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Assessment of ketamine effect as adjuvant to morphine in post-operative pain reduction in donor kidney transplanted

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Journal Iranian Red Crescent Medical Journal
Year 2010
Links http://ircmj.com/index.php?page=article&article_id=40

This article is included in 1 Systematic review Systematic reviews (1 reference) 1 Broad synthesis Broad syntheses (1 reference)

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BACKGROUND: morphine is a strong analgesic agent being used in acute pain but adverse effects may lead to its discontinuation before sufficient pain relief is obtained. Ketamine is an anti-nociceptive drug which blocks n-methyl-d-aspartate receptors and can modulate acute pain. In this study, ketamine effect as an adjuvant with morphine for post-operative pain management is evaluated. METHOD: in a double blind randomized clinical trial, 50 kidney donors undergoing nephrectomy and receiving morphine as analgesics were enrolled. Patients were divided into two groups receiving ketamine (ketamine group) and saline serum (placebo group). Post-operative pain was assessed by measuring cumulative morphine consumption and visual analog scale pain scores were assessed in 48 hours duration after surgery. RESULTS: pain intensity and cumulative morphine consumption were lower and sedation score was higher in the ketamine group. Both groups were similar regarding the side effects. CONCLUSION: regarding post-operative analgesia management, ketamine administration improved pain intensity and when its administration was continued for 48 hours post-operatively, there was a significant decrease in morphine consumption.

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Low-dose ketamine via intravenous patient-controlled analgesia device after various transthoracic procedures improves analgesia and patient and family satisfaction.

Journal Pain management nursing : official journal of the American Society of Pain Management Nurses
Year 2010
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This article is included in 3 Systematic reviews Systematic reviews (3 references) 1 Broad synthesis Broad syntheses (1 reference)

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Abstract: Ketamine was recently shown to attenuate postoperative pain when used in combination with morphine in patients who had undergone general and orthopedic surgery. We assessed its effects in 46 patients undergoing minimally invasive direct coronary artery bypass, off-pump coronary artery bypass, or thoracotomy and correlated them with patient and family satisfaction. Patient-controlled analgesia (PCA) was available for 72 hours. One group received 2mg/bolus morphine randomly and double-blindly (group MO), and another group received 1mg morphine plus 5mg ketamine/bolus (group MK), both using IV-PCA. The patients'' pain and satisfaction rates were assessed three times daily during hospitalization using a visual analog scale. Their families'' satisfaction was assessed as well. Although the 3-day mean amount of morphine used by the MK patients was approximately 60% of that used by the MO patients, their levels of pain and satisfaction were better than those of the MO group. There was an inverted and statistically significant correlation between the patients'' level of satisfaction on the second postoperative day (POD) and the satisfaction of their families on POD 2, 3, and 7 and the POD 3 patients'' pain assessment in the MK group but not in the MO group. There were no differences in hemodynamic, respiratory, side effects, or complication rates between the groups. The conclusion is that the effects of adding a small ketamine dose to half of the standard morphine dose via IV-PCA after thoracotomy was superior to the standard morphine dose in terms of the patients'' self–reported pain score and satisfaction, as well as the family satisfaction rate.

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Intraoperative Ketamine Reduces Perioperative Opiate Consumption in Opiate-dependent Patients with Chronic Back Pain Undergoing Back Surgery.

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Journal Anesthesiology
Year 2010
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This article is included in 2 Systematic reviews Systematic reviews (2 references) 1 Broad synthesis Broad syntheses (1 reference)

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BACKGROUND:: Ketamine is an N-methyl-d-aspartate receptor antagonist that has been shown to be useful in the reduction of acute postoperative pain and analgesic consumption in a variety of surgical interventions with variable routes of administration. Little is known regarding its efficacy in opiate-dependent patients with a history of chronic pain. We hypothesized that ketamine would reduce postoperative opiate consumption in this patient population. METHODS:: This was a randomized, prospective, double-blinded, and placebo-controlled trial involving opiate-dependent patients undergoing major lumbar spine surgery. Fifty-two patients in the treatment group were administered 0.5 mg/kg intravenous ketamine on induction of anesthesia, and a continuous infusion at 10 mug kgmin was begun on induction and terminated at wound closure. Fifty patients in the placebo group received saline of equivalent volume. Patients were observed for 48 h postoperatively and followed up at 6 weeks. The primary outcome was 48-h morphine consumption. RESULTS:: Total morphine consumption (morphine equivalents) was significantly reduced in the treatment group 48 h after the procedure. It was also reduced at 24 h and at 6 weeks. The average reported pain intensity was significantly reduced in the postanesthesia care unit and at 6 weeks. The groups had no differences in known ketamine- or opiate-related side effects. CONCLUSIONS:: Intraoperative ketamine reduces opiate consumption in the 48-h postoperative period in opiate-dependent patients with chronic pain. Ketamine may also reduce opioid consumption and pain intensity throughout the postoperative period in this patient population. This benefit is without an increase in side effects.

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Preemptive analgesic effect of ketamine in patients undergoing elective cesarean section.

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Authors Reza FM , Zahra F , Esmaeel F , Hossein A
Journal The Clinical journal of pain
Year 2010
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This article is included in 3 Systematic reviews Systematic reviews (3 references) 1 Broad synthesis Broad syntheses (1 reference)

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OBJECTIVES: In this study, the preemptive effect of a small dose of ketamine on postoperative wound pain and morphine consumption in patients undergoing elective cesarean section was evaluated. METHODS: In a randomized, double-blind clinical trial, 60 women with American Society of Anesthesiologists class I and II identification undergoing elective cesarean section were enrolled. In the case group, the patients received 0.5 mg/kg ketamine, and in the control group, they received isotonic saline, 5 minutes before the induction of anesthesia. Anesthesia was induced with 4 mg/kg thiopental followed by 1.5 mg/kg succinylcholine. A further neuromuscular block was achieved by using 0.2 mg/kg of atracurium. Anesthesia was maintained with nitrous oxide 50% and halothane in oxygen. The lungs were mechanically ventilated. After fetus delivery, fentanyl (2 μg/kg) and morphine (0.15 mg/kg) were given intravenously. In the postanesthesia care unit and in the ward, all patients received morphine. Pain was assessed by the Visual Analog Scales at 2, 6, 12, and 24 hours postoperatively; the amount of morphine used and side effects were recorded. RESULTS: There was no significant difference between the patients considering their operative details, homodynamic variables, side effects, and Apgar scores of their babies at first and fifth minutes. Significantly, lower amounts of morphine were used in the case group (4.8 mg ± 2.5 mg vs. 8.1 mg ± 4.2 mg) during the first 2 hours after surgery (P=0.01), but the difference was not significant during 2 to 24 hours (3.2 ± 2.2 vs. 3.1 ± 2.3). There were no statistical differences between the groups in pain 2, 6, 12, and 24 hours postoperatively. DISCUSSION: Intraoperative low-dose ketamine had no effect on morphine consumption during 2 to 24 hours after surgery. No significant differences were seen in the pain scores of the 2 groups during the study period. The preoperative administration of 0.5 mg/kg ketamine in patients undergoing cesarean section did not elicit a preemptive analgesic effect. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

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Remifentanil in combination with ketamine versus remifentanil in spinal fusion surgery - A double blind study

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Journal International journal of clinical pharmacology and therapeutics
Year 2010
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Aim: This study is aimed at conducting a program for two different anesthetic methods used during a spinal fusion surgery to ensure better intra-operative hemodynamic stability and post-operative pain control. Methods: A prospective, randomized, double blind study in patients scheduled for spinal fusion surgery, who were randomly allocated to two groups, G1 and G2, (n = 15 per group), class I - II ASA, was carried out. Both groups received pre-operatively midazolam, followed intra-operatively by propofol, sevoflurane, atracurium, and either remifentanil infusion 0.2 μg/kg/min (G1), or the same dose of remifentanil infusion and low doses of ketamine infusion 1 μg/ kg/min (G2) anesthetics, antidote medication and post-operative morphine doses. HR, MAP, vital signs, surgical bleeding, urine output, duration of surgery and duration of anesthesia were recorded. In a 24-h recovery period in a post-anesthesia care unit (PACU) the recovery time, the first pain score and analgesic requirements were measured. Results: Intra-operative HR and arterial BP were significantly less (p < 0.05) in G1 as compared to G2. In the PACU the first pain scores were significantly less (p < 0.05) in G2 than in G1. The time for the first patient analgesia demand dose was greater in G2, as also morphine consumption which was greater in G1 than G2 (p < 0.05). Other results were the same. None of the patients had any adverse drug reaction. Conclusions: Adding low doses of ketamine hydrochloride could be a routine therapy to improve the hemodynamic stability and reduce the post-operative morphine consumption during spinal fusion surgery. ©2010 Dustri-Verlag Dr. K. Feistle.

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Effects of patient-controlled analgesia with small dose ketamine combined with morphine and the influence thereof on plasma β-endorphin level in patients after radical operation for esophageal carcinoma

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Authors Wu YQ , Li H , Xiong JC , Xu ZM , Ma LY , Huang XM , Zhang DT , Feng J
Journal Zhonghua yi xue za zhi
Year 2009
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This article is included in 2 Systematic reviews Systematic reviews (2 references) 1 Broad synthesis Broad syntheses (1 reference)

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Objective: To evaluate the effects of patient-controlled analgesia (PCA) with small dose ketamine combined with morphine on analgesia and influence thereof on the plasma β-cndorphin (EP) level in the patients after radical operation for esophageal carcinoma. Methods: Thirty ASA I-II patients, aged 35-65, weighing 42-75 kg, with visual analogue score ≥3, undergoing elective radical operation for esophageal carcinoma under general anesthesia received intravenous morphine 2-3 mg were randomly divided into 2 equal groups: group m receiving morphine 0.02 mg · kg-1 · h-1, and with group mk receiving morphine 0.02 mg · kg-1 · h-1 combined with ketamine 0.08 mg · kg-1 · h-1 for 50 h. In the course of treatment the patients received intravenous injection of morphine 2-3 mg when the VAS was ≥3. VAS was recorded 4, 8, 20, 24, and 48 h after operation. The amount of morphine used after operation, PCA button pressing times (effective/active), side effects, and vital signs including pulse, saturation of blood oxygen, respiratory rate, heart rate, and average arterial pressure were recorded. Central venous blood samples were collected when entering the operation room (T0), by the end of operation (T1), and 6 h (T2), 24 h (T3), and 48 h (T4) after operation respectively to examine the β-endorphm level. Results: During the period 4-48 h after operation the VAS scores of the group mk were significantly lower than those of the group m in activity state (all P < 0.05) and were not significantly different those of the group m at resting state (all P > 0.05). The total amount of morphine consumed and the actual PCA button pressing times were significantly less in the group mk than in the group m (both P < 0.05). The incidence rates of nausea, vomiting, and pruritus of the group mk were all significantly lower than those of the group m (all P < 0.05). There were not significant differences in the incidence rates of dreaming and pseudoesthesia between these 2 groups. All the vital signs were stable in the 2 groups. The plasma β-EP levels at the time point T1 of these 2 groups were both significantly higher than those at T0 (both P < 0.05). The plasma β-endorphin levels at T2-4 of the group mk decreased gradually from the level at T 1 to the level at T0, and the plasma β-endorphin levels of the group m rapidly decreased from the level at T0 to the T0 level and remained at this level to the 48 h after operation. Conclusion: The combination of small dose of ketamine with morphine provides optimal analgesia with low side-effect rate and little effect on the plasma β-EP level.

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A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy

Journal Anesthesia and analgesia
Year 2009
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This article is included in 5 Systematic reviews Systematic reviews (5 references) 1 Broad synthesis Broad syntheses (1 reference)

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BACKGROUND:: Gabapentin and ketamine are popular analgesic adjuvants for improving perioperative pain management. We designed this double-blind, placebo-controlled study to test and compare the preventive effects of perioperative ketamine and gabapentin on early and chronic pain after elective hysterectomy. METHODS:: Sixty patients undergoing abdominal hysterectomy were randomly assigned to 1 of the following 3 groups: control group received oral placebo capsules and bolus plus infusion of saline; ketamine group received oral placebo capsules and, before incision, 0.3 mg/kg IV bolus and 0.05 mg•kg-1•h-1 infusion of ketamine until the end of surgery; and gabapentin group received oral gabapentin 1.2 g and bolus plus infusion of saline. The anesthetic technique was standardized, and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Patients were questioned at 1, 3, and 6 mo after surgery for chronic postoperative pain. RESULTS:: Postoperative pain scores were significantly lower in the gabapentin group compared with the ketamine and control groups, and patient-controlled analgesia morphine use was significantly reduced in both treatment groups (versus control group) (P < 0.001). Total patient-controlled analgesia morphine use was decreased by 35% and 42% in the ketamine and gabapentin groups, respectively, compared with the control group (P < 0.001). Patient satisfaction with pain treatment was significantly improved in the ketamine and gabapentin groups compared with the control group (P < 0.001).The incidence of incisional pain and related pain scores at the 1-, 3-, and 6-mo follow-up were significantly lower in the gabapentin group compared with the ketamine and control groups (P < 0.001). CONCLUSION:: Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months. Copyright © 2009 International Anesthesia Research Society.

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The early and delayed analgesic effects of ketamine after total hip arthroplasty: A prospective, randomized, controlled, double-blind study

Journal Anesthesia and analgesia
Year 2009
Links Pubmed DOI

This article is included in 5 Systematic reviews Systematic reviews (5 references) 1 Broad synthesis Broad syntheses (1 reference)

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BACKGROUND: Ketamine has been shown to have a morphine-sparing effect soon after surgery. Nevertheless, whether this effect still exists after being combined with nonsteroidal antiinflammatory drugs and acetaminophen, and whether ketamine can decrease chronic pain after nononcologic surgery remain unclear. Thus, we designed a study to assess ketamine's effect on acute and chronic postoperative pain when combined with multimodal analgesia after total hip arthroplasty (THA). METHODS: Patients scheduled for primary nononcologic THA using standardized general anesthesia were randomized. They received IV ketamine before incision (0.5 mg/kg), and a 24-h infusion (2 μg • kg -1 • min-1) or a similar blinded saline bolus and infusion. Postoperative analgesia included IV acetaminophen, ketoprofen, plus morphine/droperidol patient-controlled analgesia for 48 h. Data pertaining to pain scores, morphine consumption, and need for crutches were collected for 6 mo after THA. Our primary outcome was 24-h morphine consumption. RESULTS: One hundred fifty-four patients were included (placebo, 75; ketamine, 79). Patients and operative data were similar in both groups. Ketamine decreased morphine consumption at 24 h from 19 ± 12 mg to 14 ± 13 mg (P = 0.004). At Day 30, ketamine decreased the proportion of patients needing 2 crutches or a walking frame from 56% to 31% (P = 0.0035). From Day 30 to Day 180, ketamine decreased the proportion of patients with persistent pain at rest in the operated hip (P = 0.008). At Day 180, 21% of placebo group patients (15 of 70) experienced pain at rest in the operated hip versus 8% (6 of 72) in the ketamine group (P = 0.036, odds ratio 0.33, 95% confidence interval 0.12-0.91, risk reduction 67%). CONCLUSIONS: Ketamine had a morphine-sparing effect after THA, even when morphine was combined with multimodal systemic analgesia. It also facilitated rehabilitation at 1 mo and decreased postoperative chronic pain up to 6 mo after surgery. © 2009 International Anesthesia Research Society.

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Postoperative analgesia and early rehabilitation after total knee replacement: a comparison of continuous low-dose intravenous ketamine versus nefopam.

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Journal European journal of pain (London, England)
Year 2009
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The effects of nefopam and ketamine on pain control and rehabilitation after total knee replacement were compared in a prospective, double blinded study. Seventy-five patients were randomly assigned to receive a 0.2mg kg(-1) bolus of nefopam or ketamine, followed by a 120microg kg(-1) h(-1) continuous infusion until the end of surgery, and 60microg kg(-1) h(-1) until the second postoperative day, or an equal volume of saline considered as placebo. Pain scores measured on a visual analog scale at rest and on mobilization, and patient-controlled intravenous morphine consumption, were assessed during 48h. We measured the maximal knee flexion on the third postoperative day, and the delay to obtain a 90 degrees flexion. Ketamine and nefopam reduced morphine consumption (p&lt;0.0001). Pain scores, were lower at rest and on mobilization in the ketamine group compared to the two other groups at all times of measurement. Pain score were lower in patients receiving nefopam compared to placebo, on arrival in the recovery room and at 2h. Ketamine improved knee flexion on post operative day 3 (59 degrees [33-63] vs. 50 degrees [47-55] and 50 degrees [44-55] in ketamine, placebo and nefopam groups, respectively, p&lt;0.0002) and decreased the delay to flex the knee at 90 degrees (9.1+/-4.2 vs. 12.3+/-4.0 days, in ketamine and placebo groups, respectively, p=0.01). Ketamine produces opioid-sparing, decreases pain intensity, and improves mobilization after total knee replacement. Nefopam achieves less significant results in that circumstances.

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Remifentanil combined with low-dose ketamine for post-operative analgesia of lower limb fracture: A double-blind, controlled study

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Authors Deng GF , Zheng JP , Wang S , Tian B , Zhang SG
Journal Chinese journal of traumatology = Zhonghua chuang shang za zhi / Chinese Medical Association
Year 2009
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Objective: To investigate the adjuvant effect of intra-operative and postoperative low-dose ketamine administration to remifentanil consumption in patient-controlled analgesia (PCA) for lower limb fracture. Methods: A total of 200 patients with lower limb fracture receiving the surgery were randomly divided into 4 groups. In Groups A, B and C, patients received 0.5 mg/kg ketamine infusion under general anesthesia, and ketamine in a dose of 0.1 mg/ kg, 0.05 mg/kg, 0.01 mg/kg per hour continuously for 24 hours after surgery, respectively. The control group (Group D) received an equivalent volume of normal saline only. With 20 μg/ml remifentanil in normal saline, postoperative PCA was administered with a background infusion at 2 ml/h following 2 ml as a loading dose and 1ml demand dose with a 3-minute lockout period. Remifentanil consumption, 11-point visual analog scale (VAS) scores, global satisfaction score (GSS), and side effects were also recorded by the acute pain service. Results: Cumulative PCA remifentanil consumption in Groups A and B were (1378±377) μg and (1531±402) μg, significantly lower than (1807±510) μg and (1838±523) μg in Groups C and D (P<0.01). VAS scores in Groups A and B were significantly lower than those in Groups C and D (P<0.01). In the first 12 hours after operation, GSS was improved (P<0.01). No respiratory depression was observed. No significant difference in side effects was observed among groups. Conclusion: Low-dose ketamine can relieve postoperative pain and moderately decrease remifentanil consumption for PCA, with no obvious side effects of ketamine.