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Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery

Published online by Cambridge University Press:  01 April 2008

T. Murali Krishna ,
N. B. Panda ,
Y. K. Batra  and
S. Rajeev
T. Murali Krishna
Affiliation:
Postgraduate Institute of Medical Education and Research, Department of Anaesthesia and Intensive Care, Chandigarh, India
N. B. Panda*
Affiliation:
Postgraduate Institute of Medical Education and Research, Department of Anaesthesia and Intensive Care, Chandigarh, India
Y. K. Batra
Affiliation:
Postgraduate Institute of Medical Education and Research, Department of Anaesthesia and Intensive Care, Chandigarh, India
S. Rajeev
Affiliation:
Postgraduate Institute of Medical Education and Research, Department of Anaesthesia and Intensive Care, Chandigarh, India
*
Correspondence to: Nidhi Bidyut Panda, Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh 160012, India. E-mail: nidhibp@gmail.com; Tel: 91 172 2756500; Fax: 91 172 2744401
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Summary

Background

Intrathecal ketamine produces a short period of analgesia with stable haemodynamics. Midazolam with bupivacaine prolongs the duration of analgesia when administered intrathecally but does not prevent hypotension. The objective of this study was to assess the effect of a combination of intrathecal bupivacaine, ketamine and midazolam on the duration of analgesia and haemodynamic parameters.

Methods

A prospective, randomized, double-blind study was carried out in 60 ASA I and II patients undergoing lower limb surgery under spinal anaesthesia. Patients were divided into three groups of 20 each. Patients in all the three groups received 3 mL of hyperbaric bupivacaine (0.5%) intrathecally. In addition, patients in Groups II and III received intrathecal ketamine (0.1 mg kg−1) and the same dose of ketamine along with midazolam (0.02 mg kg−1), respectively. All patients were evaluated for block characteristics, duration of pain-free period, total rescue analgesic requirement in the 24-h postoperative period, total dose of mephenteramine to treat hypotension and any central or neurological complication.

Results

No patients in Group II required mephenteramine while 40% of patients in Group I and 10% in Group III required mephenteramine to maintain blood pressure after spinal anaesthesia. The mean ± standard deviation duration of pain-free period was 331.5 ± 89.9, 369.7 ± 124.2 and 730.5 ± 81.5 min in Group I, II and III, respectively. The pain-free interval was significantly greater in Group III compared to Groups I and II (P < 0.001). No patient had any complications.

Conclusion

A low dose of midazolam and ketamine with bupivacaine intrathecally results in prolonged analgesia and less haemodynamic fluctuations. However, the safety of this combination needs to be proved before its use in clinical practice.

Keywords

ANAESTHESIA SPINALANAESTHETICS LOCALBUPIVACAINEMIDAZOLAMKETAMINEPAIN ACUTE AND POSTOPERATIVE
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 4 , April 2008 , pp. 299 - 306
Copyright
Copyright © European Society of Anaesthesiology 2007

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References

1.David, LB. Spinal, epidural and caudal anesthesia. In: Miller, RD, ed. Millers Anesthesia, 6th edn, Vol. 63. New York: Elsevier Churchill Livingstone, 2004 1653–1684.Google Scholar
2.Moore, DC. Spinal anaesthesia: bupivacaine compared with tetracaine. Anesth Analg 1980; 59: 743–750.Google ScholarPubMed
3.Ben, DB, Solomon, E, Levin, H, Admoni, H, Goldik, Z. Intrathecal fentanyl with small-dose dilute bupivacaine. Better anesthesia without prolonging recovery. Anesth Analg 1997; 85: 560–565.Google Scholar
4.Eisenach, JC, De Kock, M, Walter, K. Alpha2 adrenergic agonists for regional anesthesia. A clinical review of clonidine (1984–95). Anesthesiology 1996; 85: 655–674.CrossRefGoogle Scholar
5.Liu, SS, Hodgson, PS, Moore, JM, Trautman, WJ, Daniel, LB. Dose-Response effects of spinal neostigmine added to bupivacaine spinal anesthesia in volunteers. Anesthesiology 1999; 90: 710–717.CrossRefGoogle ScholarPubMed
6.Irifune, M, Shimizu, T, Nomoto, M. Ketamine induced anesthesia involves the N-methyl-D-asparate receptor–channel complex in mice. Brain Res 1992; 596: 1–9.CrossRefGoogle Scholar
7.Bion, JF. Intrathecal ketamine for war surgery. A preliminary review. Anaesthesia 1984; 39: 1023–1028.CrossRefGoogle Scholar
8.Hawksworth, C, Serpell, M. Intrathecal anaesthesia with ketamine. Reg anaesth 1992; 69: 292–297.Google Scholar
9.Kathirvel, S, Sadasivam, S. Effect of intrathecal ketamine added to bupivacaine for spinal anaesthesia. Anaesthesia 2000; 55: 899–910.CrossRefGoogle ScholarPubMed
10.Togal, T, Demirbelik, S, Koroglu, A, Yapici, E, Ersoy, O. Effects of S (+) ketamine added to bupivacaine for spinal anaesthesia for prostate surgery in elderly patients. Eur J Anaesthesiol 2004; 21: 193–197.CrossRefGoogle ScholarPubMed
11.Bharti, N, Madan, R, Mohanty, PR, Kaul, HL. Intrathecal midazolam added to bupivacaine improves the duration and quality of spinal anaesthesia. Acta Anaesthesiol Scand 2003; 47: 1101–1105.CrossRefGoogle ScholarPubMed
12.Kim, MH, Lee, YM. Intrathecal midazolam increase the analgesic effects of spinal blockade with bupivacaine in patients undergoing hemorrhoidectomy. Br J Anaesth 2001; 86: 77–79.CrossRefGoogle Scholar
13.Nishiyama, T, Gyermek, L, Lee, C, Yatsugi, SK, Yamaguchi, T. Synergistic analgesic effects of intrathecal midazolam and NMDA or AMPA receptor antagonists in rats. Can J Anesth 2004; 48: 288–294.CrossRefGoogle Scholar
14.Bromage, PR. A comparison of the hydrochloride and carbon dioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand Suppl 1965; 16: 55–69.CrossRefGoogle ScholarPubMed
15.Ramsay, MA, Savege, TM, Simpson, BR, Goodwin, R. Controlled sedation with Alphaxalone-alphadalone. BMJ 1974; 2: 656–659.CrossRefGoogle Scholar
16.Nishiyama, T, Matsukawa, T, Hanaoka, K. Continuous epidural administration of midazolam and bupivacaine for postoperative analgesia. Acta Anaesthesiol Scand 1999; 43: 568–572.CrossRefGoogle ScholarPubMed
17.Martindale, SJ, Dix, P. Double blind randomized controlled trial of caudal S (+) ketamine for supplementation of caudal analgesia in children. Br J Anaesth 2004; 92: 344–347.CrossRefGoogle ScholarPubMed
18.Malinovsky, JM, Lepage, JY. Is ketamine or its preservative responsible for neurotoxicity in the rabbit? Anesthesiology 1993; 78: 109–115.CrossRefGoogle ScholarPubMed
19.Brock-Utne, JG, Mankowitz, E, Lallichurum, S. Effects of intrathecal saline and ketamine with and without preservative on the spinal nerve roots of monkeys. S Afr Med J 1982; 61: 360–361.Google ScholarPubMed
20.Vranken, JH, Troost, D, Wegener, JT et al. Neuropathological finding after continuous intrathecal administration of S (+) ketamine for the management of neuropathic cancer pain. Pain 2005; 117: 231–235.CrossRefGoogle ScholarPubMed
21.Vranken, JH, Troost, D, Haan, PD et al. Severe toxic damage to the rabbit spinal cord after intrathecal administration of preservative-free S (+) ketamine. Anesthesiology 2006; 105: 813–818.CrossRefGoogle Scholar
22.Borgbjerg, FM, Svenssson, BA. Histopathology after repeated intrathecal injections of preservative free ketamine in the rabbits: a light and electron microscopic examination. Anesth Analg 1994; 79: 105–111.CrossRefGoogle Scholar
23.Nishiyama, T, Hanaoka, K. Midazolam can potentate the analgesic effects of intrathecal bupivacaine on thermal or inflammatory induced pain. Anesth Analg 2003; 96: 1386–1391.CrossRefGoogle ScholarPubMed
24.Tucker, AP, Cindy, L, Raymond, N. Intrathecal midazolam I: a cohort study investigating safety. Anesth Analg 2004; 98: 1512–1520.CrossRefGoogle Scholar
25.Borg, PAJ, Krijnen, HJ. Long term intrathecal administration of midazolam and clonidine. Clin J Pain 1996; 12: 63–68.CrossRefGoogle ScholarPubMed
26.Nishiyama, T, Matsukawa, T, Hanoaka, K. Acute phase histopathological study of spinally administered midazolam in cats. Anesth Analg 1999; 89: 717–720.CrossRefGoogle ScholarPubMed
27.Johansen, M, Tamara, LG, William, CS, Wallace, BB, Keith, H, Lawrence, T. Safety of continuous intrathecal midazolam infusion in the sheep model. Anesth Analg 2004; 98: 1528–1535.CrossRefGoogle ScholarPubMed
28.Hodgson, PS, Neal, JM, Pollock, JE, Liu, SS. The neurotoxicity of drugs given intrathecally (spinal). Anesth Analg 1999; 88: 797–809.Google ScholarPubMed
29.Ugur, B, Basaloglu, K, Yurtseven, T, Ates, U et al. Neurotoxicity with single dose intrathecal midazolam administration. Eur J Anaesthesiol 2005; 22: 907–912.CrossRefGoogle ScholarPubMed
30.Demirel, E, Ugur, HC, Dolgun, H et al. The neurotoxic effects of intrathecal midazolam and neostigmine in rabbits. Anesth Intensive Care 2006; 34: 218–223.CrossRefGoogle ScholarPubMed