Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Michelet, Pierre; Guervilly, Christophe; Hélaine, A.; Avaro, J.-P.; Blayac, D.; Gaillat, F.; Dantin, T.; Thomas, Philippe; Kerbaul, François

doi:10.1093/bja/aem168

Cited by 102 publications

(75 citation statements)

References 35 publications

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“…22 Of the 70 studies meeting inclusion criteria, 64 were suitable for inclusion in the quantitative analysis, and the remaining six were added to the qualitative analysis. These six studies reported data which were not useable in the quantitative analysis, such as median and range (two), mean only (one), mean and range (one), graphical data and SEM (one), and number of events of non-opioid rescue analgesia (one) were initially analyzed quantitatively, an additional 17 studies [70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86] were used to corroborate the results within the quantitative analysis, and the remaining six studies [87][88][89][90][91][92] were added to the qualitative analysis. All 70 studies had either low or unclear risks of bias in all six categories of the Cochrane Collaboration's tool for assessing risk of bias (see Table 1).…”

Section: Resultsmentioning

confidence: 99%

A systematic review of intravenous ketamine for postoperative analgesia

Laskowski

Stirling

McKay

et al. 2011

Can J Anesth/J Can Anesth

503

313

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Purpose Perioperative intravenous ketamine may be a useful addition in pain management regimens. Previous systematic reviews have included all methods of ketamine administration, and heterogeneity between studies has been substantial. This study addresses this issue by narrowing the inclusion criteria, using a random effects model, and performing subgroup analysis to determine the specific types of patients, surgery, and clinical indications which may benefit from perioperative ketamine administration. Source We included published studies from 1966 to 2010 which were randomized, double-blinded, and placebocontrolled using intravenous ketamine (bolus or infusion) to decrease postoperative pain. Studies using any form of regional anesthesia were excluded. No limitation was placed on the ketamine dose, patient age, or language of publication. Principal findings Ninety-one comparisons in seventy studies involving 4,701 patients met the inclusion criteria (2,652 in ketamine groups and 2,049 in placebo groups). Forty-seven of these studies were appropriate for evaluation in the core meta-analysis, and the remaining 23 studies were used to corroborate the results. A reduction in total opioid consumption and an increase in the time to first analgesic were observed across all studies (P \ 0.001). The greatest efficacy was found for thoracic, upper abdominal, and major orthopedic surgical subgroups. Despite using less opioid, 25 out of 32 treatment groups (78%) experienced less pain than the placebo groups at some point postoperatively when ketamine was efficacious. This finding implies an improved quality of pain control in addition to decreased opioid consumption. Hallucinations and nightmares were more common with ketamine but sedation was not. When ketamine was efficacious for pain, postoperative nausea and vomiting was less frequent in the ketamine group. The dose-dependent role of ketamine analgesia could not be determined. Conclusion Intravenous ketamine is an effective adjunct for postoperative analgesia. Particular benefit was observed in painful procedures, including upper abdominal, thoracic, and major orthopedic surgeries. The analgesic effect of ketamine was independent of the type of intraoperative opioid administered, timing of ketamine administration, and ketamine dose. RésuméObjectif La ke´tamine intraveineuse pe´riope´ratoire peut constituer un ajout utile a`l'arsenal the´rapeutique de prise en charge de la douleur. Les revues me´thodiques pre´ce´dentes ont examine´toutes les me´thodes d'administration de la ke´tamine, et l'he´te´roge´ne´ite´entre les e´tudes est conside´rable. Cette e´tude aborde la question en limitant les crite`res d'inclusion, en utilisant un mode`le a`effets ale´atoires et en re´alisant une analyse de sous-groupe afin de de´terminer les types spe´cifiques de patients et de chirurgie ainsi que les indications cliniques qui pourraient be´ne´ficier de l'administration pe´riope´ratoire de ke´tamine.

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Section: Resultsmentioning

confidence: 99%

A systematic review of intravenous ketamine for postoperative analgesia

Laskowski

Stirling

McKay

et al. 2011

Can J Anesth/J Can Anesth

503

313

View full text Add to dashboard Cite

show abstract

“…Supplementary 18,[20][21][22][25][26][27]29,30,32,34,36,40,41,44,45,50 cardiac or thoracic surgery (six trials), 19,23,35,37,38,53 orthopedic surgery (ten trials), 24,28,31,33,39,43,[47][48][49]51 and other surgery (three trials). 42,46,52 General anesthesia was used in 34 trials; one trial used PCA during and after a uterine artery embolization procedure, 29 and one used either general or regional anesthesia.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials

Wang

Johnston

Kaushal

et al. 2015

Can J Anesth/J Can Anesth

104

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Purpose To determine whether ketamine added to morphine or hydromorphone patient-controlled analgesia (PCA) provides clinically relevant reductions in postoperative pain, opioid requirements, and adverse events when compared with morphine or hydromorphone PCA in adults undergoing surgery.Source We systematically searched six databases up to June 2, 2015 for randomized controlled trials (RCTs) comparing ketamine plus morphine/hydromorphone PCA vs morphine/hydromorphone PCA for postoperative pain in adults. Principal findings Thirty-six RCTs including 2,502 patients proved eligible, and 22 of these were at low risk of bias. The addition of ketamine to morphine/

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“…A more recent study of 352 patients also showed a lack of benefit (Sveticic et al, 2008 Level II), but in another, the addition of ketamine to morphine PCA reduced pain scores and the incidence of nausea and vomiting, was opioid-sparing, and led to shorter duration of use of PCA compared with PCA morphine alone (Kollender et al, 2008 Level II). In patients after thoracotomy, although the addition of ketamine to PCA morphine did not improve pain relief it was opioid-sparing, and patients in the ketamine group spent less time with oxygen saturation levels <90% and had better forced expiratory volumes (Michelet et al, 2007 Level II).…”

Section: Ketaminementioning

confidence: 98%

“…In a study of postthoracotomy patients, the addition of ketamine to morphine for PCA was opioid-sparing but failed to improve analgesia; however patients in the ketamine group had better respiratory parameters (Michelet et al, 2007 Level II).…”

Section: Chaptermentioning

confidence: 99%

Safety of opioid patch initiation in Australian residential aged care

Gadzhanova

Roughead

Pont

2015

Medical Journal of Australia

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Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Design: A cross‐sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. Setting: Sixty residential aged care facilities in New South Wales. Participants: Residents receiving an initial opioid patch during the study period. Main outcome measure: The proportion of residents who were opioid‐naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. Results: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid‐naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up‐titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. Conclusions: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid‐naive in the 4 weeks before initiation.

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Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Abstract: Adding small doses of ketamine to morphine in PCA devices decreases the morphine consumption and may improve respiratory disorders after thoracic surgery.

Cited by 102 publications

References 35 publications

A systematic review of intravenous ketamine for postoperative analgesia

A systematic review of intravenous ketamine for postoperative analgesia

Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials

Safety of opioid patch initiation in Australian residential aged care

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