Abstract
Purpose
Pre-emptive analgesia can improve postoperative pain management. The purpose of this study was to examine the effectiveness of ketamine as a pre-emptive analgesic as previous studies have shown the involvement of N-methyl-D-Aspartate (NMDA) receptor in neuroplasticity.
Methods
Forty-five ASA 1–2 patients, undergoing unilateral total knee replacement were studied. In the study groups, epidural lidocaine was used as the primary anaesthestic. Patients received ketamine + morphine epidurally 30 min either before (group EB) or after skin incision (group EA). Group G patients received general anaesthesia and ketamine + morphine were given 30 min after skin incision via an epidural catheter used for postoperative pain control. Epidural morphine and ketamine in lidocaine was given to all patients at the end of surgery and every 12 hr for three days for analgesia supplemented with PCA morphine. The time until first PCA trigger, morphine consumption, pain scores, satisfaction scores, and morphine related side effects were recorded at 6, 12, 24, 48 and 72 hr after surgery.
Results
Epidural ketamine plus morphine with lidocaine before surgical incision produced better pain relief and patient satisfaction than when given after incision. A longer time to PCA and decreased morphine consumption were observed in group EB than in group G. In group EA, epidural anaesthesia also produced some pre-emptive analgesic effect compared with general anaesthesia shown by decreased morphine consumption.
Conclusions
Administration of ketamine plus morphine with epidural lidocaine anaesthesia before surgery provided improved postoperative analgesia compared with general anaesthesia alone or when analgesics were given after skin incision.
Résumé
Objectif
La coanalgésie (pre-emptive analgesia) peut améliorer le traitement de la douleur postopératoire. L’objectif de cette étude était d’évaluer l’efficacité de la kétamine comme analgésique préventif en s’appuyant sur plusieurs études qui ont montré l’influence des récepteurs du N-méthyl-D-aspartate (NMDA) sur la neuroplasticité.
Méthodes
Quarante-cinq patients ASA 1 et 2 opérés pour un remplacement total d’un seul genou participaient à l’étude. Dans ce groupe, la lidocaïne épidurale constituait l’anesthésie principale. Les patients recevaient de la kétamine avec de la morphine 30 min soit avant (groupe EB) soit après l’incision de la peau (groupe EA). Le groupe G recevait une anesthésie générale et de la kétamine avec de la morphine après l’incision par le cathéter épidural utilisé pour le contrôle de la douleur postopératoire. De la morphine associée à de la kétamine dans de la lidocaïne épidurale était administrée à tous les patients à la fin de la chirurgie et à toutes les 12 heures pendant trois jours pour l’analgésie avec ajout de morphine en PCA Le moment de la première activation de la PCA, la consommation de morphine, les scores de douleur et les effets secondaires étaient enregistrés 6, 12, 24, 48 et 72 h après la chirurgie.
Résultats
L’association kétamine-morphine épidurale avec de la lidocaïne administrée avant l’incision procure un meilleur soulagement et une satisfaction plus grande au patient que lorsqu’elle est administrée après l’incision. Dans le groupe EB, un délai était plus long avant la PCA et la consommation de morphine était plus faible que dans le groupe G. Dans le groupe EA, l’anesthésie épidurale produisait aussi une analgésie préventive contrairement à l’anesthésie générale comme l’a montré une diminution de la consommation de morphine.
Conclusion
Ladministration avant la chirurgie de la kétamine associée à la morphine avec l’anesthésie épidurale à la lidocaïne améliore l’analgésie comparativement à l’anesthésie générale seule ou lorsque des analgésiques sont administrés après l’incision de la peau.
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Supported by grants from National Science Council (NSC 84-2331B016-087) and Institute of Physics Academia Sinica (IBMS-CRC85-S06) of Taiwan, Republic of China.
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Wong, CS., Lu, CC., Cherng, CH. et al. Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement. Can J Anesth 44, 31–37 (1997). https://doi.org/10.1007/BF03014321
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DOI: https://doi.org/10.1007/BF03014321