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Xiang J, Cao C, Chen J, Kong F, Nian S, Li Z, Li N. Efficacy and safety of ketamine as an adjuvant to regional anesthesia: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2024; 94:111415. [PMID: 38394922 DOI: 10.1016/j.jclinane.2024.111415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/03/2023] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Abstract
STUDY OBJECTIVE To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. DESIGN A Systematic review and meta-analysis of randomized controlled trials. SETTING The major dates were obtained in the operating room and the postoperative recovery ward. PATIENTS A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion. INTERVENTIONS After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block. MEASUREMENT The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system. MAIN RESULT Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I2 = 57%). CONCLUSION This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.
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Affiliation(s)
- Jiajia Xiang
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China; Kunming Medical University, Kunming, Yunnan, China
| | - Chunyan Cao
- Department of Obstetrics and Gynecology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China
| | - Jiayu Chen
- Department of Orthopedics, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Fanyi Kong
- Department of Neurology, Affiliated Hospital of Yunnan University, Kunming, Yunnan, China
| | - Sunqi Nian
- Department of Orthopedics, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Zhigui Li
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China.
| | - Na Li
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China.
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Abate SM, Mergia G, Nega S, Basu B, Tadesse M. Efficacy and safety of wound infiltration modalities for postoperative pain management after cesarean section: a systematic review and network meta-analysis protocol. Syst Rev 2022; 11:194. [PMID: 36071535 PMCID: PMC9450460 DOI: 10.1186/s13643-022-02068-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pain after a cesarean section has negative consequences for the mother during the postoperative period. Over the years, various postoperative pain management strategies have been used following cesarean section. Opioid-based analgesics and landmark approaches have negative side effects, while ultrasound-based regional analgesia necessitates resources and experience, but various wound infiltration adjuvants are innovative with few side effects and are simple to use. The efficacy and safety of each adjuvant, however, are unknown and require further investigation. OBJECTIVE This network meta-analysis is intended to provide the most effective wound infiltration drugs for postoperative management after cesarean section. METHOD A comprehensive search will be conducted in PubMed/MEDLINE, Cochrane Library, Science Direct, CINHAL, and LILACS without date and language restrictions. All randomized trials comparing the effectiveness of wound infiltration drugs for postoperative pain management after cesarean section will be included. Data extraction will be conducted independently by two authors. The quality of studies will be evaluated using the Cochrane risk of bias tool, and the overall quality of the evidence will be determined by GRADEpro software. DISCUSSION The rate of postoperative acute and chronic pain is very high which has a huge impact on the mother, family, healthcare practitioners, and healthcare delivery. It is a basic human right to give every patient with postoperative pain treatment that is realistic in terms of resources, technique, cost, and adverse event profile. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021268774.
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Affiliation(s)
- Semagn Mekonnen Abate
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia.
| | - Getachew Mergia
- Departemnt of Obstetrics and Gynecology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Solomon Nega
- Departemnt of Internal Medicine, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Bivash Basu
- Department of Anesthesiology, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Moges Tadesse
- School of Public Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
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Farahmand Rad R, Imani F, Emami A, Salehi R, Ghavamy AR, Shariat AN. Postoperative Pain Management: Efficacy of Caudal Tramadol in Pediatric Lower Abdominal Surgery: A Randomized Clinical Study. Anesth Pain Med 2021; 11:e119346. [PMID: 34692449 PMCID: PMC8520683 DOI: 10.5812/aapm.119346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND One of the methods of pain control after pediatric surgical procedures is regional techniques, including caudal block, despite their limitations. OBJECTIVES In this study, the pain score and complications of caudal tramadol were evaluated in pediatrics following lower abdominal surgery. METHODS In this study, 46 children aged 3 to 10 years were allocated into two equal groups (R and TR) for performing caudal analgesia after lower abdominal surgery. The injectate contained 0.2% ropivacaine 1 mL/kg in the R group (control group) and tramadol (2 mg/kg) and ropivacaine in the TR group. The pain score, duration of pain relief, amount of paracetamol consumption, hemodynamic alterations, and possible complications at specific times (1, 2, and 6 hours) were evaluated in both groups. RESULTS No considerable difference was observed in the pain score between the groups in the first and second hours (P > 0.05). However, in the sixth hour, the TR group had a significantly lower pain score than the R group (P < 0.05). Compared to the R group, the TR group had a longer period of analgesia and lower consumption of analgesic drugs (P < 0.05). Heart rate and blood pressure differences were not significant between the two groups (P > 0.05). Similarly, the duration of operation and recovery time were not remarkably different between the two groups (P > 0.05). Complications had no apparent differences between these two groups, as well (P > 0.05). CONCLUSIONS In this study, the addition of tramadol to caudal ropivacaine in pediatric lower abdominal surgery promoted pain relief without complications.
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Affiliation(s)
- Reza Farahmand Rad
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Emami
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Salehi
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Ghavamy
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Nima Shariat
- Icahn School of Medicine of Mount Sinai, Mount Sinai Morningside Hospital Center, New York, USA
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Flores-Arriaga JC, Chavarría-Bolaños D, Pozos-Guillén ADJ, Escobar-Barrios VA, Cerda-Cristerna BI. Synthesis of a PVA drug delivery system for controlled release of a Tramadol-Dexketoprofen combination. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2021; 32:56. [PMID: 33961138 PMCID: PMC8105240 DOI: 10.1007/s10856-021-06529-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 04/19/2021] [Indexed: 06/12/2023]
Abstract
The local administration of analgesic combinations by means of degradable polymeric drug delivery systems is an alternative for the management of postoperative pain. We formulated a Tramadol-Dexketoprofen combination (TDC) loaded in poly(vinyl alcohol) (PVA) film. Films were prepared by the solvent casting method using three different molecular weights of PVA and crosslinking those films with citric acid, with the objective of controlling the drug release rate, which was evaluated by UV-vis spectrometry. Non-crosslinked PVA films were also evaluated in the experiments. Differential scanning calorimetry (DSC) analysis of samples corroborated the crosslinking of PVA by the citric acid. Blank and loaded PVA films were tested in vitro for its impact on blood coagulation prothrombin time (PT) and partial thromboplastin time (PTT). The swelling capacity was also evaluated. Crosslinked PVA films of higher-molecular weight showed a prolonged release rate compared with that of the lower-molecular-weight films tested. Non-crosslinked PVA films released 11-14% of TDC. Crosslinked PVA films released 80% of the TDC loaded (p < 0.05). This suggests that crosslinking films can modify the drug release rate. The blank and loaded PVA films induced PT and PTT in the normal range. The results showed that the polymeric films evaluated here have the appropriate properties to allow films to be placed directly on surgical wounds and have the capacity for controlled drug release to promote local analgesia for the control of postoperative pain.
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Affiliation(s)
- Juan Carlos Flores-Arriaga
- Advanced Polymers Lab, Instituto Potosino de Investigación Científica y Tecnológica (IPICYT), Camino a la Presa 2055, Lomas 4a, 78216, San Luis Potosí, SLP, Mexico
| | - Daniel Chavarría-Bolaños
- Diagnostic and Surgical Sciences Department, Faculty of Dentistry, Universidad de Costa Rica, San Jose, Costa Rica
| | - Amaury de Jesús Pozos-Guillén
- Basic Science Laboratory, Faculty of Dentistry, San Luis Potosi University, Manuel Nava 2, Zona Universitaria, 78290, San Luis Potosí, SLP, México
| | - Vladimir Alonso Escobar-Barrios
- Advanced Polymers Lab, Instituto Potosino de Investigación Científica y Tecnológica (IPICYT), Camino a la Presa 2055, Lomas 4a, 78216, San Luis Potosí, SLP, Mexico.
| | - Bernardino Isaac Cerda-Cristerna
- Facultad de Odontología, Región Orizaba-Córdoba, Universidad Veracruzana, Abasolo Sur, SN, Tenango de Río Blanco, 94732, Veracruz, México.
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Al-Kaabneh A, Qamar AA, Al-Hammouri F, Al-Majali A, Alasmar A, Al-Sayedeh N, Khori F, Qapaha A, Beidas M. The effect of anaesthesia on flank incisional pain: infiltration versus intercostal nerve block, a comparative study. Pan Afr Med J 2020; 36:356. [PMID: 33224422 PMCID: PMC7664139 DOI: 10.11604/pamj.2020.36.356.24279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022] Open
Abstract
The object of this study is to determine which local wound analgesic option is superior, local anaesthetic infiltration or intercostal nerve block, by combined local anaesthetic agents (0.5% bupivacaine + 2% lidocaine) and to detect which option can best alleviate the post-operative pain management and significantly prolong the time to the first rescue analgesic requirement and the total consumption of opioids in the first post-operative 72 hrs. The medical records of 1458 patients who underwent flank incision procedures by two different surgeons in our institute were retrospectively reviewed. Each surgeon used a different type of local incisional pain management; the first one used infiltration of flank incision routinely, the second surgeon used an intercostal block with all his patients. These elective procedures were carried out in our Urology Centre between June 2007 and June 2019. The duration of follow-up was from the recovery transfer until the end of the third post-operative day. Patients were divided into two groups: group 1 (729 patients-infiltration of flank incision) and group 2 (729 patients-intercostal nerve block). Patients were aged between 19-78 years. No significant differences were seen regarding the demographic data between both groups, P > 0.05. On the other hand, there were significant differences between group 1 and group 2 according to the mean visual analogue scale score (lower in group 1, P < 0.05), the total mean analgesic requirements during the first post-operative 72 hrs (lower in group 1, P < 0.05) and the time to the first analgesic demand (higher in group 1, P < 0.05). There were no statistically significant differences in post-operative complications between both groups, P > 0.05. The infiltration of flank incision with combined local anaesthetic agents (0.5% Bupivacaine + 2% lidocaine) is more effective in alleviating post-operative pain, decreasing total analgesic consumption during the first post-operative 72 hrs and prolonging the time required for the first rescue opioid.
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Affiliation(s)
- Awad Al-Kaabneh
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Adnan Abo Qamar
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Firas Al-Hammouri
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Ashraf Al-Majali
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Ali Alasmar
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Nizar Al-Sayedeh
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Firas Khori
- Department of Urology, Prince Hussein Urology Institute, King Hussein Medical Centre, Amman, Jordan
| | - Anan Qapaha
- Anaesthesia Department, King Hussein Medical Centre, Amman, Jordan
| | - Mohammad Beidas
- Anaesthesia Department, King Hussein Medical Centre, Amman, Jordan
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Bai JW, An D, Perlas A, Chan V. Adjuncts to local anesthetic wound infiltration for postoperative analgesia: a systematic review. Reg Anesth Pain Med 2020; 45:645-655. [DOI: 10.1136/rapm-2020-101593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/31/2022]
Abstract
Local anesthetics (LAs) are commonly infiltrated into surgical wounds for postsurgical analgesia. While many adjuncts to LA agents have been studied, it is unclear which adjuncts are most effective for co-infiltration to improve and prolong analgesia. We performed a systematic review on adjuncts (excluding epinephrine) to local infiltrative anesthesia to determine their analgesic efficacy and opioid-sparing properties. Multiple databases were searched up to December 2019 for randomized controlled trials (RCTs) and two reviewers independently performed title/abstract screening and full-text review. Inclusion criteria were (1) adult surgical patients and (2) adjunct and LA agents infiltration into the surgical wound or subcutaneous tissue for postoperative analgesia. To focus on wound infiltration, studies on intra-articular, peri-tonsillar, or fascial plane infiltration were excluded. The primary outcome was reduction in postoperative opioid requirement. Secondary outcomes were time-to-first analgesic use, postoperative pain score, and any reported adverse effects. We screened 6670 citations, reviewed 126 full-text articles, and included 89 RCTs. Adjuncts included opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, magnesium, neosaxitoxin, and methylene blue. Alpha-2 agonists have the most evidence to support their use as adjuncts to LA infiltration. Fentanyl, ketorolac, dexamethasone, magnesium and several other agents show potential as adjuncts but require more evidence. Most studies support the safety of these agents. Our findings suggest benefits of several adjuncts to local infiltrative anesthesia for postoperative analgesia. Further well-powered RCTs are needed to compare various infiltration regimens and agents.Protocol registrationPROSPERO (CRD42018103851) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103851)
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Imani F, Varrassi G. Ketamine as Adjuvant for Acute Pain Management. Anesth Pain Med 2019; 9:e100178. [PMID: 32280623 PMCID: PMC7119219 DOI: 10.5812/aapm.100178] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
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Etezadi F, Sajedi Y, Khajavi MR, Moharari RS, Amirjamshidi A. Preemptive Effect of Intraurethral Instillation of Ketamine-lidocaine Gel on Postoperative Catheter-related Bladder Discomfort after Lumbar Spine Surgery. Asian J Neurosurg 2018; 13:1057-1060. [PMID: 30459867 PMCID: PMC6208219 DOI: 10.4103/ajns.ajns_314_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Catheter-related bladder discomfort (CRBD) is one of the main reasons of agitation after surgery, leading to urgency and frequency during recovery. Ketamine has been used as an effective drug for reducing the signs and severity of this problem. We hypothesized that intraurethral instillation of ketamine–lidocaine gel before urinary catheterization can reduce the incidence of CRBD in the postoperative period. Materials and Methods: A total of 136 male patients, who underwent two-level laminectomy/discectomy were enrolled in this randomized clinical trial. Patients were randomized into the two groups before urinary catheterization. The ketamine group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL (100 mg) ketamine. Patients in control group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL distilled water. The primary outcome was the incidence of CRBD. CRBD was assessed using four-stage criteria when arriving in the recovery room and at 1, 2, and 6 h after surgery. Postsurgical pain and the number of sedatives given and opioid requirement were also the secondary outcomes in this study. Results: Intraurethral instillation of ketamine–lidocaine gel reduced the incidence of CRBD at recovery (P < 0.001) along with a reduction in the severity of CRBD (P < 0.05) during the 1st and 2nd visit compared with control group. The mean pain intensity score (visual analog scale) and opioid requirement to relieve postsurgical pain were lower in the ketamine group during all the study timepoints from recovery and after transfer to the ward (P < 0.008). A higher rate of sedation (72% vs. 11%) also was seen at recovery period in the ketamine group (P < 0.008). Conclusion: Intraurethral instillation of ketamine–lidocaine gel before bladder catheterization is an effective technique for reducing the incidence and severity of postoperative CRBD.
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Affiliation(s)
- Farhad Etezadi
- Department of Anesthesiology and critical care, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yasamin Sajedi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Khajavi
- Department of Anesthesiology and critical care, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shariat Moharari
- Department of Anesthesiology and critical care, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Amirjamshidi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
BACKGROUND Traumatic lacerations to the skin represent a fairly common reason for seeking emergency department care. Although the incidence of lacerations has decreased over the past decades, traumatic cutaneous lacerations remain a common reason for patients to seek emergency department care. OBJECTIVE Innovations in laceration management have the potential to improve patient experience with this common presentation. DISCUSSION Studies have confirmed that delays in wound closure rarely confer increased rates of infection, although comorbidities such as diabetes, chronic renal failure, obesity, human immunodeficiency virus, smoking, and cancer should be considered. Antibiotics should be reserved for high-risk wounds, such as those with comorbidities, gross contamination, involvement of deeper structures, stellate wounds, and selected bite wounds. Topical anesthetics, which are painless to apply, have a role in select populations. In most studies, absorbable sutures perform similarly to nonabsorbable sutures and do not require revisit for removal. Novel atraumatic closure devices and expanded use of tissue adhesives for wounds under tension further erode the primacy of regular sutures in wound closure. Maintaining a moist wound environment with occlusive dressings is more important than previously thought. Most topical wound agents are of limited benefit. CONCLUSIONS Recent innovations in wound closure are allowing emergency physicians to shift toward painless, atraumatic, and rapid closure of lacerations.
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The effect of nephrostomy tract infiltration of ketamine on postoperative pain and peak expiratory flow rate in patients undergoing tubeless percutaneous nephrolithotomy: a prospective randomized clinical trial. Urolithiasis 2017; 45:591-595. [DOI: 10.1007/s00240-017-0971-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/02/2017] [Indexed: 10/20/2022]
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