Addition of low-dose ketamine to midazolam and low-dose bupivacaine improves hemodynamics and postoperative analgesia during spinal anesthesia for cesarean section

Abstract

Background and Aims:Spinal anesthesia for cesarean section (CS) is associated with an incidence of hypotension of 60-94%. This study hypothesizes that intrathecal combination of low-dose ketamine, midazolam, and low-dose bupivacaine improves hemodynamics and postoperative analgesia compared with fentanyl and low-dose bupivacaine during CS.Material and Methods:Fifty parturients undergoing elective CS were randomized equally to receive ketamine (10 mg), midazolam (2 mg) and 0.5% hyperbaric bupivacaine (8 mg) in group ketamine-midazolam-bupivacaine (KMB) or fentanyl (25 μg) and 0.5% hyperbaric bupivacaine (8 mg) in group fentanyl-bupivacaine (FB). Heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation, sensorimotor block characteristics, pain-free period, side-effects including: hypotension, bradycardia, nausea, vomiting, sedation, pruritus, respiratory depression and dissociative manifestations, Apgar score at 1 and 5 min, and patients' satisfaction visual analog scores (VAS) were recorded. Patients in group KMB were followed for 6 months in order to assess any neurological disorder.Results:Group KMB showed higher sensory level (P = 0.006), rapid sensory (P = 0.001) and motor (P = 0.005) onsets, prolonged sensory (P = 0.008) and motor (P = 0.002) blocks, and prolonged pain free period (P = 0.002). Ketamine-midazolam stabilized HR and MAP, and significantly reduced incidence of hypotension (P = 0.002), bradycardia (P = 0.013) and vomiting (P = 0.019). Apgar scores at 1 and 5 min were comparable in both groups (P = 0.699 and 0.646 respectively). Patients' satisfaction VAS scores were significantly higher in group KMB (P = 0.001). No patients in KMB group showed dissociative or neurotoxic manifestations.Conclusion:Intrathecal low-dose ketamine combined with midazolam and low-dose bupivacaine stabilizes hemodynamics and prolongs postoperative analgesia without significant side-effects in parturients undergoing CS.

Low dose ketamine reduces pain perception and blood pressure, but not muscle sympathetic nerve activity, responses during a cold pressor test

“…Finally, low dose ketamine has additional clinical uses that should be mentioned. Namely, low dose ketamine improves BP support and analgesia in peri-and post-operative settings (Mayer et al 1990;Atashkhoyi et al 2013;Singh et al 2013;Basuni, 2016), and reduces opioid requirements to maintain analgesia (Galinski et al 2007;Li & Chen, 2019). Separately, the National Institutes of Health and National Institute on Drug Abuse seek to reduce the burden of the opioid addiction crisis (Azari et al 2012;Volkow & Collins, 2017).…”

“…The results from this work will inform guidelines for the use of low dose ketamine in both pre-hospital and hospital-based setting. For example, low dose ketamine provides cardiovascular support during anaesthesia and improves peri-and post-operative analgesia (Mayer et al 1990;Atashkhoyi et al 2013;Singh et al 2013;Basuni, 2016). Also, out-patient use of low dose ketamine has recently increased because of its efficacy as a non-opioid based analgesic alternative to treat chronic pain conditions in light of the opioid addiction crisis (Galinski et al 2007;Azari et al 2012;Volkow & Collins, 2017;Karlow et al 2018;Li & Chen, 2019).…”

To compare the analgesic efficacy of two different doses of epidural ketamine in chronic low back-pain patients: A randomised double-blind study

“…used it intrathecally in patients with no such side effects. [ 13 14 15 ] Despite the concerns raised by the above study and FDA announcement regarding intrathecal use of ketamine, some authors still favour its use for lumbar epidural or intrathecal administration. [ 4 5 8 9 ]…”

“…[ 8 16 17 ] For neuropathic and chronic pain, 0.2–0.5 mg/kg or a single dose of 30 mg or 50 mg used through intravenous or spinal/epidural route was found useful in relieving pain. [ 4 5 8 9 10 11 12 13 14 15 ] Xie et al . reported more significant pain relief with a single low dose of epidural ketamine (0.5 mg/kg) as compared to its intravenous use (0.5 mg/kg).…”

Status Review of Assessment and Clinical Decision Making of Surgical Nurses for Vital Signs

“…37 Bu çalışmada, cerrahi hemşirelerinin klinik kararlarındaki ifadelerinden, literatürde belirtilen cerrahi sonrası süreçlerde sempatik sinir sistemini uyaran sebeplere bağlı olarak bradikardi olması durumuna göre benzerliğe raslanmamıştır. [38][39][40] S So or ru u 4 4: : Ne yaparsınız? Ameliyat ile birlikte solunum yapı ve fonksiyonlarında değişiklikler oluşmaktadır.…”