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From the Department of Anesthesiology and Critical Care Medicine, Gifu University School of Medicine, 40 Tsukasa-machi, Gifu City, Gifu 500-8705, Japan.
Address correspondence to: Shuji Dohi MD. Phone: +81-58-267-2295; Fax: +81-58-267-2961; E-mail: shu-dohi{at}cc.gifu-u.ac.jp
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Abstract |
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Methods: Sixty patients were randomly assigned to one of three groups: saline group (n=20), saline 2 ml; ketamine group (n=20), 5 mg ketamine; or fentanyl group (n=20), 50 µg fentanyl. Each drug was administered intravenously (iv) five to ten minutes before the epidural procedures began. After epidural catheter placement had been accomplished, anxiety and pain were rated using a visual analog scale.
Results: The anxiety scores given for ketamine(20.2 ± 18.5, mean ± SD) and fentanyl (24.6 ± 20.3) were similar, and both were lower than that for saline (44.1 ± 32.7) (P=0.0034 and 0.0153 vs saline group, respectively). Pain scores were similar for all three groups. A decrease in hemoglobin oxygen saturation during the procedure was only observed in the fentanyl group, and two patients in fentanyl group had SpO2 <90%.
Conclusion: Ketamine, 5 mg iv, is as effective as 50 µg fentanyl, iv, in alleviating patient anxiety and in providing adequate sedation during the procedures necessary for epidural catheter placement, without inducing severe complications.
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Introduction |
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Methods |
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All patients were premedicated with 0.5 mg atropine im 30 min before the epidural procedures. The patients were assigned to one of three groups using random number tables: saline group, saline 2 ml iv; ketamine group, 5 mg ketamine dissolved in 2 ml of saline iv; fentanyl group, 50 µg fentanyl dissolved in 2 ml of saline iv (n=20 in each group). Blood pressure was measured intermittently and an electrocardiogram and hemoglobin oxygen saturation(SpO2) (by pulse oximetry; Model 88S, Hewlett-Packard, Andover, MA) were measured continuously. After baseline vital signs were taken, each patient received one of the three injections in the supine position (five to ten minutes before the epidural procedures). Then, with the patient in the lateral position, 1.5 ml lidocaine 1% was injected in the region in which epidural catheterization was to take place. A 17 guage Tuohy needle (Hakko, Tokyo, Japan) was inserted at thoracic (T 6–12) or lumbar (L 1–5) level by the loss-of-resistance technique, and a polyethylene catheter was inserted. An observer continuously recorded SpO2 and systolic blood pressure during the procedures. After the epidural procedures, the patient was placed in the supine position with their glasses on if required, and one anesthesiologist (blinded to the patient group) evaluated patient anxiety and pain during the epidural procedures, and noted any complications. Each patient rated his or her anxiety and pain scores on a visual analog scale (VAS; sliding cursor 100 mm scale) (anxiety scores: 0=not anxious, 100=extremely anxious; pain scores: 0=no pain, 100=worst pain imaginable). We had informed about VAS to each patient on the day before operation and just before VAS evaluation. We used a VAS to measure patient anxiety since it has been widely used as observational measure of anxiety.3 Exclusion criteria included time for epidural catheter placement >5 min and need for the Tuohy needle to be inserted more than five times.
All values are expressed as mean ± SD. The patients' demographic and clinical data were analyzed using an analysis of variance followed by Bonferroni/Dunn, with P < 0.05 being considered significant.
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Results |
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). Eight patients were excluded on the basis of the above criteria.
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). Anxiety scores were lower in ketamine (20.2 ± 18.5) or fentanyl groups (24.6 ± 20.3 ) than in saline group (44.1 ± 32.7) (Figure 1B). There was no difference between the ketamine and fentanyl groups in anxiety scores. In the fentanyl group, SpO2 decreased compared with saline and ketamine groups during the catheterization procedures (Table II). Two patient in the fentanyl group needed oxygen because of a decreased SpO2 <90%. One patient in the fentanyl group complained of nausea and one patient in the ketamine group complained of vertigo, but they improved without treatment.
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Discussion |
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During the performance of painful or uncomfortable procedures, it is important to provide analgesia and anxiolysis without inducing cardiorespiratory problems. Intravenous or intramuscular administration of 1.5 mg·kg–1 ketamine alone4 or of 0.4–1.6 mg·kg–1 ketamine combined with other agents5,6 has been used to provide balanced sedation while avoiding respiratory depression or significant changes in blood pressure. However, such subanesthetic doses of ketamine have been reported to cause upper airway obstruction, and also disorientation when combined with agents such as opioids, benzodiazepine, etc.4,5,6 Kortilla et al.7 found that patients who received 0.5 mg·kg–1 ketamine iv combined with 0.15 mg·kg–1 diazepam iv before nerve-conduction anesthesia experienced no more side effects and had no more need for postoperative care than unpremedicated controls, while patient-acceptance was higher in the ketamine group. However, the patients given those doses of ketamine and diazepam showed an increase in systolic blood pressure, and 50% of those patients did not stay awake during the operation.
In a previous study, Lauretti et al.8 felt that there were advantages in 0.2 mg·kg–1 ketamine iv with intrathecal bupivacaine and neostigmine, because while this combination produced prolonged postoperative analgesia similar to that produced by 1 µg·kg–1 fentanyl iv with intrathecal bupivacaine and neostigmine, the low-dose of ketamine resulted in less nausea and vomiting than the low-dose of fentanyl. Furthermore although low-dose fentanyl can provide adequate sedation similar to that produced by ketamine during nerve block, 100 µg fentanyl iv tends to cause complications as respiratory depression, nausea, and vomiting.9 In addition, although ketamine is known to induce nausea, vomiting, cardiovascular effects, and emergence phenomena characterized by vivid dreams,10 we did not find any such complications in any of the patients received 5 mg ketamine iv without benzodiazepine.
In conclusion, the present results suggest that 5 mg ketamine iv is as effective as 50 µg fentanyl iv in alleviating patient anxiety during epidural catheter placement, without inducing severe complications.
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Footnotes |
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Accepted for publication May 25, 2000.
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2 Beekhuis GJ, Kahn DL. Anesthesia for facial cosmetic surgery. Low dosage ketamine-diazepam anesthesia. Laryngoscope 1978; 88: 1709–12.[Medline]
3 Kain ZN, Wang SM, Caramico LA, Hofstadter M, Mayes LC. Parental desire for perioperative information and informed consent: a two-phase study. Anesth Analg 1997; 84: 299–306.[Abstract]
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Slogoff S, Allen GW, Wessels LV, Cheney DH. Clinical experience with subanesthetic ketamine. Anesth Analg 1974; 53: 354–8.
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Liang HS, Liang HG. Minimizing emergence phenomena: subdissociative dosage of ketamine in balanced surgical anesthesia. Anesth Analg 1975; 54: 312–6.
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Sadove MS, Shulman M, Hatano S, Fevold N. Analgesic effects of ketamine administered in subdissociative doses. Anesth Analg 1971; 50: 452–7.
7 Korttila K, Levanen J. Untoward effects of ketamine combined with diazepam for supplementing conduction anaesthesia in young and middle-aged adults. Acta Anaesthesiol Scand 1978; 22: 640–8.[Medline]
8 Lauretti GR, Azevedo VMS. Intravenous ketamine or fentanyl prolongs postoperative analgesia after intrathecal neostigmine. Anesth Analg 1996; 83: 766–70.[Abstract]
9 Shirasaka T, Shimizu Y, Takasaki M. Comparison of epidural versus intravenous administration of fentanyl during epidural block. (Japanese) Masui 1997; 46: 358–62.
10 White PF, Way WL, Trevor AJ. Ketamine-its pharmacology and therapeutic uses. Anesthesiology 1982; 56: 119–36.[Medline]
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P=0.0034 vs saline group.