The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

doi:10.1016/j.arthro.2003.11.038

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 20, Issue 3, March 2004, Pages 300-305

https://doi.org/10.1016/j.arthro.2003.11.038 Get rights and content

Abstract

Purpose

The purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery.

Type of study

Prospective, randomized, double-blind, clinical study.

Methods

In this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient.

Results

VAS values were lower for the 3 medication groups compared with the placebo at rest and 90° knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P < .05). The total amount of pethidine and analgesia time were longer for the 3 medication groups.

Conclusions

Our basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects.

Level of evidence

Level I.

Section snippets

Methods

After obtaining informed written consent from eligible patients and getting an approval from the hospital review board, a double-blind, prospective, randomized and placebo-controlled study was undertaken to evaluate postoperative pain and analgesic profiles. Between August 1999 and February 2001, a group of 60 patients (35 men, 25 women) who underwent arthroscopic surgery at the Ankara City Hospital were included in this study. The age, height, and weight of the patients, surgery and tourniquet

Results

No significant differences were seen among the 4 groups in terms of age, height, weight, surgery, tourniquet times, and length of the anesthesia (Table 1). VAS scores of rest and 90° flexion for ketamine, bupivacaine, and neostigmine were lower than placebo for all time intervals Table 2, Table 3.

VAS scores for pain were significantly lower at postoperative 8, 12, 20, and 24 hours in ketamine group (I), at the postoperative 4, 8, 12, 16, 20, and 24 hours in the neostigmine group (II), at all

Discussion

Ketamine is a noncompetitive antagonist that blocks the ion channel, coupled to the phencyclidine site of the NMDA receptor. It inhibits the facilitated state of spinal processing caused by repetitive persistent small afferent (C-fiber) input, “wind-up,” and long-term potentiation of transmission.8 It also interacts with multiple binding sites, including NMDA and non-NMDA glutamate receptors, nicotinic receptors, and muscarinic cholinergic, and monoaminergic and opioid receptors.9 Other

Acknowledgements

Special thanks to Ülkü Aypar M.D., Professor in Anesthesiology and Chairman of the Hacettepe University Department of Anesthesiology and Reanimation, for her contributions.

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To evaluate the comparative efficacy and safety of single-dose intra-articular injection of commonly used analgesics after knee arthroscopy.
A systematic literature review was done to search for randomized controlled trials (RCTs) published from database inception to October 1, 2020, that compared analgesics (i.e., morphine, bupivacaine, ropivacaine, and magnesium alone or in combination) with placebo or each other after knee arthroscopy. The primary outcomes were postoperative pain intensity at 2 hours and 24 hours. Secondary outcomes included the time to first analgesic request, number of patients requiring supplementary analgesics and side effects. We estimated summary standardized mean differences (SMDs) or odds ratios with 95% credible intervals (95% CrIs) using Bayesian network meta-analysis with random effects.
In total, 78 randomized controlled trials comprising 4,425 participants were included. Compared with placebo, magnesium plus bupivacaine was most likely to be effective in relieving pain at both 2-hour (SMD = –3.81, 95% CrI –5.28 to –2.35) and 24-hour after surgery (SMD = –2.81, 95% CrI: –4.29 to -1.30). Following was morphine plus bupivacaine (2-hour: SMD = –2.19, 95% CrI –3.05 to –1.31; 24-hour: SMD = –1.44, 95% CrI –2.14 to –0.73) and bupivacaine alone (2-hour: SMD = –1.66, 95% CrI –2.33 to –0.98; 24-hour: SMD = –0.67, 95% CrI –1.22 to –0.07); ropivacaine alone and magnesium alone were not effective on pain relief. The interval time to first analgesic request was significantly extended compared with placebo except for ropivacaine alone and magnesium alone. The number of patients requiring supplementary analgesics was reduced in all groups except ropivacaine alone. No statistically significant difference was found between any studied analgesics or placebo with regard to side effects.
Of 6 common postoperative intra-articular analgesics, magnesium plus bupivacaine provides the most effective pain relief without increasing short-term side effects after knee arthroscopy.
Level II, meta-analysis of Level I and II studies.
Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
The significant difference in VAS scores cannot be explained by the direct analgesic effect of bupivacaine, but it may be influenced by superior initial pain management, a more effective pain management loading dose, psychological factors related to the initial level of pain experienced after surgery, or other unknown factors. Additionally, previous studies have shown the effectiveness of intra-articular bupivacaine ranges up to 24 hours postoperatively.29,30 After the first 18 hours pain management, narcotics consumption remains important.
To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy.
Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery.
Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P < .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption.
Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.
Level I, randomized controlled trial.
Comparative study of intra-articular dexmedetomidine versus ketamine as adjuvant analgesics after knee arthroscopy
2015, Egyptian Journal of Anaesthesia
Citation Excerpt :
Ketamine is proved to have local effects; it interacts with multitude of receptors including opioid, cholinergic, adrenergic, serotonergic and NMDAr, all of which have significant role in analgesia [18]. Dal et al used ketamine intra-articularly and reported a significant analgesic effect that was comparable to intra-articular neostigmine, without reported side effects [19]. The study investigating the analgesic effect of intra-articular ketamine and tramadol revealed that both ketamine and tramadol produce peripheral analgesic effect when injected intra-articularly in the knee following arthroscopic surgeries.
Knee arthroscopy is one of the day case procedures which may be diagnostic or therapeutic. Postoperative analgesia is important for early ambulation and short hospital stay. This prospective randomized study was designed to compare the analgesic effect of intra-articular dexmedetomidine versus ketamine as adjuvant to bupivacaine following knee arthroscopy.
75 patients ASA physical status I and II undergoing knee arthroscopy under general anesthesia were included in this study. Patients were divided into three groups according to intra-articular injected combination at the end of the arthroscopy. Group B/D received 25 ml 0.25% bupivacaine and dexmedetomidine 1 μg/kg, group B/K received 25 ml 0.25% bupivacaine and ketamine 1 mg/kg, and control group B received 25 ml 0.25% bupivacaine only. Postoperative pain using visual analogue score (VAS), the time to the first postoperative analgesic request, the total dose of postoperative analgesia during the first 24 h, and possible side effects were recorded.
Visual analogue score (VAS) was significantly less in B/D group in comparison with B/K group after the 1st hour and thereafter. Also VAS was higher in B group compared to the other two groups (P < 0.05). Time to first postoperative analgesic request was longer in the B/D group (479.2 ± 34.9 min) than in B/K group (356.7 ± 39.2 min), but in both groups it was longer than in B group (312.4 ± 18.8 min), (P < 0.05).
The total dose of postoperative analgesia (paracetamol consumption) during the first 24 h was significantly low in B/D group (758.0 ± 153.0 mg) compared to both B/K and B groups (1041.2 ± 178.6 mg and 1368.0 ± 227.2 mg) respectively (P < 0.05).
Intra-articular bupivacaine/dexmedetomidine provides better analgesia compared to bupivacaine/ketamine and both are superior to bupivacaine alone following knee arthroscopy.
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View full text

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

Abstract

Purpose

Type of study

Methods

Results

Conclusions

Level of evidence

Section snippets

Methods

Results

Discussion

Acknowledgements

Arthroscopy

Reg Anesth

Neurosci Lett

Reg Anesth

Eur J Pharmacol

Br J Anaesth

Intra-articular morphine administration provides pain relief after knee arthroscopy

Eur J Anest

Postoperative analgesia by intra-articular neostigmine in patients undergoing knee arthroscopy

Anesthesiology

Intra-articular ketamine for pain control following arthroscopic knee surgery

Acta Anesthesiol Sin

Adding ketamine in a multimodal patient controlled epidural regimen reduces postoperative pain and analgesic consumption

Anesth Analg

Excitatory amino acid receptor involvement in peripheral nociceptive transmission in rats

Eur J Pharmacol

Epidural morphine plus ketamine for upper abdominal surgeryImproved analgesia from preincisional versus postincisional administration

Anesth Analg

KetamineTeaching an old drug new tricks

Anesth Analg