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Eftekhar N, Eslami B, Orandi AH, Chabouk L, Ghotbizadeh Vahdani F, Mohammad khani H, Amoozadeh L. Effect of Local Ketamine Subcutaneous Injection at the Incision Site in Reducing the Postoperative Pain Score after Transabdominal Hysterectomy. Anesthesiol Res Pract 2023; 2023:7782847. [PMID: 37953884 PMCID: PMC10640139 DOI: 10.1155/2023/7782847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 11/14/2023] Open
Abstract
Background Pain control after operations is essential in decreasing the patient recovery period and potential morbidity. Prescribing opiates is very effective, but significant side effects accompany them. This study aims to examine the effect of local ketamine infiltration in decreasing pain intensity in patients undergoing transabdominal hysterectomy. Methods In this double-blind, randomized, controlled clinical trial, a total of 92 patients undergoing transabdominal hysterectomy aged 30-60 years were selected and divided into two intervention and control groups randomly. For the intervention group, ketamine was injected subcutaneously into the incision site at a dose of 0.5 mg/kg after the operation. In the control group, 5 mg normal saline was used in the same method. Postoperative pain intensity was measured using the visual analog scale (VAS: 0-10). The pain score and dose of administered opioids were documented at 1, 2, 4, 6, 12, and 24 hours and compared between the two groups. Results Postoperative pain intensity was significantly lower in the intervention group than in the control group, except for hour 24. The mean amounts of administered opioids were significantly lower in the intervention group at hours 6 and 12, as well as the total amount of used opioids, and no significant side effects were documented. Conclusion Local ketamine subcutaneous injection in the incisional site is effective and is a safe procedure for reducing pain scores in patients who underwent a transabdominal hysterectomy.
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Affiliation(s)
- Negar Eftekhar
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Eslami
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Orandi
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Chabouk
- Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Ghotbizadeh Vahdani
- Obstetrics and Gynecology Department, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Mohammad khani
- Obstetrics and Gynecology Department, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Laya Amoozadeh
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Effect of Ketamine Added to Ropivacaine in Nerve Block for Postoperative Pain Management in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Randomized Trial. Clin Ther 2020; 42:882-891. [DOI: 10.1016/j.clinthera.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/14/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
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3
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Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Soleimanpour H, Safari S, Shahsavari Nia K, Sanaie S, Alavian SM. Opioid Drugs in Patients With Liver Disease: A Systematic Review. HEPATITIS MONTHLY 2016; 16:e32636. [PMID: 27257423 PMCID: PMC4887963 DOI: 10.5812/hepatmon.32636] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/27/2015] [Accepted: 12/27/2015] [Indexed: 12/11/2022]
Abstract
CONTEXT The liver, one of the most important organs of the body, is known to be responsible for several functions. The functional contribution of the liver to the metabolism of carbohydrates, protein, drugs and toxins, fats and cholesterol and many other biological processes are still unknown. Liver disorders are classified into two types: acute and chronic. Different drugs are used in liver diseases to treat and control pain. Most pain relief medications such as opioids are metabolized via the liver; therefore, the adverse reactions of drugs are probably higher for patients with liver disease. The current study aimed to evaluate the effects of opioid drugs on patients with liver disease; therefore, it is necessary to select suitable opioids for such patients. EVIDENCE ACQUISITION This review was written by referring to research literature including 70 articles and four textbooks published from 1958 to 2015 on various reputable sites. Searches were carried out on the key phrases of narcotic pain relievers (opioids), acute and chronic hepatic failure, opioid adverse drug reactions, drug-induced liver injury (DILI) and other similar keywords. References included a variety of research papers (descriptive and analytical), intervention and review articles. RESULTS In patients with liver disease, administration of opioid analgesics should be observed, accurately. As a general rule, lower doses of drugs should be administered at regular intervals based on the signs of drug accumulation. Secondly, the interactions of opioid drugs with different levels of substrates of the P450 cytochrome enzyme should be considered. CONCLUSIONS Pain management in patients with liver dysfunction is always challenging to physicians because of the adverse reactions of drugs, especially opioids. Opioids should be used cautiously since they can cause sedation, constipation and sudden encephalopathy effects. Since the clearance of these drugs in patients with hepatic insufficiency is decreased, the initial dose must be decreased, the intervals between doses should be increased and some patients need to be continuously assessed.
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Affiliation(s)
- Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Saeid Safari
- Pain Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Kavous Shahsavari Nia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Sarvin Sanaie
- Tuberculosis and Lung Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Tehran Hepatitis Center, Tehran, IR Iran
- Corresponding Author: Seyed Moayed Alavian, Baghiyatallah Research Center for Gastroenterology and Liver Diseases, Baghiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-2181262072, Fax: +98-2181262072, E-mail:
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Chan ACS, Qiu Q, Choi SW, Wong SSC, Chan ACY, Irwin MG, Cheung CW. Effects of Intra-Operative Total Intravenous Anaesthesia with Propofol versus Inhalational Anaesthesia with Sevoflurane on Post-Operative Pain in Liver Surgery: A Retrospective Case-Control Study. PLoS One 2016; 11:e0149753. [PMID: 26901037 PMCID: PMC4763721 DOI: 10.1371/journal.pone.0149753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/04/2016] [Indexed: 12/11/2022] Open
Abstract
Background Patients receiving total intravenous anesthesia (TIVA) with propofol have been shown to experience less postoperative pain. We evaluated the post-operative analgesic effects of propofol compared with sevoflurane maintenance of anesthesia in liver surgery. This study was registered at ClinicalTrials.gov (NCT02179437). Methods In this retrospective study, records of patients who underwent liver surgery between 2010 and 2013 were reviewed. Ninety-five patients anesthetized with propofol TIVA were matched with 95 patients anesthetized with sevoflurane. Numeric pain rating scale (NRS) pain scores, postoperative morphine consumption, side effects and patients’ satisfaction with pain relief were evaluated. Results The TIVA group reported lower NRS pain scores during coughing on postoperative days 1 and 2 but not 3 (p = 0.0127, p = 0.0472, p = 0.4556 respectively). They also consumed significantly less daily (p = 0.001 on day 1, p = 0.0231 on day 2, p = 0.0004 on day 3), accumulative (p = 0.001 on day 1, p<0.0001 on day 2 and p = 0.0064 on day 3) and total morphine (p = 0.03) when compared with the sevoflurane group. There were no differences in total duration of intravenous patient controlled analgesia (PCA) morphine use and patient satisfaction. No difference was found in reported side effects. Conclusion Patients anesthetized with propofol TIVA reported less pain during coughing and consumed less daily, accumulative and total morphine after liver surgery.
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Affiliation(s)
| | - Qiu Qiu
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Siu Wai Choi
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Stanley Sau Ching Wong
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | | | - Michael G Irwin
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
- * E-mail:
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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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Ramspoth T, Roehl AB, Macko S, Heidenhain C, Junge K, Binnebösel M, Schmeding M, Neumann UP, Rossaint R, Hein M. Risk factors for coagulopathy after liver resection. J Clin Anesth 2014; 26:654-62. [PMID: 25468574 DOI: 10.1016/j.jclinane.2014.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 08/09/2014] [Accepted: 08/22/2014] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To identify risk factors for coagulopathy in patients undergoing liver resection. DESIGN A retrospective cohort study. SETTING Patients who underwent liver resection at a university hospital between April 2010 and May 2011 were evaluated within seven days after surgery. PATIENTS One hundred forty-seven patients were assessed for eligibility. Thirty needed to be excluded because of incomplete data (23) or a preexisting coagulopathy (7). MEASUREMENTS Coagulopathy was defined as 1 or more of the following events: international normalized ratio ≥1.4, platelet count <80,000/μL, and partial thromboplastin time >38 seconds. Related to the time course and coagulation profile thresholds, 3 different groups could be distinguished: no coagulopathy, temporary coagulopathy, and persistent coagulopathy. MAIN RESULTS Seventy-seven patients (65.8%) had no coagulopathy, whereas 33 (28.2%) developed temporary coagulopathy and 7 (6%) developed persistent coagulopathy until day 7. Preoperative international normalized ratio (P = .001), postoperative peak lactate levels (P = .012), and resected liver weight (P = .005) were identified as independent predictors. Preoperative liver transaminases and transfusion volumes of red blood cells and fresh frozen plasma were significantly higher in patients with persistent coagulopathy. CONCLUSIONS Epidural anesthesia is feasible in patients scheduled for liver resection. Caution should be observed for patients with extended resection (≥3 segments) and increased postoperative lactate. In patients with preexisting liver disease, epidural catheters should be avoided.
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Affiliation(s)
- Tina Ramspoth
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Anna B Roehl
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Stephan Macko
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Cristoph Heidenhain
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Karsten Junge
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Marcel Binnebösel
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Maximilian Schmeding
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Ulf P Neumann
- General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, University Hospital Aachen, RWTH, Aachen, Germany.
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8
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Erol İM, Özdoğan L, Örnek D, Taşpınar V, Kalaycı D, Barçın S, Şahin F, Erk G, Dikmen B. Effect of Ketamine on the Quality of Anesthesia and Postoperative Analgesia in Epidural Anesthesia. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jecm.2014.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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9
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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10
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Yuan FS, Ng SY, Ho KY, Lee SY, Chung AY, Poopalalingam R. Abnormal coagulation profile after hepatic resection: the effect of chronic hepatic disease and implications for epidural analgesia. J Clin Anesth 2012; 24:398-403. [PMID: 22626687 DOI: 10.1016/j.jclinane.2011.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 11/14/2011] [Accepted: 11/26/2011] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of chronic hepatic disease on postoperative coagulation. DESIGN Retrospective cohort study. SETTING Operating room with postoperative inpatient followup. MEASUREMENTS The records of 153 patients who underwent elective open hepatic resection were reviewed. The perioperative coagulation profile of each patient was assessed. The postoperative period was subdivided into the early [postoperative day (POD) 0-3] and late (POD 4 - POD 7) periods. MAIN RESULTS 68 (44.4%) patients had chronic hepatic disease and 50 (32.7%) had cirrhosis. Eighty-four (54.9%) patients had an abnormal early postoperative coagulation profile and 46 (30.1%) had an abnormal late postoperative coagulation profile. The proportion of patients having an abnormal coagulation profile peaked on POD 2, at 39.2%. Only 5.3% of patients had an abnormal coagulation profile on POD 7. The independent predictors of abnormal early and late postoperative coagulation profiles were preexisting hepatic cirrhosis [early: odds ratio (OR) 3.73(1.49 - 9.29), late: OR 6.84(2.11 - 22.21)], abnormal preoperative coagulation profile [early: OR 9.68 (1.97 - 47.5), late: OR 11.71 (3.61- 38.02)], major hepatic resection [early: OR 4.15 (1.66 - 10.4), late: OR 5.43 (1.68 - 17.47)], and intraoperative blood loss. CONCLUSIONS An abnormal postoperative coagulation profile after hepatic surgery is common in a patient population with chronic hepatic disease.
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Affiliation(s)
- Flora Shiyi Yuan
- Department of Anaesthesiology, Singapore General Hospital, Outram Rd., Singapore 169608, Republic of Singapore
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Celis-Rodríguez E, Besso J, Birchenall C, de la Cal M, Carrillo R, Castorena G, Ceraso D, Dueñas C, Gil F, Jiménez E, Meza J, Muñoz M, Pacheco C, Pálizas F, Pinilla D, Raffán F, Raimondi N, Rubiano S, Suárez M, Ugarte S. Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo. Med Intensiva 2007; 31:428-71. [DOI: 10.1016/s0210-5691(07)74853-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW In this review, emphasis is placed on adjuvant drugs that are already in clinical use. The list of adjuvants studied during the review period includes adrenaline, clonidine, ketamine, neostigmine, nondepolarizing muscle relaxants, and nonsteroidal antiinflammatory drugs. Some future aspects are considered in a couple of experimental studies on slow-release local anaesthetic formulations. RECENT FINDINGS Adrenaline not only acts as a vasoconstrictor, it may also produce analgesia through an alpha2-adrenergic mechanism. Adrenaline may facilitate the uptake of the local anaesthetic into nerves. The addition of adrenaline to a mixture of ropivacaine and fentanyl clearly improves thoracic epidural analgesia. Several recent studies have shown a synergism of clonidine with local anaesthetics in various types of blocks, as well as with spinal opioids. Bradycardia and hypotension may be associated with the use of clonidine. Neostigmine may cause antinociception both in the spinal cord and in peripheral nerves. Neostigmine has been found to potentiate the effect of spinal opioids, but gastrointestinal side effects are frequent. Biodegradable microcapsules containing bupivacaine and dexamethasone have been tested in humans and found to produce analgesia for several days (intercostal block). Local inflammatory reactions and paraesthesias, however, were observed in 30% of cases. SUMMARY Adrenaline and opioids may be regarded as the best investigated and most important adjuvants in regional anaesthesia. Other drugs, such as clonidine and neostigmine, may prolong analgesia in various regional anaesthetic techniques, but possible side effects may limit their clinical application. Further development is needed concerning extra-long acting analgesic formulations.
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Affiliation(s)
- Johannes G Förster
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.
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Bilir A, Gulec S, Erkan A, Ozcelik A. Epidural magnesium reduces postoperative analgesic requirement. Br J Anaesth 2007; 98:519-23. [PMID: 17324976 DOI: 10.1093/bja/aem029] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Magnesium has antinociceptive effects in animal and human models of pain. Our hypothesis was that the addition of magnesium to postoperative epidural infusion of fentanyl may decrease the need for fentanyl. METHODS Fifty patients undergoing hip surgery were enrolled to receive either fentanyl (Group F) or fentanyl plus magnesium sulphate (Group FM) for 24 h for epidural analgesia. All patients were equipped with a patient-controlled epidural analgesia device and the initial settings of a demand bolus dose of fentanyl 25 microg. In Group FM, patients received 50 mg magnesium sulphate epidurally as an initial bolus dose followed by a continuous infusion of 100 mg day(-1). Ventilatory frequency, heart rate, blood pressure, pain assessment using a visual analogue scale (VAS), sedation scores and fentanyl consumption were recorded in the postoperative period. RESULTS There was no significant difference between groups in the time to first analgesic requirement. Compared with Group F, patients in Group FM received smaller doses of epidural fentanyl (P < 0.05). The cumulative fentanyl consumption in 24 h was 437 (SD110) microg in Group F and 328 (121) microg in Group FM (P < 0.05). Patients in Group F showed a higher VAS score in the first hour of the postoperative period (P < 0.05). The groups were similar with respect to haemodynamic and respiratory variables, sedation, pruritus, and nausea. CONCLUSION Co-administration of magnesium for postoperative epidural analgesia results in a reduction in fentanyl consumption without any side-effects.
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Affiliation(s)
- A Bilir
- Department of Anaesthesiology and Reanimation, Osmangazi University Medical Faculty, Turkey.
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15
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Abstract
BACKGROUND Postoperative pain management is often limited by adverse effects such as nausea and vomiting. Adjuvant treatment with an inexpensive opioid-sparing drug such as ketamine may be of value in giving better analgesia with fewer adverse effects. OBJECTIVES To evaluate the effectiveness and tolerability of ketamine administered perioperatively in the treatment of acute postoperative pain in adults. SEARCH STRATEGY Studies were identified from MEDLINE (1966-2004), EMBASE (1980-2004), the Cochrane Library (2004) and by handsearching reference lists from review articles and trials. The manufacturer of ketamine (Pfizer) provided search results from their in-house database, PARDLARS. SELECTION CRITERIA Randomised controlled trials (RCTs) of adult patients undergoing surgery, being treated with perioperative ketamine or placebo. Studies where ketamine was administered in addition to a basic analgesic (such as morphine or NSAID) in one study group, and compared with a group receiving the same basic analgesic (but without ketamine) in another group, were also included. DATA COLLECTION AND ANALYSIS Two independent reviewers identified fifty five RCTs for potential inclusion. Quality and validity assessment was performed by two independent reviewers. In the case of discrepancy, a third reviewer was consulted. Patient reported pain intensity and pain relief was assessed using visual analogue scales or verbal rating scales and adverse effects data were collated. MAIN RESULTS Thirty-seven trials were included (2240 participants). Eighteen trials were excluded.Twenty-seven of the 37 trials found that perioperative subanaesthetic doses of ketamine reduced rescue analgesic requirements or pain intensity, or both. Quantitative analysis showed that treatment with ketamine reduced 24 hour PCA morphine consumption and postoperative nausea or vomiting (PONV). Adverse effects were mild or absent. AUTHORS' CONCLUSIONS Ketamine in subanaesthetic dose (that is a dose which is below that required to produce anaesthesia) is effective in reducing morphine requirements in the first 24 hours after surgery. Ketamine also reduces postoperative nausea and vomiting. Adverse effects are mild or absent.
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Affiliation(s)
- R F Bell
- Haukeland University Hospital/ University of Bergen, Pain Clinic/Dept. of Surgical Sciences, Bergen, Norway, N-5021.
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16
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Abstract
Given the expanding role of ambulatory surgery and the need to facilitate an earlier hospital discharge, improving postoperative pain control has become an increasingly important issue for all anesthesiologists. As a result of the shift from inpatient to outpatient surgery, the use of IV patient-controlled analgesia and continuous epidural infusions has steadily declined. To manage the pain associated with increasingly complex surgical procedures on an ambulatory or short-stay basis, anesthesiologists and surgeons should prescribe multimodal analgesic regimens that use non-opioid analgesics (e.g., local anesthetics, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, alpha 2-agonists) to supplement opioid analgesics. The opioid-sparing effects of these compounds may lead to reduced nausea, vomiting, constipation, urinary retention, respiratory depression and sedation. Therefore, use of non-opioid analgesic techniques can lead to an improved quality of recovery for surgical patients.
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Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
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Lauretti GR, Rodrigues AM, Paccola CAJ, Mattos AL. The combination of epidural clonidine and S(+)-ketamine did not enhance analgesic efficacy beyond that for each individual drug in adult orthopedic surgery. J Clin Anesth 2005; 17:79-84. [PMID: 15809121 DOI: 10.1016/j.jclinane.2004.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Accepted: 04/21/2004] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVES To evaluate the benefit of epidural clonidine and S(+)-ketamine combination through the epidural route in adult orthopedic surgery. DESIGN Randomized double-blinded study. SETTING Teaching hospital. PATIENTS Scheduled to undergo knee surgery, 56 American Society of Anesthesiologists physical status 1 and 2 adult patients. INTERVENTIONS Patients were randomized to 1 of 4 groups to receive the combined epidural-intrathecal technique. A 10-mL epidural injection of either study drug or normal saline was first administered to all patients. Intrathecal anesthesia was performed with 15 mg of bupivacaine. The control group (CG) received epidural saline. The 0.1-mg/kg S(+)-ketamine epidural group received 0.1 mg/kg epidural S(+)-ketamine. The 0.5-microg/kg clonidine epidural group received 0.5 microg/kg epidural clonidine. The S(+)-ketamine/clonidine group received 0.1 mg/kg epidural S(+)-ketamine plus 0.5 microg/kg epidural clonidine. MEASUREMENTS AND MAIN RESULTS Pain and adverse effects were evaluated by visual analog scale. Rescue analgesics were available to patients. The groups were demographically similar. Sensory level to pinprick, surgical and anesthetic time, and visual analog scale scores for pain at first rescue medication were similar among the groups. The time to first rescue analgesic (minute) was lowest in CG (P < .005). The CG required more rescue analgesics in 24 hours than any of the other groups (P < .0005). Patients who received either epidural clonidine, S(+)-ketamine, or both displayed similar analgesia. The frequency of adverse effects was similar among groups (P > .05). CONCLUSIONS The association of epidural clonidine or S(+)-ketamine did not result in a greater analgesic effect in the model of acute postoperative pain studied, although the interaction of epidural clonidine and S(+)-ketamine is not attributable to sharing of a common second messenger system.
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Affiliation(s)
- Gabriela R Lauretti
- Department of Biomechanic, Medicine and Rehabilitation of the Locomotor Members, Teaching Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo 14015 110, Brazil.
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18
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Abstract
Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.
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Affiliation(s)
- Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA
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Clerc S, Vuilleumier H, Frascarolo P, Spahn DR, Gardaz JP. Is the Effect of Inguinal Field Block With 0.5% Bupivacaine on Postoperative Pain After Hernia Repair Enhanced by Addition of Ketorolac or S(+) Ketamine? Clin J Pain 2005; 21:101-5. [PMID: 15599137 DOI: 10.1097/00002508-200501000-00012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to assess whether coadministration of S(+) ketamine or ketorolac would enhance or prolong local analgesic effect of bupivacaine after inguinal hernia repair. DESIGN Prospective double-blind randomized study evaluating pain intensity after surgery under general anesthesia. SETTING Outpatient facilities of the University Hospital of Lausanne. PATIENT Thirty-six ASA I-II outpatients scheduled for elective day-case inguinal herniorraphy. INTERVENTION Analgesia strategy consisted of a wound infiltration and an inguinal field block either with 30 mL bupivacaine (0.5%) or with the same volume of a mixture of 27 mL bupivacaine (0.5%) + 3 mL S(+) ketamine (75 mg) or a 28 mL bupivacaine (0.5%) + 2 mL ketorolac (60 mg). Postoperative analgesic regimen was standardized. OUTCOME MEASURES Pain intensity was assessed with a Visual Analog Scale, a verbal rating score, and by pressure algometry 2, 4, 6, 24, and 48 hours after surgery. RESULTS The 3 groups of patients experienced the highest Visual Analog Scale pain score at 24 hours, which was different from those at 6 and 48 hours (P < 0.05). Apart from a significantly lower pain sensation (verbal rating score) in the ketorolac group at 24 and 48 hours and only at 48 hours with ketamine, there were no other differences in pain scores, pain pressure thresholds, or rescue analgesic consumption between groups throughout the 48-hour study period. CONCLUSION The addition of S(+)-ketamine or ketorolac only minimally improves the analgesic effect of bupivacaine. This may be related to the tension-free hernia repair technique associated with low postoperative pain.
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Affiliation(s)
- Steve Clerc
- Department of Anesthesiology, University Hospital, Lausanne, Switzerland
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Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as Adjuvant Analgesic to Opioids: A Quantitative and Qualitative Systematic Review. Anesth Analg 2004; 99:482-95, table of contents. [PMID: 15271729 DOI: 10.1213/01.ane.0000118109.12855.07] [Citation(s) in RCA: 279] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Animal studies on ketamine and opioid tolerance have shown promising results. Clinical trials have been contradictory. We performed a systematic review of randomized, double-blind clinical trials of ketamine added to opioid analgesia. Thirty-seven trials with 51 treatment arms and 2385 patients were included. Studies were divided into 5 subgroups: IV ketamine as single dose (n = 11), continuous infusion (n = 11), patient-controlled analgesia (PCA) (n = 6), epidural ketamine with opioids (n = 8), and studies in children (n = 4). Outcome measures included pain scores, time to first request for analgesia, supplemental analgesics, and adverse events. Efficacy was estimated by statistical significance (P < 0.05) of outcome measures as reported in studies and also by calculation of weighted mean difference for pain scores during the first 24 h after surgery. As compared to morphine alone, IV PCA with ketamine and morphine did not improve analgesia. Intravenous infusion of ketamine decreased IV and epidural opioid requirements in 6 of 11 studies. A single bolus dose of ketamine decreased opioid requirements in 7 of 11 studies. Five of 8 trials with epidural ketamine showed beneficial effects. Adverse effects were not increased with small dose ketamine. We conclude that small dose ketamine is a safe and useful adjuvant to standard practice opioid-analgesia.
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MESH Headings
- Adult
- Analgesia, Epidural
- Analgesia, Patient-Controlled
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthetics, Dissociative/administration & dosage
- Anesthetics, Dissociative/adverse effects
- Anesthetics, Dissociative/therapeutic use
- Child
- Double-Blind Method
- Drug Therapy, Combination
- Humans
- Infusions, Intravenous
- Ketamine/administration & dosage
- Ketamine/adverse effects
- Ketamine/therapeutic use
- Pain/drug therapy
- Pain Measurement
- Postoperative Nausea and Vomiting/epidemiology
- Randomized Controlled Trials as Topic
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology, Critical Care & Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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McCartney CJL, Sinha A, Katz J. A Qualitative Systematic Review of the Role of N-Methyl-d-Aspartate Receptor Antagonists in Preventive Analgesia. Anesth Analg 2004; 98:1385-400, table of contents. [PMID: 15105220 DOI: 10.1213/01.ane.0000108501.57073.38] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED We evaluated in a qualitative systematic review the effect of N-methyl-D-aspartate (NMDA) receptor antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Randomized trials examining the use of an NMDA antagonist in the perioperative period were sought by using a MEDLINE (1966-2003) and EMBASE (1985-2003) search. Reference sections of relevant articles were reviewed, and additional articles were obtained if they evaluated postoperative analgesia after the administration of NMDA antagonists. The primary outcome was a reduction in pain, analgesic consumption, or both in a time period beyond five half-lives of the drug under examination. Secondary outcomes included time to first analgesic request and adverse effects. Forty articles met the inclusion criteria (24 ketamine, 12 dextromethorphan, and 4 magnesium). The evidence in favor of preventive analgesia was strongest in the case of dextromethorphan and ketamine, with 67% and 58%, respectively, of studies demonstrating a reduction in pain, analgesic consumption, or both beyond the clinical duration of action of the drug concerned. None of the four studies examining magnesium demonstrated preventive analgesia. IMPLICATIONS We evaluated, in a qualitative systematic review, the effect of N-methyl D-aspartate antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Dextromethorphan and ketamine were found to have significant immediate and preventive analgesic benefit in 67% and 58% of studies, respectively.
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Affiliation(s)
- Colin J L McCartney
- Department of Anesthesia and Pain Management, Toronto Western Hospital and University of Toronto, Ontario, Canada.
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.
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