On Effects of Ketamine to Axillary Block in Hand Surgery

Abstract

We have been using axillary block for upper extremity surgery anesthesia in the Istanbul Hand Surgery Microsurgery Center since 1992. Although articain is fast in effect, acting as a local anesthetic, it seems to be insufficient for controlling tourniquet pain. 1 We decided to combine ketamine and articain, to be able to begin operative procedures immediately and to control tourniquet pain.In search of a new anesthetic agent, a prospective study was designed to compare the effectiveness of the two drugs, articaine and ketamine, used in three different combinations. Three groups of patients, each consisting of 15 patients (25 to 45 years old), were formed randomly. Only ketamine (2 mg/kg + 38 ml 0.9 percent NaCl) was used in one group, with Ultracaine (articaine 2 percent Ϫ 40 ml) in the second group and, with Ultracaine + ketamine (articaine 2 percent Ϫ 40 ml + ketamine 2 mg/kg) in the third group. The time interval between the application of the tourniquet (300 mmHg) and the first sign of pain was recorded in all groups. The operation was started immediately in Groups 1 and 3 that were given ketamine. In Group 2, the operation was delayed for 10 min for the onset of anesthesia.We observed that ketamine alone was not sufficient to achieve adequate anesthesia duration (mean 0.1 hr). Ultracaine only patients had a mean 1.2 hr of anesthesia (onset of tourniquet pain), while patients who had Ultracaine and ketamine together had a mean anesthesia time of 4.2 hr.The sudden onset of anesthesia in Groups 1 and 3 who were given ketamine may be explained as a result of antogonism to NMDA receptors. 2,3 Intrathecal ketamine was shown to block axonal conduction by Gebhardt. 4 We believe that an axonal conduction block may contribute to the analgesic mechanism of regional ketamine. We concluded that articaine and ketamine in combination are more successful than articaine alone. We explain this by the following reasons. Ketamine might increase the binding capacity of local anesthetic to albumin alpha acid glucoprotein and change ionic balance. Another mechanism might be due to two isomers (S) and (R): S isomer blocks the opiate receptors and R isomer has hypnotic effects. 5

Does the Addition of Tramadol and Ketamine to Ropivacaine Prolong the Axillary Brachial Plexus Block?

“…Ketamine, a dissociative anesthetic N-methyl-D-aspartate (NMDA) antagonist, abolishes peripheral afferent noxious stimulation [9]. …”

Interscalene Brachial Plexus Block: Comparison of Efficacy of Varying Doses of Dexamethasone Combined With Levobupivacaine: A Double-Blind Randomised Trail.

“…Once again, there was no difference in the duration of motor block between Group L and Group H. (Table.2) Postoperative analgesic consumption (the number of acetaminophen tablets) was compiled for the first and second postoperative days. Analgesic consumption for the first postoperative 48 h was significantly lower in Group L (6.5, range [4][5][6][7][8] tabs) and in Group H (5.5, range [4][5][6][7] tabs) than in Group C (9.5, range [8][9][10][11][12] tabs) (p<0.01). Although there was a trend for lower analgesic consumption in Group H when compared to Group L, this difference did not reach statistical significance.…”

“…[2] Investigators have tried mixing local anesthetics with adjuvant drugs in an attempt to prolong analgesia from nerve blocks. Adjuvants including epinephrine, clonidine, [3,4] opioids, [5,6] ketamine [7,8] and midazolam [9] have met with limited success. However, the glucocorticoid dexamethasone appears to be effective in a small number of preclinical [10,11] and clinical [12] studies.…”

Perineural versus Intravenous Dexamethasone for Prolongation of Multiple Nerve Blocks for Pain Relief after Total Knee Arthroplasty

“…A significant limitation of this excellent method of anesthesia and analgesia "is its relatively short effect" [4] usually lasting less than 24 hours, even when a long-acting local anesthetic bupivacaine with adjuvant as adrenaline is applied [4]. The use of additional adjuvants were approbated in clinical practice with the aim of prolonging the duration of the single shot PNB, for example, clonidine [50], opioids [51], midazolam [52], ketamine [53] with little effect. DXM was evaluated and appear to be an effective agent for prolonging the duration of PNB in preclinical [23,24], and clinical investigations [13-19, 25, 26].…”