Anesth Pain Med.  2016 Jan;11(1):71-75. 10.17085/apm.2016.11.1.71.

The effect of preemptive intravenous ketamine on postoperative pain in patients undergoing arthroscopic rotator cuff repair with intra articular ropivacaine injection

• Hong EP
• Jeong DH
• Kang HY
• Choi JH
• Park SW

• KMID: 2169078
• DOI: http://doi.org/10.17085/apm.2016.11.1.71

Abstract

BACKGROUND
A low dose of ketamine can be an effective preemptive analgesic by preventing central sensitization when administered before surgical trauma. In this study, we assessed the preemptive analgesic effect of low-dose ketamine administered intravenously to patients undergoing arthroscopic rotator cuff repair with intra articular ropivacaine injection.
METHODS
This randomized, double-blinded study included fifty-six patients scheduled for elective arthroscopic rotator cuff repair. Normal saline (group C) or 0.5 mg/kg of ketamine (group K) was injected intravenously before the skin incision. An intra articular injection using 20 ml of 0.75% ropivacaine was performed in both groups just before wound closure by the surgeon at the end of the surgery. Postoperative pain was assessed by the numeric rating scale (NRS) in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. The total dose of fentanyl consumption and side effects were recorded.
RESULTS
There were no significant differences between the C and K groups for the NRS of pain in the PACU and at 12, 24, and 48 hours after the surgery. In addition, there was also no significant difference in total fentanyl consumption between the two groups.
CONCLUSIONS
Preemptive ketamine did not reduce preemptive pain scores and fentanyl consumption in patients who underwent arthroscopic rotator cuff repair with intra articular local anesthetic injection. Therefore, more aggressive and multimodal pain control is required in patients undergoing arthroscopic shoulder surgery regardless of the use of preemptive intravenous ketamine injection.

Keyword

Arthroscopic shoulder surgery; Intra articular injection; Ketamine; Preemptive analgesics

MeSH Terms

Central Nervous System Sensitization
Fentanyl
Humans
Ketamine*
Pain, Postoperative*
Rotator Cuff*
Shoulder
Skin
Wounds and Injuries
Fentanyl
Ketamine

Figure

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  Fig. 1 The above graph represents the pain intensity of the control and ketamine groups during the immediate 48 hours postoperative. Pain intensity was measured by a numeric rating scale (NRS; 0 = no pain and 10 = worst pain imaginable). There were no significant differences between the two groups (P > 0.05).

Reference

1. Al-Kaisy A, McGuire G, Chan VW, Bruin G, Peng P, Miniaci A, et al. Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery. Reg Anesth Pain Med. 1998; 23:469–73. DOI: 10.1016/S1098-7339(98)90029-3. PMID: 9773699.

2. Ritchie ED, Tong D, Chung F, Norris AM, Miniaci A, Vairavanathan SD. Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality? Anesth Analg. 1997; 84:1306–12. DOI: 10.1213/00000539-199706000-00024. PMID: 9174311.

3. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005; 94:505–13. DOI: 10.1093/bja/aei085. PMID: 15681586.

4. Scoggin JF 3rd, Mayfield G, Awaya DJ, Pi M, Prentiss J, Takahashi J. Subacromial and intra-articular morphine versus bupivacaine after shoulder arthroscopy. Arthroscopy. 2002; 18:464–8. DOI: 10.1053/jars.2002.29895. PMID: 11987055.

5. Niiyama Y, Omote K, Sumita S, Kawamata T, Okamura K, Namiki A. The effect of continuous intra-articular and intra-bursal infusion of lidocaine on postoperative pain following shoulder arthroscopic surgery. Masui. 2001; 50:251–5. PMID: 11296434.

6. Krone SC, Chan VW, Regan J, Peng P, Poate EM, McCartney C, et al. Analgesic effects of low-dose ropivacaine for interscalene brachial plexus block for outpatient shoulder surgery-a dose- finding study. Reg Anesth Pain Med. 2001; 26:439–43. DOI: 10.1053/rapm.2001.25914. PMID: 11561264.

7. Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth Analg. 2004; 99:589–92. DOI: 10.1213/01.ANE.0000125112.83117.49. PMID: 15271745.

8. Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty. Anesth Analg. 2005; 100:475–80. DOI: 10.1213/01.ANE.0000142117.82241.DC. PMID: 15673878. PMCID: PMC1388093.

9. Joseph C, Gaillat F, Duponq R, Lieven R, Baumstarck K, Thomas P, et al. Is there any benefit to adding intravenous ketamine to patient-controlled epidural analgesia after thoracic surgery? A randomized double-blind study. Eur J Cardiothorac Surg. 2012; 42:e58–65. DOI: 10.1093/ejcts/ezs398. PMID: 22790008.

10. Suzuki M, Haraguti S, Sugimoto K, Kikutani T, Shimada Y, Sakamoto A. Low-dose intravenous ketamine potentiates epidural analgesia after thoracotomy. Anesthesiology. 2006; 105:111–9. DOI: 10.1097/00000542-200607000-00020. PMID: 16810002.

11. Singh H, Kundra S, Singh RM, Grewal A, Kaul TK, Sood D. Preemptive analgesia with Ketamine for Laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol. 2013; 29:478–84. DOI: 10.4103/0970-9185.119141. PMID: 24249984. PMCID: PMC3819841.

12. Menigaux C, Guignard B, Fletcher D, Sessler DI, Dupont X, Chauvin M. Intraoperative small-dose ketamine enhances analgesia after outpatient knee arthroscopy. Anesth Analg. 2001; 93:606–12. DOI: 10.1097/00000539-200109000-00016. PMID: 11524327.

13. Kwok RF, Lim J, Chan MT, Gin T, Chiu WK. Preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery. Anesth Analg. 2004; 98:1044–9. DOI: 10.1213/01.ANE.0000105911.66089.59. PMID: 15041596.

14. Lee YS, Kim WY, Cha MH, Kim JH, Kim JH, Park YC, et al. Effects of preincisional ketamine on postoperative pain after laparoscopic assisted vaginal hysterectomy. Anesth Pain Med. 2006; 1:44–7.

15. Yang L, Zhang J, Zhang Z, Zhang C, Zhao D, Li J. Preemptive analgesia effects of ketamine in patients undergoing surgery. A meta-analysis. Acta Cir Bras. 2014; 29:819–25. DOI: 10.1590/S0102-86502014001900009. PMID: 25517496.

16. Boss AP, Maurer T, Seiler S, Aeschbach A, Hintermann B, Strebel S. Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results. J Shoulder Elbow Surg. 2004; 13:630–4. DOI: 10.1016/j.jse.2004.04.005. PMID: 15570231.

17. Cho CH, Song KS, Min BW, Jung GH, Lee YK, Shin HK. Efficacy of interscalene block combined with multimodal pain control for postoperative analgesia after rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2015; 23:542–7. DOI: 10.1007/s00167-012-2272-3. PMID: 23108685.

18. Laurila PA, Lopponen A, Kanga-Saarela T, Flinkkila T, Salomaki TE. Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery. Acta Anaesthesiol Scand. 2002; 46:1031–6. DOI: 10.1034/j.1399-6576.2002.460818.x. PMID: 12190808.

19. Rodola F, Vagnoni S, D’Avolio S, Vurchio M, Micci D, Chierichini A, et al. Intra-articular analgesia following arthroscopic surgery of the shoulder. Eur Rev Med Pharmacol Sci. 2001; 5:143–6. PMID: 12067083.

20. Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother. 2006; 60:341–8. DOI: 10.1016/j.biopha.2006.06.021. PMID: 16854557.

21. Voscopoulos C, Lema M. When does acute pain become chronic? Br J Anaesth. 2010; 105(Suppl 1):i69–85. DOI: 10.1093/bja/aeq323. PMID: 21148657.

22. Kohrs R, Durieux ME. Ketamine: teaching an old drug new tricks. Anesth Analg. 1998; 87:1186–93. DOI: 10.1213/00000539-199811000-00039. PMID: 9806706.

23. Nesek-Adam V, Grizelj-Stojcic E, Mrsic V, Rasic Z, Schwarz D. Preemptive use of diclofenac in combination with ketamine in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study. Surg Laparosc Endosc Percutan Tech. 2012; 22:232–8. DOI: 10.1097/SLE.0b013e31824f8ae4. PMID: 22678319.

24. Behdad A, Hosseinpour M, Khorasani P. Preemptive use of ketamine on post operative pain of appendectomy. Korean J Pain. 2011; 24:137–40. DOI: 10.3344/kjp.2011.24.3.137. PMID: 21935491. PMCID: PMC3172326.

25. Reza FM, Zahra F, Esmaeel F, Hossein A. Preemptive analgesic effect of ketamine in patients undergoing elective cesarean section. Clin J Pain. 2010; 26:223–6. DOI: 10.1097/AJP.0b013e3181bff86d. PMID: 20173436.

26. Woo JH, Kim YJ, Baik HJ, Han JI, Chung RK. Does intravenous ketamine enhance analgesia after arthroscopic shoulder surgery with ultrasound guided single-injection interscalene block? : a randomized, prospective, double-blind trial. J Korean Med Sci. 2014; 29:1001–6. DOI: 10.3346/jkms.2014.29.7.1001. PMID: 25045235. PMCID: PMC4101767.