Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies

Abstract

ObjectiveTo examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty.DesignSystematic review and meta-analysis.Data sourcesPubMed, EMBASE and Cochrane Library from inception to 22 May 2019.Eligibility criteria for selecting studiesRandomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty.Data extraction and synthesisData (ie, pain intensity, morphine consumption, gastrointestinal and psychotic adverse effects) were extracted by two reviewers independently. The Cochrane Collaboration’s recommended tool was used to determine the methodological quality of included studies.ResultsA total of 10 studies were included. One of them was rated as low quality. Compared with placebo, intravenous ketamine was effective for pain relief during 0–8-hour (weighted mean difference (WMD) −1.21, 95% CI −1.45 to −0.98, p<0.001; three studies, 149 participants) but not during 8–24-hour postoperative periods, and effective for reduction of cumulative morphine consumption during both 0–24-hour (WMD −17.76, 95% CI −31.25 to −4.27, p=0.01; five studies, 366 participants) and 0–48-hour (WMD −21.79, 95% CI −25.46 to −18.11, p<0.001; four studies, 252 participants) postoperative periods, without increasing risks of gastrointestinal or psychotic adverse effects. The limited data available for intra-articular (WMD −0.49, 95% CI −0.70 to −0.29, p<0.001; two studies, 83 participants) and epidural (WMD −2.10, 95% CI −3.30 to −0.90, p<0.001; one study, 20 participants) ketamine pointed to a significant reduction in pain intensity during 8–24-hour postoperative period.ConclusionsIntravenous administration of ketamine is effective and safe for postoperative pain relief in patients undergoing total knee or hip arthroplasty. Nevertheless, the analgesic efficacy and safety of ketamine in such patients seem to vary by different administration routes and still warrant further studies to explore.

Pain management after total knee arthroplasty

“…Three meta-analyses assessed analgesic effects of peri-operative ketamine after TKA 61 or after both TKA and THA 62,63 . Five RCTs assessed intravenous low doses of ketamine after TKA (other studies assessed intra-articular, epidural or only postoperative PCA, or assessed ketamine use in THA).…”

“…Three meta-analyses assessed analgesic effects of perioperative ketamine after TKA 61 or after both TKA and THA. 62,63 Five RCTs assessed intravenous low doses of ketamine after TKA (other studies assessed intra-articular, epidural or only postoperative PCA, or assessed ketamine use in THA). In three RCTs, ketamine was used as a bolus dose (0.5 mg kg À1 ) and a continuous infusion of 4 to 6 mg kg À1 min À1 until the end of surgery, whereas in two RCTs, a ketamine bolus (0.5 mg kg À1 ) was followed by a continuous infusion of 1.5 to 3.0 mg kg À1 min À1 over 48 h after surgery (Table S2, http://links.lww.com/EJA/A701).…”

No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty

“…Our current institutional perioperative analgesic regimen comprises a single injection adductor canal block, low-dose intrathecal morphine (100 μg), intraoperative IV dexamethasone (8 mg), periarticular local anesthetic infiltration, and round-the-clock oral acetaminophen and celecoxib, with immediate-release opioids as needed. We studied the addition of five recently described analgesic modalities to this regimen: a preoperative iPACK block, 13 an intraoperative IV infusion of low-dose dexmedetomidine 5,14–16 (1 μg/kg) and ketamine 17 (0.5 mg/kg), a second dose of IV dexamethasone 18 (8 mg) on postoperative day 1, and two additional adductor canal block 19 bolus injections on postoperative days 0 and 1.…”

The Effect of Ketamine on Acute and Chronic Wound Pain in Patients Undergoing Breast Surgery: A Meta‐Analysis and Systematic Review

“…15,[34][35][36] However, most reviews focused on the intravenous administration of ketamine. 14,15,35,37 As far as we know, this is the first meta-analysis that focused on the efficacy and feasibility of ketamine in breast surgery. In our study, we included 13 trials focusing on patients undergoing breast surgery, Figure 5.…”