Perioperative ketamine for postoperative pain management in patients with preoperative opioid intake: A systematic review and meta-analysis

Meyer-Frießem, Christine H; Lipke, Erik; Weibel, Stephanie; Kranke, Peter; Reichl, Sylvia U; Pogatzki-Zahn, Esther; Zahn, Peter; Schnabel, Alexander

doi:10.1016/j.jclinane.2022.110652

Cited by 36 publications

(29 citation statements)

References 48 publications

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“…The addition of Ketamine significantly decreased the pain intensity and consumption of opioids. This reduction in the patients' postoperative pain score in the ketamine group might be on account of the analgesic properties of this drug, as well as strengthening the opioid effect, which is applied via cholinergic, and monoaminergic mechanisms (12). On the other hand, ketamine prevents intense drug tolerance and hyperalgesia, which decreases morphine consumption.…”

Section: Discussionmentioning

confidence: 95%

Does adding ketamine to morphine in a patient-controlled intravenous analgesia pump after orthopedic surgeries help better management of postoperative pain in obese patients? A double-blinded clinical trial

Moradi

Abedini

2022

J Renal Endocrinol

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Introduction: Low doses of ketamine can cause an antagonistic effect on NMDA-receptors by blocking the magnesium-gated channels. Several studies demonstrated the effect of ketamine in improving the analgesia using opioids, however, obese people reported different reactions to this problem. Objectives: This study seeks to answer the following question: Does adding ketamine to morphine in a patient-controlled intravenous analgesia pump (PCIA) after orthopedic surgeries help better management of postoperative pain in obese patients? Patient and Methods: This double-blinded clinical trial involved 60 obese (body mass of higher than 30 kg/m²) lower limb orthopedic surgery candidates at Shohada hospital (Tabriz, Iran). The participants were randomly categorized into three groups. In group M, 20 mg morphine sulfate, in group MK1 100 mg ketamine + 20 mg morphine sulfate, and in group MK2 200 mg ketamine+10 mg morphine sulfate was added to the analgesia pump. Pain intensity (VAS), sedation score (Ramsay Scale), as well as nausea and vomiting (N&V score) were compared among different groups at 12, 24, 36, and 48 hours after the operation. Results: Group M manifested a significantly higher pain intensity than two other groups during all examined times, and group MK2 demonstrated a significantly lower pain intensity than other groups. In the course of the research, the amount of opioid consumption in group MK2 was significantly lower than in the other groups. Conclusion: The addition of a low dose of ketamine to morphine in the PCIA pump after orthopedic surgeries in obese patients results in proper postoperative pain management. Trial Registration: The trial protocol was approved in the Iranian registry of clinical trial (identifier: IRCT2017101636822N1, https://www. irct.ir/trial/27429, ethical code; IR.TBZMED.REC.1400.820).

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Section: Discussionmentioning

confidence: 95%

Does adding ketamine to morphine in a patient-controlled intravenous analgesia pump after orthopedic surgeries help better management of postoperative pain in obese patients? A double-blinded clinical trial

Moradi

Abedini

2022

J Renal Endocrinol

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“…ketamine, which disrupts the NMDA-MOR interaction associated with OIH, as discussed in the next section, has been suggested as potentially useful in the perioperative period in these patients [ 59 , 60 ]. A recent meta-analysis of nine RCTs in adult opioid users, with at least two weeks preoperative opioid intake, undergoing surgery showed that perioperative ketamine reduced cumulative mean opioid consumption by 97.3 mg (95%CI: −164.8 to −29.7) after 24 h and 186.4 mg (95%CI: −347.6 to −25.2) after 48 h [ 61 ] ( Table 3 ).…”

Section: Resultsmentioning

confidence: 99%

“…Indeed, the interaction between MOR and the NMDA receptor has been documented before, at the PAG level, but presented as a mechanism to explain opioid tolerance [ 112 ]; however, since the effect of the opioid is to promote pain signaling through increased neuronal activity, via NMDA activation through the calmodulin-dependent protein kinase (CAMKII) pathway [ 102 , 112 ], the resulting hyperalgesia in this case is opioid-induced, and not due to lack of opioid receptor stimulation, constituting a phenomenon of OIH, by definition. Additionally, individuals that show clinical OIH may have been prone to enhanced manifestation of this interaction because of previous opioid exposure modifying the MOR-isoform profile itself [ 11 , 61 ]. Additionally, Zhang and collaborators contributed to the consideration of genetic variability as a determinant of the individual-specific sum of impact from the mentioned molecular signaling pathways, and therefore a determinant for opioid-response and observable clinical variability, as the team demonstrated OPRM1 gene polymorphisms influenced individual women’s response to fentanyl analgesia after lower segment caesarean section surgeries [ 113 ].…”

Section: Resultsmentioning

confidence: 99%

Knowing the Enemy Is Halfway towards Victory: A Scoping Review on Opioid-Induced Hyperalgesia

Sampaio-Cunha

Martins

2022

JCM

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Opioid-induced hyperalgesia (OIH) is a paradoxical effect of opioids that is not consensually recognized in clinical settings. We conducted a revision of clinical and preclinical studies and discuss them side by side to provide an updated and renewed view on OIH. We critically analyze data on the human manifestations of OIH in the context of chronic and post-operative pain. We also discuss how, in the context of cancer pain, though there are no direct evidence of OIH, several inherent conditions to the tumor and chemotherapy provide a substrate for the development of OIH. The review of the clinical data, namely in what concerns the strategies to counter OIH, emphasizes how much OIH rely mechanistically on the existence of µ-opioid receptor (MOR) signaling through opposite, inhibitory/antinociceptive and excitatory/pronociceptive, pathways. The rationale for the maladaptive excitatory signaling of opioids is provided by the emerging growing information on the functional role of alternative splicing and heteromerization of MOR. The crossroads between opioids and neuroinflammation also play a major role in OIH. The latest pre-clinical data in this field brings new insights to new and promising therapeutic targets to address OIH. In conclusion, although OIH remains insufficiently recognized in clinical practice, the appropriate diagnosis can turn it into a treatable pain disorder. Therefore, in times of scarce alternatives to opioids to treat pain, mainly unmanageable chronic pain, increased knowledge and recognition of OIH, likely represent the first steps towards safer and efficient use of opioids as analgesics.

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“…They do note that it may increase the psychotomimetic adverse event rate. Another meta-analysis looked at the effect of ketamine in the treatment of postoperative pain in patients who use opioids [ 31 ]. This meta-analysis looked at nine studies that included a total of 802 patients with at least two weeks of opioid use.…”

Section: Introductionmentioning

confidence: 99%

“…This meta-analysis looked at nine studies that included a total of 802 patients with at least two weeks of opioid use. The authors found a clinically relevant opioid-sparing effect without an increased risk of postoperative sedation [ 31 ]. This shows that ketamine can be useful in the setting of pain control but with close monitoring.…”

Section: Introductionmentioning

confidence: 99%

Ketamine Evolving Clinical Roles and Potential Effects with Cognitive, Motor and Driving Ability

Edinoff

Sall

Koontz

et al. 2023

Neurology International

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While driving under the influence of drugs, drivers are more likely to be involved in and cause more accidents than drivers who do not drive under the influence. Ketamine is derived from phencyclidine and acts as a noncompetitive antagonist and allosteric modulator of N-methyl-D-aspartate receptors. Ketamine has been used to treat a variety of psychiatric disorders, with the most notable being treatment-resistant depression. With the rise of at-home ketamine treatment companies, the safety of unsupervised administration remains under evaluation. A study with ketamine and a ketamine-like medication, rapasitnel, showed that those who were given ketamine experienced more sleepiness and had decreased self-reported motivation and confidence in their driving abilities. Moreover, there seem to be significant differences in the acute versus persistent effects of ketamine, as well as the anesthetic versus subanesthetic doses, both in terms of effects and outcomes. These divergent effects complicate the clinical uses of ketamine, specifically involving driving, drowsiness, and cognitive abilities. This review aims to describe not only the various clinical uses of ketamine but also the potentially detrimental effects of driving under the influence, which should be understood to help with counseling the patients who use these substances, both for their well-being and to protect public safety.

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Perioperative ketamine for postoperative pain management in patients with preoperative opioid intake: A systematic review and meta-analysis

Cited by 36 publications

References 48 publications

Does adding ketamine to morphine in a patient-controlled intravenous analgesia pump after orthopedic surgeries help better management of postoperative pain in obese patients? A double-blinded clinical trial

Does adding ketamine to morphine in a patient-controlled intravenous analgesia pump after orthopedic surgeries help better management of postoperative pain in obese patients? A double-blinded clinical trial

Knowing the Enemy Is Halfway towards Victory: A Scoping Review on Opioid-Induced Hyperalgesia

Ketamine Evolving Clinical Roles and Potential Effects with Cognitive, Motor and Driving Ability

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