Effect of Using Low-Dose Ketamine after Spinal Anesthesia on the Severity of Postoperative Pain in Patients with Orthopedic Surgery
Background: Pain relief is one of the most important goals in patients undergoing surgery without using high-dose opioid analgesics due to their complications. The aim of this study was to evaluate the effect of using low-dose ketamine after spinal anesthesia on the severity of postoperative pain in the patients with orthopedic surgery.
Methods: The present double-blind clinical trial after obtaining approval was performed on 60 patients with lower limb fracture. The patients were selected by convenience sampling method and then divided into two equal (n=30) intervention and control groups using random number table. The patients in the intervention group after spinal anesthesia received 0.2mg/kg intravenous ketamine diluted with 10cc normal saline. The same amount of normal saline was injected intravenously in the control group. Then, the intensity of pain using VAS and the level of need for analgesics were measured in both groups at different times up to 24 hours after surgery.
Results: The intervention group included 21 males and 9 females with a mean age of 30 ± 1.2 years and control group consisted of 19 males and 11 females with a mean age of 29 ± 4 years. There was no significant difference between the age and sex of the patients in the intervention and control groups (P=0.677), (P=0.589). In the intervention group with the VAS, the lowest pain score was found at the first turn of the assessment (2.4 ± 0.6), and the highest pain at 24 h (4.3 ± 2.6). The control group had the lowest pain score at the first turn of the assessment (3.6 ± 0.8) and the maximum pain at the first turn of the assessment (5.2 ± 1.7). According to independent t-test, there was a significant difference between the two groups at all times, except for the first turn of the assessment. In the intervention group, 12 (40%) patients did not receive analgesics within 24 hours. In the control group, 2 (6.7%) had no analgesics. Chi-square showed a significant difference between the two groups (P=0.002).
Conclusion: The present study showed that low-dose intravenous ketamine could relieve pain in patients and reduce postoperative analgesics.
Brennan TJ, Kehlet H. Preventive analgesia to Reduce Wound Hyperalgesia and Persistent Postsurgical PainNot an Easy Path. Anesthesiology. 2005; 103(4):681-3.
Watkins LR, Wiertelak EP, Goehler LE, Smith KP, Martin D, Maier SF. Characterization of cytokine-induced hyperalgesia. Brain Res. 1994; 654(1):15-26..
Ricardo Buenaventura M, Rajive Adlaka M, Nalini Sehgal M. Opioid complications and side effects. Pain physician. 2008; 11(2 Suppl):S105-20.
Manchikanti L, Manchikanti KN, Pampati V, Cash KA. Prevalence of side effects of prolonged low or moderate dose opioid therapy with concomitant benzodiazepine and/or antidepressant therapy in chronic non-cancer pain. Pain Physician. 2009; 12(1):259-67.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet. 2006; 367(9522):1618-25.
Schwenk ES, Goldberg SF, Patel RD, Zhou J, Adams DR, Baratta JL, et al. Adverse drug effects and preoperative medication factors related to perioperative low-dose ketamine infusions. Reg Anesth Pain Med. 2016; 41(4):482-7.
Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu WA, Sengupta DK, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010; 113(3):639-46.
Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth. 2011; 58(10):911-23.
McNicol E, Schumann R, Haroutounian S. A systematic review and meta‐analysis of ketamine for the prevention of persistent post‐surgical pain. Acta Anaesthesiol Scand. 2014; 58(10):1199-213.
Wang L, Johnston B, Kaushal A, Cheng D, Zhu F, Martin J. Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials. Can J Anaesth. 2016; 63(3):311-25.
Sirous A, Pazouki S, Ghoudarzi D, Yavariy M, Babaei E, Pirasteh S. Evaluation of the effects of oral Ketamine as an adjuvant drug in treatment of renal colic. Arak University of Medical Sciences. 2008; 11(2):56-63.
Marzban S, Hadadi S, Movahedi H, Parvizi A, Haghighi M. The effect of ketamine on sore throat after tonsillectomy. Journal of Mazandaran University Of Medical Sciences. 2007; 16(56):53-9.
Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America. 2005; 23(1):185-202.
Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001 Jul;87(1):62-72.
Jendoubi A, Naceur IB, Bouzouita A, Trifa M, Ghedira S, Chebil M, et al. A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth. 2017; 11(2):177-184.
EL-Rahman AMA, El Sherif FA. Efficacy of Postoperative Analgesia of Local Ketamine Wound Instillation Following Total Thyroidectomy; A Randomized, Double-blind, Controlled-clinical Trial. Clin J Pain. 2017.
Krishna TM, Panda N, Batra Y, Rajeev S. Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery. Eur J Anaesthesiol. 2008; 25(4):299-306.
Salama AK. Comparison between ketamine and hyoscine for the management of postoperative catheter-related bladder discomfort: A randomized controlled double-blind study. J Anaesthesiol Clin Pharmacol. 2017; 33(1):76-80.
Suzuki M, Haraguti S, Sugimoto K, Kikutani T, Shimada Y, Sakamoto A. Low-dose intravenous ketamine potentiates epidural analgesia after thoracotomy. Anesthesiology. 2006; 105(1):111-9.