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Correspondence |
Chandigarh, India
To the Editor:
The incidence of pain on injection of rocuronium is high; reports suggest that 50 to 80% of patients suffer pain that can be distressing.1,2 We assessed the effectiveness of ketamine in minimizing pain on injection of rocuronium in adult patients.
After Institutional Ethics Committee approval and obtaining patients’ written informed consent, 150 adult patients ASA physical status I and II who were to undergo elective operations were included in the study. Patients with a history of allergy or convulsions, taking sedatives and analgesic medication, difficult venous access and those requiring rapid sequence induction were excluded. Patients were informed that they would be receiving drugs that may "sting" in their arm at the start of the anesthetic. They were instructed to score pain on a four-point scale: [none (0), mild (1), moderate (2) or severe (3)].2 All patients were interviewed by the investigators six to eight hours after the surgical procedure regarding any weakness or shortness of breath immediately before going to sleep and satisfaction with anesthesia.
On arrival in the operation room, a 20-gauge cannula was placed in the largest vein on the dorsum of the hand without the use of a local anesthetic. Patients were randomly allocated to receive 2 mL isotonic saline (control group), ketamine l0 mg in 2 mL saline (K-10 group), or ketamine 20 mg in 2 mL saline (K-20 group) at ambient temperature. Thirty seconds later, an intubating dose of rocuronium 0.6 mg•kg–1 at room temperature was injected and severity of the pain was assessed. Thirty seconds after the administration of rocuronium, propofol was administered intravenously until loss of consciousness and anesthesia proceeded as usual.
The incidence of pain in the control group (78%) was significantly higher than in the ketamine 10-mg and ketamine 20-mg groups (40% and 12% respectively); (P < 0.05 and P < 0.01 respectively). In addition, patients treated with ketamine 20 mg were less likely to suffer moderate or severe pain (P < 0.05; Table
). Five patients in the control group complained of slight muscle weakness before 30 sec and received propofol immediately. Two of these patients could recall the induction sequence. However, none of these patients expressed dissatisfaction. Our results indicate that ketamine pretreatment, preferably in a dose of 20 mg, significantly reduces the pain associated with the injection of rocuronium in adults.
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References
1 Cheong KF, Wong WH. Pain on injection of rocuronium: influence of two doses of lidocaine pretreatment. Br J Anaesth 2000; 84: 106–7.
2 Turan A, Memis D, Karamanlioglu B, Sut N, Pamukcu Z. The prevention of pain from injection of rocuronium by magnesium sulphate, lignocaine, sodium bicarbonate and alfentanil. Anaesth Intensive Care 2003; 31: 277–81.[Medline]
3 Tan CH, Onsiong MK, Kua SW. The effect of keta-mine pretreatment on propofol injection pain in 100 women. Anaesthesia 1998; 53: 302–5.[Medline]
4 Suzuki S, Masamune T, Nonaka A, Kumazawa T. Pretreatment with ketamine reduces incidence and severity of pain on propofol injection (Japanese). Masui 2002; 51: 140–3.[Medline]
5 Hirota K, Lambert DG. ketamine: its mechanism(s) of action and unusual clinical uses. Br J Anaesth 1996; 77: 441–4.
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