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.

A number of mechanisms have been proposed for the elevation in oxygen consumption following exercise. Biochemical processes that return muscle to its preexercise state do not account for all the oxygen consumed after exercise. It is possible that mechanical activity in resting muscle, which produces low frequency vibrations (i.e., muscle sounds: mechano-myographic [MMG] activity), could contribute to the excess postexercise oxygen consumption. Therefore the purpose of this study was to determine whether the resting MMG amplitude changes after exercise, and whether the change is related to the elevation in oxygen consumption (VO2). Ten young male subjects (22.9 yrs) performed 30 minutes of exercise on a cycle ergometer at an intensity corresponding to 70% peak VO2. Oxygen consumption was measured by indirect calorimetry, and MMG by an accelerometer placed over the mid-quadriceps before exercise and for 5.5 hours after exercise. MMG activity, expressed as mean absolute acceleration, was significantly elevated for the 5.5 hours of measurement after exercise (p < 0.05). MMG and VO2 decayed exponentially after exercise with time constants of 7.2 minutes and 7.4 minutes, respectively. We conclude that muscle is mechanically active following exercise and that this may contribute to an elevated VO2.

Background It remains unclear whether the opioidsparing effects of dexmedetomidine seen in patients undergoing general anesthesia are reproducible in patients undergoing spinal anesthesia. We hypothesized that the administration of intravenous dexmedetomidine for sedation during total knee arthroplasty under spinal anesthesia would decrease postoperative morphine consumption in the first 24 hr following surgery. Methods We conducted this prospective double-blind randomized-controlled trial in 40 patients (American Society of Anesthesiologists physical status I-III) undergoing total knee arthroplasty with a standardized spinal anesthetic. Patients were randomized to receive either a dexmedetomidine loading dose of 0.5 lgÁkg -1 over ten minutes, followed by an infusion of 0.5 lgÁkgÁhr -1 for the duration of the surgery, or a normal saline loading dose and an infusion of an equivalent volume. The primary outcome was the consumption of morphine delivered via patientcontrolled analgesia in the first 24 hr following surgery. Results The mean (SD) cumulative morphine at 24 hr in the dexmedetomidine group was 29.2 (11.2) mg compared with 61.2 (17.2) mg in the placebo group (mean difference, 32.0 mg; 95% confidence interval, 22.7 to 41.2; P \ 0.001). In the dexmedetomidine group, there was a delay in the time to first analgesic request (P = 0.003) and a reduction in the mean morphine use at six and 12 hr following surgery (both P \ 0.001).Conclusions Dexmedetomidine was associated with a significant decrease in morphine use in the first 24 hr following total knee arthroplasty. Our study shows that an intraoperative infusion of dexmedetomidine for sedation in patients receiving spinal anesthesia can produce postoperative analgesic effects. This offers another potential adjunct in the multimodal pain management of these patients. This trial was registered at ClinicalTrials.gov (identifier NCT02026141).

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