Najafi
- Sina Hospital; Tehran University of Medical Sciences; Tehran Iran
| | | | - Farhad Etezadi
- Sina Hospital; Tehran University of Medical Sciences; Tehran Iran
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Sandkühler J, Ruscheweyh R. Opioids and central sensitisation: I. Pre-emptive analgesia. Eur J Pain 2012; 9:145-8. [PMID: 15737804 DOI: 10.1016/j.ejpain.2004.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Accepted: 05/17/2004] [Indexed: 11/20/2022]
Abstract
Opioids are powerful analgesics when used to treat acute pain and some forms of chronic pain. A large body of literature has shown that opioids can, in addition, also prevent (this review) or induce and perhaps reverse, some forms central sensitisation in in vitro and in vivo animal models of pain. However, the concept of central sensitisation is, at present, ambiguous and the usefulness of opioids as preemptive analgesics in human pain patients is still not clear.
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Affiliation(s)
- Jürgen Sandkühler
- Department of Neurophysiology, Centre for Brain Research, Medical University of Vienna, Spitalgasse 4, A-1090 Vienna, Austria.
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Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial. Ann Surg 2011; 254:28-38. [PMID: 21670611 DOI: 10.1097/sla.0b013e318221f0cf] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Two wounds are created after abdominal surgery. The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions. In animal models vagotomy blunts the intraperitoneal response to induced inflammation. This is not feasible in humans. However a transient chemical afferentectomy after colectomy by using neuraxial blockade (epidural) and intraperitoneal blockade may be possible. We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic (IPLA) on recovery parameters after colectomy, in the setting of an established enhanced recovery after surgery (ERAS) program. METHODS Double blinded, randomized, placebo controlled design. The study group (IPLA) received instillation of intraperitoneal ropivacaine (75 mg) before dissection and postoperative infusion of 0.2% solution at 4 mL/hour for 3 days continuously. The placebo group (NS) was treated as above with 0.9% saline solution. All patients were cared for under ERAS standardized perioperative care. Epidural infusion was stopped on day 2. Patients were discharged from day 3 onwards once criteria met. Perioperative data, surgical recovery score (SRS), complications, and length of stay were recorded. Systemic cytokines response, neuroendocrine parameters, pain measures and opioid use data were collected. Patients were followed up for 60 days. RESULTS Sixty patients were recruited. Patients were equivalently matched at baseline. There were no local anesthetic related adverse events. The complication rate, including anastomotic leak rate, was equivalent between groups. IPLA group had better SRS scores for the duration of intraperitoneal infusion. Pain and opioid use was reduced in the IPLA group. Systemic cytokine and cortisol response was diminished in the IPLA group. IPLA group had consistently higher systemic ropivacaine levels than placebo group. CONCLUSION Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery. This was associated with a blunting of postsurgical systemic cytokines and cortisol. Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion. Therefore a transient chemical afferentectomy with clinical benefit is possible with this method. A longer IPLA infusion duration needs to be studied. This study is registered at clinicaltrials.gov and carries the ID number NCT00722709.
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Safavi M, Honarmand A, Nematollahy Z. Pre-incisional analgesia with intravenous or subcutaneous infiltration of ketamine reduces postoperative pain in patients after open cholecystectomy: a randomized, double-blind, placebo-controlled study. PAIN MEDICINE 2011; 12:1418-26. [PMID: 21812910 DOI: 10.1111/j.1526-4637.2011.01205.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In literature, there is controversy on the use of ketamine for management of postoperative pain. The aim of the present study was to evaluate the efficacy of pre-incisional intravenous or subcutaneous infiltration of ketamine on postoperative pain relief after open cholecystectomy. METHODS One hundred twenty patients, aged 18-60 years, scheduled for open cholecystectomy was enrolled in this randomized, double-blind, placebo-controlled study. Patients were divided into four groups of 30 each and received subcutaneous infiltration of ketamine 1 mg/kg (group KS1), subcutaneous infiltration of ketamine 2 mg/kg (group KS2), intravenous ketamine 1 mg/kg (group KI), or subcutaneous infiltration of normal saline 20 mL (group C) before surgery. Visual analog scale (VAS) values and analgesic consumption were evaluated for 24 hours after operation. RESULTS VAS scores were significantly lower at arrival to the postanesthesia care unit, 15 and 30 minutes in Group KS1, Group KS2, and Group KI compared with Group C (P<0.05). In Group KS2, VAS scores were significantly lower than Group KS1 (P<0.05). Postoperative VAS scores were significantly lower at 1, 2, 3, 4, 8, 12, and 24 hours after operation in Group KS1, Group KS2, and Group KI compared with Group C (P<0.05). In Group KS2, VAS scores were significantly lower than Group KS1 (P<0.05). CONCLUSION A 2 mg/kg dose of subcutaneous infiltration ketamine or 1 mg/kg dose of intravenous ketamine given at approximately 15 minutes before surgery provides an adjunctive analgesia during 24 hours after surgery in patients undergoing cholecystectomy surgery.
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Affiliation(s)
- Mohammadreza Safavi
- Department of Anesthesiology and Intensive Care Unit, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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From preemptive to preventive analgesia: time to reconsider the role of perioperative peripheral nerve blocks? Reg Anesth Pain Med 2011; 36:4-6. [PMID: 21455081 DOI: 10.1097/aap.0b013e31820305b8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth 2011; 20:3-9. [PMID: 21224020 DOI: 10.1016/j.ijoa.2010.10.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 10/06/2010] [Accepted: 10/07/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ketamine at subanesthetic doses has analgesic properties that have been shown to reduce postoperative pain and morphine consumption. We hypothesized that intravenous ketamine 10mg administered during spinal anesthesia for cesarean delivery, in addition to intrathecal morphine and intravenous ketorolac, would decrease the incidence of breakthrough pain and need for supplemental postoperative analgesia. METHODS Using a randomized double-blind placebo-controlled design, healthy women scheduled for cesarean delivery receiving hyperbaric spinal bupivacaine, fentanyl and morphine were randomized to intravenous ketamine 10mg or saline following delivery. Postoperative analgesia included scheduled ketorolac and acetaminophen/hydrocodone tablets as needed for breakthrough pain. The primary outcome was the incidence of breakthrough pain in the first 24h. Secondary outcomes included the number of acetaminophen/hydrocodone tablets administered and numeric rating scale for pain (0-10). RESULTS Group characteristics did not differ. There was no difference in the incidence of breakthrough pain (ketamine 75% VS. saline 74%, P=0.86). There was no difference in 24-h or 72-h use of supplemental acetaminophen/hydrocodone tablets between groups. Pain scores in the first 24h were similar, but lower in the ketamine compared to the saline group 2weeks postpartum (difference -0.6, 95% CI -1.1 to -0.9). CONCLUSIONS We found no additional postoperative analgesic benefit of low-dose ketamine during cesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2weeks postpartum.
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Affiliation(s)
- J R Bauchat
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Park SY, Kim SH, Noh JI, Lee SM, Kim MG, Kim SH, Ok SY, Kim SI. The effect of intravenous low dose ketamine for reducing postoperative sore throat. Korean J Anesthesiol 2010; 59:22-6. [PMID: 20651994 PMCID: PMC2908222 DOI: 10.4097/kjae.2010.59.1.22] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 04/06/2010] [Accepted: 04/20/2010] [Indexed: 11/10/2022] Open
Abstract
Background This study was performed to evaluate the effectiveness of intravenous low dose ketamine for reducing the incidence and severity of postoperative sore throat (POST). Methods This was a prospective, randomized, double-blind clinical trial. The study population consisted of 70 patients between 20 and 70 years old who were classified as American Society of Anesthesiologists I-II and were scheduled for elective laparoscopic cholecystectomy. The patients were divided randomly into two groups. Patients in the ketamine group received an intravenous injection of 0.5 mg/kg of ketamine just before induction, followed by 10 µg/kg/min throughout the operation. Patients in the control group received intravenous saline instead of ketamine. The patients were interviewed 1, 6, and 24 h after the operation. The incidence and severity of POST were recorded. Results No significant differences in the incidence and severity of POST during the 24 h after the operation were found between the two groups (21/31 in the ketamine group vs. 26/34 in the control group, P = 0.398). Conclusions Intravenous injection of low dose ketamine was not effective for reducing POST.
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Affiliation(s)
- Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, College of Medicine, Soonchunhyang University, Seoul, Korea
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Taleska G, Trajkovska T, Kokareva A, Popovska A, Naumoska M, Gavrilovska A, Dzhambazovska-Trajkovska V, Toleska M, Dimov A. Preemptive Epidural Analgesia with Bupivacaine and Sufentanyl and the Effects of Epiduraly Added Epinephrine for Thoracic Surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.3889/mjms.1857-5773.2010.0092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lester L, Braude DA, Niles C, Crandall CS. Low-dose ketamine for analgesia in the ED: a retrospective case series. Am J Emerg Med 2010; 28:820-7. [PMID: 20837262 DOI: 10.1016/j.ajem.2009.07.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 07/30/2009] [Accepted: 07/30/2009] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the use and effect of low-dose ketamine (LDK) for analgesia in the emergency department (ED). METHODS A chart review was performed to identify all adult patients who received LDK for analgesia in our ED. Cases were identified by pharmacy record of ketamine administration. Low-dose ketamine was defined as the administration of 0.1 to 0.6 mg/kg of ketamine for pain control. Use of ketamine during procedural sedation was excluded. Data were analyzed descriptively. RESULTS Thirty-five cases in which patients received LDK in the ED for a 2-year period were identified. Doses ranged from 5 to 35 mg. Administration was intravenous in 30 (86%) of 35 cases and intramuscular in 5 (14%) of 35 cases. Opioids were administered before or coadministered with LDK in 32 (91%) of 35 cases, and in the remaining 3 cases, opioids were used before the patient came to the ED. Improvement in pain was observed in 19 (54%) of 35 cases in which patients received LDK. Pain scores did not improve in 8 (23%) of 35 cases. Insufficient data were available to determine LDK effect for 8 (23%) of 35 cases. No significant adverse events were identified in any of the 35 cases. CONCLUSIONS The administration of LDK in the ED may be a safe and effective adjunct for analgesia in some patients. However, prospective randomized controlled trials are needed before widespread use of LDK for analgesia in the ED can be recommended.
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Affiliation(s)
- Laeben Lester
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Effects of perioperative intravenous low dose of ketamine on postoperative analgesia in children. Eur J Anaesthesiol 2010; 27:47-52. [PMID: 19535988 DOI: 10.1097/eja.0b013e32832dbd2f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Low dose of ketamine reduces postoperative pain and opioid consumption in adult studies. However, there are only a few data with controversial results in the paediatric population. The aim of this randomized controlled trial was to evaluate the use of low doses of intravenous ketamine on postoperative pain in children after surgery on the lower part of the body. METHODS Thirty-seven children with ASA 1 or 2 from 6 to 60 months of age, undergoing scheduled surgery, were prospectively enrolled in a double blind sequential trial using a triangular test, with analysis every 10 patients treated. The children were randomly assigned to intravenously receive saline or 0.15 mg kg(-1) ketamine before surgery, followed by a continuous infusion of 1.4 microg kg(-1) min(-1) over 24 h. After sevoflurane induction and tracheal intubation, a caudal anaesthesia was performed in all children (1 ml kg(-1) of bupivacaine 0.25% with epinephrine). The postoperative analgesic technique was standardized with intravenous paracetamol 15 mg kg(-1) 6 h(-1), rectal morniflumate (20 mg kg(-1) 12 h(-1)) and intravenous nalbuphine infusion 1.2 mg kg(-1) 24 h(-1) for 24 h. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, additional bolus of nalbuphine (if CHEOPS >7) and side effects were recorded from eye opening every 2 h over 24 h. The primary endpoint was the CHEOPS area under the curve. RESULTS There was no difference in terms of additional bolus of nalbuphine as well as CHEOPS score area under the curve between groups, that is, 76 +/- 10 in the ketamine group versus 74 +/- 7 in the control group. No psychomimetic side effects were noted. CONCLUSION The study failed to show any evidence of benefit of ketamine to improve analgesia in children when given in addition to a multimodal analgesic therapy with paracetamol, a NSAID and an opiate.
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Lamont LA. Adjunctive analgesic therapy in veterinary medicine. Vet Clin North Am Small Anim Pract 2009; 38:1187-203, v. [PMID: 18954680 DOI: 10.1016/j.cvsm.2008.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Adjunctive analgesic therapies are interventions for pain that involve agents or techniques other than the traditional analgesics (opioids, nonsteroidal anti-inflammatory drugs, and local anesthetics). Adjunctive therapies may be pharmacologic or nonpharmacologic in nature. The focus of this article is on pharmacologic interventions with potential utility as adjunctive analgesics in veterinary medicine. Pharmacology of selected agents, including medetomidine, ketamine, amantadine, gabapentin, systemic lidocaine, and pamidronate, is discussed in addition to evidence for their safety and efficacy and guidelines for their use in veterinary patients.
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Affiliation(s)
- Leigh A Lamont
- Department of Companion Animals, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, Prince Edward Island, Canada C1A 4P3.
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Determination of ketamine and norketamine in plasma by micro-liquid chromatography–mass spectrometry. J Pharm Biomed Anal 2008; 48:171-6. [DOI: 10.1016/j.jpba.2008.05.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 05/10/2008] [Indexed: 11/21/2022]
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Doi K, Yamanaka M, Shono A, Fukuda N, Saito Y. Preoperative epidural fentanyl reduces postoperative pain after upper abdominal surgery. J Anesth 2007; 21:439-41. [PMID: 17680204 DOI: 10.1007/s00540-007-0519-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 03/06/2007] [Indexed: 10/23/2022]
Abstract
Forty patients, American Society of Anesthesiology (ASA) physical status 1-2, undergoing subtotal gastrectomy were enrolled in this study. The patients were allocated to two groups with or (group P) and without (group C) preoperative epidural fentanyl 100 microg. Postoperatively, all patients received continuous infusion of the study solution, containing fentanyl 30 microg x ml(-1) and 2 mg/ml bupivacaine, at a rate of 0.7 ml x h(-1) for 72 h. The scores on the Prince Henry Hospital self-assessed pain scale (PHPS) were recorded at 0, 4, 12, 24, 48, and 72 h after the surgery. We compared the total rescue doses of analgesics during each period of 24 h until 72 h postoperatively. Although the total rescue doses of analgesics were not different between the groups, the median PHPS score was lower in group P than in group C, except at 0 h after the surgery. Preoperative epidural fentanyl 100 microg may increase the analgesic potency of postoperative epidural low-dose infusion of bupivacaine with fentanyl.
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Affiliation(s)
- Katsushi Doi
- Department of Anesthesiology, Miyoshi General Hospital, Miyoshi, Japan
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White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 2007; 104:1380-96, table of contents. [PMID: 17513630 DOI: 10.1213/01.ane.0000263034.96885.e1] [Citation(s) in RCA: 247] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery. METHODS A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician. RESULTS Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery. CONCLUSION The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.
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Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas, USA.
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Abstract
The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.
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Affiliation(s)
- Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Chizh BA. Low dose ketamine: a therapeutic and research tool to explore N-methyl-D-aspartate (NMDA) receptor-mediated plasticity in pain pathways. J Psychopharmacol 2007; 21:259-71. [PMID: 17591654 DOI: 10.1177/0269881105062484] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ketamine is a dissociative anaesthetic that has been used in the clinic for many years. At low, sub-anaesthetic doses, it is a relatively selective and potent antagonist of the N-methyl-D-aspartate (NMDA) receptor. It belongs to the class of uncompetitive antagonists and blocks the receptor by binding to a specific site within the NMDA receptor channel when it is open. Like other compounds of this class, ketamine can cause hallucinations or other untoward central effects which limit its use in the clinic. Nevertheless, because of the evidence on the importance of NMDA receptor-mediated pLasticity in chronic pain, low doses of ketamine have been explored in a wide range of pain conditions. The majority of studies with ketamine have shown efficacy; however, it has not been possible to separate safely the pain relief from the side effects of the drug. Hence, clinical use of ketamine as a pain treatment is very limited. Nevertheless, ketamine has served as a useful tool to provide a compelling rationale for developing other NMDA antagonists. Some of the new compounds of this class, particularly those acting at the NR2B subtype of the NMDA receptor, have shown promise in preclinical and clinical studies.
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Affiliation(s)
- Boris A Chizh
- GlaxoSmithKline, Addenbrooke's Centre for Clinical Investigation, Addenbrooke's Hospital, Cambridge, UK.
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Wang X, Xie H, Wang G. Improved postoperative analgesia with coadministration of preoperative epidural ketamine and midazolam. J Clin Anesth 2007; 18:563-9. [PMID: 17175423 DOI: 10.1016/j.jclinane.2006.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Revised: 03/03/2006] [Accepted: 03/06/2006] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To assess postoperative pain regulation and pharmacokinetic effects of preoperative administration of ketamine and midazolam. DESIGN Double-blind, randomized clinical study. SETTING University hospital. PATIENTS 46 ASA physical status I and II patients (age, 26-58 yrs), scheduled for gastrectomy. INTERVENTIONS Patients were randomly assigned to three treatment groups: a preoperative epidural injection of 10 mL (1) ketamine (0.5 mg/kg) solution (Ket group); (2) ketamine (0.5 mg/kg) plus midazolam (0.05 mg/kg) solution (KM group); or (3) normal saline solution (Ctr group). MEASUREMENTS Analgesic effects were evaluated by Visual Analog Scale (VAS) pain scores at rest, time to first request for analgesic (TFA), and morphine consumption during the initial postoperative time of 48 hours. Plasma concentration of ketamine in the Ket group and the KM group was measured by high-performance liquid chromatography, and the elimination half-life of ketamine was calculated. MAIN RESULTS Compared with the Ctr group, the Ket and KM groups had lower VAS pain scores, longer TFA, and lower morphine consumption. The KM group had the longest TFA and the lowest morphine consumption of the three groups. The KM group also had higher plasma concentrations of ketamine 90 to 240 minutes after injection, and a longer elimination half-life of ketamine, than did the Ket group. CONCLUSIONS Preoperative epidural coadministration of a low dose of ketamine with midazolam is more effective in relieving postoperative pain than using ketamine alone. In addition, epidural midazolam prolongs the elimination of ketamine.
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Affiliation(s)
- Xin Wang
- Department of Anesthesiology, General Hospital of Tianjin Medical University, Tianjin 300052, PR China.
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Pascoe PJ, Ilkiw JE, Craig C, Kollias-Baker C. The effects of ketamine on the minimum alveolar concentration of isoflurane in cats. Vet Anaesth Analg 2007; 34:31-9. [PMID: 17238960 DOI: 10.1111/j.1467-2995.2006.00297.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the minimum alveolar concentration (MAC) of isoflurane during the infusion of ketamine. STUDY DESIGN Prospective, experimental trial. ANIMALS Twelve adult spayed female cats weighing 5.1 +/- 0.9 kg. METHODS Six cats were anesthetized with isoflurane in oxygen, intubated and attached to a circle-breathing system with mechanical ventilation. Catheters were placed in a peripheral vein for the infusion of fluids and ketamine, and the jugular vein for blood sampling for the measurement of ketamine concentrations. An arterial catheter was placed to allow blood pressure measurement and sampling for the measurement of PaCO2, PaO2 and pH. PaCO2 was maintained between 29 and 41 mmHg (3.9-5.5 kPa) and body temperature was kept between 37.8 and 39.3 degrees C. Following instrumentation, the MAC of isoflurane was determined in triplicate using a tail clamp method. A loading dose (2 mg kg(-1) over 5 minutes) and an infusion (23 microg kg(-1) minute(-1)) of ketamine was started and MAC was redetermined starting 30 minutes later. Two further loading doses and infusions were used, 2 mg kg(-1) and 6 mg kg(-1) with 46 and 115 microg kg(-1) minute(-1), respectively and MAC was redetermined. Cardiopulmonary measurements were taken before application of the noxious stimulus. The second group of six cats was used for the measurement of steady state plasma ketamine concentrations at each of the three infusion rates used in the initial study and the appropriate MAC value determined from the first study. RESULTS The MAC decreased by 45 +/- 17%, 63 +/- 18%, and 75 +/- 17% at the infusion rates of 23, 46, and 115 microg kg(-1) minute(-1). These infusion rates corresponded to ketamine plasma concentrations of 1.75 +/- 0.21, 2.69 +/- 0.40, and 5.36 +/- 1.19 microg mL(-1). Arterial blood pressure and heart rate increased significantly with ketamine. Recovery was protracted. CONCLUSIONS AND CLINICAL RELEVANCE The MAC of isoflurane was significantly decreased by an infusion of ketamine and this was accompanied by an increase in heart rate and blood pressure. Because of the prolonged recovery in our cats, further work needs to be performed before using this in patients.
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Affiliation(s)
- Peter J Pascoe
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA.
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Unlugenc H, Ozalevli M, Gunes Y, Olguner S, Evrüke C, Ozcengiz D, Akman H. A double-blind comparison of intrathecal S(+) ketamine and fentanyl combined with bupivacaine 0.5% for Caesarean delivery. Eur J Anaesthesiol 2006; 23:1018-24. [PMID: 16824240 DOI: 10.1017/s0265021506000950] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor and analgesic block characteristics of S(+) ketamine, fentanyl and saline given intrathecally (IT) in addition to 0.5% plain bupivacaine (10 mg) for spinal analgesia. METHODS Ninety ASA I or II adult patients undergoing Caesarean section were randomly allocated to receive 1.0 mL of 0.9% saline in Group S (n = 30), 0.05 mg kg-1 of S(+) ketamine (1.0 mL) in Group K (n =30) or 25 microg (1.0 mL) of fentanyl in Group F (n =30) following 10 mg of plain bupivacaine 0.5% IT. We recorded onset and duration of sensory and motor block, time to reach the maximal dermatomal level of sensory block and duration of spinal analgesia. RESULTS The onset time of sensory and motor block was significantly shorter in Groups K and F than in Group S (P < 0.014). Their duration was significantly longer in Group F than in Groups K and S (P < 0.009). The time to reach the maximal dermatomal level of sensory block was significantly shorter in Groups K and F than in Group S (P < 0.001). The duration of spinal analgesia was significantly longer in Group F than in Groups K and S (P < 0.001). CONCLUSION In patients undergoing Caesarean section with spinal analgesia, the addition of S(+) ketamine (0.05 mg kg-1) IT to 10 mg of spinal plain bupivacaine (0.5%) led to rapid onset of both sensory and motor blockade and enhanced the segmental spread of spinal block without prolonging the duration of spinal analgesia, whereas fentanyl provided prolonged analgesia.
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Affiliation(s)
- H Unlugenc
- Cukurova University, Faculty of Medicine, Department of Anaesthesiology, Adana, Turkey.
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Christoph T, Schiene K, Englberger W, Parsons CG, Chizh BA. The antiallodynic effect of NMDA antagonists in neuropathic pain outlasts the duration of the in vivo NMDA antagonism. Neuropharmacology 2006; 51:12-7. [PMID: 16616769 DOI: 10.1016/j.neuropharm.2006.02.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 02/13/2006] [Accepted: 02/15/2006] [Indexed: 11/22/2022]
Abstract
Clinical reports have described a long-lasting relief in neuropathic pain patients treated with NMDA receptor antagonists; it is unclear, however, what mediates this effect. In this work, we have used two NMDA antagonists of different class to investigate if the antiallodynic effects in a rat neuropathy model can outlast their in vivo NMDA antagonism. Both the uncompetitive NMDA antagonist ketamine and the glycine(B) antagonist MRZ 2/576 inhibited neuronal responses to iontophoretic NMDA in anaesthetised rats with the time course consistent with their known pharmacokinetics (t(1/2) approximately 10-12min, similar in control and nerve-injured rats). Surprisingly, the antiallodynic effects of the same doses of the NMDA antagonists in the neuropathic pain model were long-lasting (>3h with ketamine, >24h with MRZ 2/576). The effect of ketamine was further prolonged (>24h) when combined with a short-acting opioid, fentanyl, which only produced a short effect ( approximately 40min) when given alone. The duration of centrally mediated side effects of ketamine and MRZ 2/576 was short, similar to the in vivo NMDA antagonism. We speculate that NMDA receptor blockade may down-regulate the central sensitisation triggered by nerve injury, resulting in a long-lasting antiallodynic effect. Development of short-acting NMDA antagonists could represent a strategy for improving their tolerability.
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Affiliation(s)
- Thomas Christoph
- Department of Pharmacology, Grünenthal GmbH Research Centre, Zieglerstrasse 6, 52078 Aachen, Germany
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Lebrun T, Van Elstraete AC, Sandefo I, Polin B, Pierre-Louis L. Lack of a pre-emptive effect of low-dose ketamine on postoperative pain following oral surgery. Can J Anaesth 2006; 53:146-52. [PMID: 16434754 DOI: 10.1007/bf03021819] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE The aim of this study was to assess the effect of pre- vs postincisional low-dose iv ketamine on postoperative pain in outpatients scheduled for oral surgery under general anesthesia. METHODS Eighty-four patients were randomly assigned to receive intravenously saline before and after surgery in Group 1, ketamine 300 microg x kg(-1) iv before and saline after surgery in Group 2, saline before and ketamine 300 microg x kg(-1) iv after surgery in Group 3. Postoperative analgesia consisted of iv proparacetamol and ketoprofen. Rescue analgesia consisted of nalbuphine 200 microg x kg(-1) iv. Analgesia at home consisted of oral ketoprofen, and acetaminophen with codeine as rescue analgesia. A telephone interview was conducted on the first and second postoperative days. RESULTS There were no significant differences between groups with respect to pain scores, the number of patients requiring nalbuphine in the postanesthesia care unit (PACU), (36.7%, 38.7%, and 39.5% for Groups 1, 2, and 3 respectively), or nalbuphine consumption in the PACU (66.5 microg x kg(-1) +/- 16.8, 75.9 microg x kg(-1) +/- 17.5, 66.7 microg x kg(-1) +/- 21.6 for Groups 1, 2, and 3 respectively). The number of rescue analgesic tablets taken at home, and time to first request for rescue analgesia, sedation scores, or side-effects were similar amongst groups. No patient required nalbuphine in the ambulatory care unit. CONCLUSIONS There was no benefit to pre-emptive administration of ketamine 300 microg x kg(-1) iv whether administered pre- or postoperatively.
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Affiliation(s)
- Thierry Lebrun
- Department of Anesthesiology, Clinique Saint-Paul, Clairière, 97200 Fort de France, Martinique, French West Indies
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Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central Hypersensitivity in Chronic Pain: Mechanisms and Clinical Implications. Phys Med Rehabil Clin N Am 2006; 17:287-302. [PMID: 16616268 DOI: 10.1016/j.pmr.2005.12.010] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The available literature consistently shows increased pain sensitivity after sensory stimulation of healthy tissues in patients who have various chronic pain conditions. This indicates a state of hypersensitivity of the CNS that amplifies the nociceptive input arising from damaged tissues. Experimental data indicate that central hypersensitivity is probably induced primarily by nociceptive input arising from a diseased tissue. In patients, imbalance of descending modulatory systems connected with psychologic distress may play a role. There is experimental support in animal studies for the persistence of central hypersensitivity after complete resolution of tissue damage. This is particularly true for neuropathic pain conditions, whereby potentially irreversible plasticity changes of the CNS have been documented in animal studies. Whether such changes are present in musculoskeletal pain states is at present uncertain. Despite the likely importance of central hypersensitivity in the pathophysiology of chronic pain, this mechanism should not be used to justify the lack of understanding on the anatomic origin of the pain complaints in several pain syndromes, which is mostly due to limitations of the available diagnostic tools. Treatment strategies for central hypersensitivity in patients have been investigated mostly in neuropathic pain states. Possible therapy modalities for central hypersensitivity in chronic pain of musculoskeletal origin are largely unexplored. The limited evidence available and everyday practice show, at best, modest efficacy of the available treatment modalities for central hypersensitivity. The gap between basic knowledge and clinical benefits remains large and should stimulate further intensive research.
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Affiliation(s)
- Michele Curatolo
- Department of Anesthesiology, Division of Pain Therapy, Inselspital, 3010 Bern, Switzerland.
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