Diz Protez Cerrahisinde Preinsizyonel ve Postinsizyonel Epidural, Bupivakain Verapamil ve Ketamin Postoperatif Analjezik Tüketimine Etkileri

Yıl 2011, Cilt: 64 Sayı: 1, 36 - 45, 01.01.2011

Evren Özgencil Feyhan Ökten Melek Tulunay Asuman Uysalel

https://doi.org/10.1501/Tipfak_0000000783

Öz

Anahtar Kelimeler

-

Diz Protez Cerrahisinde Preinsizyonel ve Postinsizyonel Epidural, Bupivakain Verapamil ve Ketamin Postoperatif Analjezik Tüketimine Etkileri

Öz

Hastalar ve Yöntem: Çalışmaya total diz artroplastisi planlanan 164 hasta dahil edilmiş, hastalar
rastgele 8 gruba ayrılmıştır. Grup 1(preB), preinsizyonal bupivakain, postinsizyonal serumfizyolojik
(SF); grup 2 (postB), preinsizyonal SF, postinsizyonal bupivakain; grup 3 (preBK), preinsizyonal
bupivakain+ketamin, postinsizyonal SF; grup 4 (postBK), preinsizyonal SF, postinsizyonal
bupivakain+ketamin; grup 5 (preBKV), preinsizyonal bupivakain+ketamin+verapamil, postinsizyonal
SF; grup 6 (postBKV), preinsizyonal SF, postinsizyonal bupivakain+ketamin+verapamil; grup 7
(preBV), preinsizyonal bupivakain+verapamil, postinsizyonal SF; grup 8 (postBV), preinsizyonal SF,
postinsizyonal bupivakain+verapamil olarak planlanmıştır. Epidural uygulanan ajanların dozları şu
şekildedir: bupivakain, %0.5’lik 50 mg; ketamin 60 mg; verapamil 5 mg ; serum fizyolojik 10 ml.
Hastaların epidural kateterleri yerleştirildikten sonra standart monitorizasyon ile genel anestezi verilmiş,
preinsizyonal uygulama için cerrahi insizyondan 15 dk. önce, postinsizyonal uygulama içinse
cerrahi insizyondan 30 dk. sonra epidural ilaçlar uygulanmıştır. Derlenme, ağrı düzeyi ve analjezik
gereksinimi, yan etkiler, hasta ve hekim memnuniyeti kaydedilmiştir. Bulgular: Bupivakaine kıyasla,
ketamin ve/veya verapamilli kombinasyonların analjezik etkinlikleri daha iyi bulunmuştur. Postoperatif
24 saat kombinasyon gruplarının analjezik tüketimleri benzer iken, ikinci 24 saatte verapamilli
kombinasyonlarınki daha düşüktür. Tüm preemptif gruplarda analjezik tüketimi postinsizyonel
olanlara göre daha düşük, global değerlendirmede ise hasta ve hekim memnuniyeti açısından en
iyi grup preBKV bulunmuştur.
Sonuç: Epidural bupivakaine ketamin ve verapamil eklenmesi ile daha etkin ve uzun analjezi sağ-
lanmakta, preemptif uygulama ile postinsizyonel uygulamaya göre postoperatif analjezik gereksinimi
azalmaktadır.

Anahtar Kelimeler

Postoperatif ağrı, diz protez cerrahisi, analjezik tüketimi, bupivakain, ketamin, verapamil, epidural

Kaynakça

• Tverskoy M, Oz Y, Isakson A, Finger J, Bradley EL, Kissin I. Preemptive effect of fentanyl and ketamine on postopera- tive pain and wound hyperalgesia. Anesth Analg 1994;78:205-9.
• Fu ES, Miguel R, Scharf JE. Preemp- tive ketamine decreases postoperative narcotic requirements in patients under- going abdominal surgery. Anesth Analg 1997;84:1086-90.
• Rabben T, Skjelbred P, Oye I. Prolonged analgesic effect of ketamine, an N-methyl- D-aspartate receptor inhibitor, in patients with chronic pain. The Journal of Phar- macology and Experimental Therapeutics 1999;289:1060-66.
• Choe H, Kim J-S, Ko S-H, Kim D-C, Han Y-J, Song H-S. Epidural verapamil reduces analgesic consumption after lower abdomi- nal surgery. Anesth Analg 1998;86:786-90.
• Omote K, Kawamato M, Satoh O, Iwasaki H, Namiki A. Spinal antinociceptive ac- tion of an N-type voltage-dependent cal- cium channel blocker and the synergijtic interaction with morphine. Anesthesiology 1996;84:636-43.
• Besson JM, Chouch A. Peripheral and spi- nal mechanisms of nociception. Phsiologi- cal Reviews 1987;67:67-186.
• Woolf CJ, Chong M. Preemptive analgesia- Treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993; 77: 362-79.
• Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain 1993; 52: 259- 285.
• Woolf CJ, Thompson SWN. The induc- tion and maintenance of central sensitiza- tion is dependent on N-methyl-D-aspartic acid receptor activation: implications for the treatment of postinjury pain hypersen- sitivity states. Pain 1991; 44: 293-299.
• Mathisen LC, Aasbo V, Reder J. Lack of preemptive analgesic effect of (R)-ketamine in laparoscopic cholecystectomy. Acta An- aesthesiol Scand 1999;43:220-24.
• Choe H, Choi Y-S, Kim Y-H, Ko S-H, Choi H-G, Han Y-J, Song H-S.Epidural morphine plus ketamine for upper ab- dominal surgery: Improved analgesia from preincisyonal versus postincisyonal admin- istration. Anesth Analg 1997;84:560-3.
• Chia Y-Y, Liu K, Liu Y-C, Chang H-C, Wong C-S. Adding ketamine in a mul- timodal patient-controlled apidural regimen reduces postoperative pain and analgesic consumption. Anesth Analg 20. Mason P. Central mechanisms of pain 1998;86:1245-9.
• Ilkjaer S, Nikolajsen L, Hansen TM, Wern- berg M, Brennum J, Dahl JB. Effect of i.v. ketamine in combination with epidural bu- pivacaine or epidural morphine on postop- erative pain and wound tenderness after re- nal surgery. Br J Anaesth 1998;81:707-712.
• Abdel-Gaffar ME, Abdulatif M, Al_Gham- di A, Mowati H, Anwar A. Epidural ket- amine reduces post-operative epidural PCA consumption of fentanyl/bupivacaine. Can J Anaesth 1998;45(2):103-9.
• Felsby S, Nielsen J, Arendt-Nielsen L, Jensen TS. NMDA receptor blockade in chronic neurophatic pain: a comparison of ketamine and magnesium chloride. Pain 1995;64:283-291.
• Omote K, Sonada H, Kawamata M, İwasaki H, Namiki A. Potentiation of anti- nociceptive effects of morphine by calcium- channel blockers at the level of the spinal cord. Anesthesiology 1993;79:746-752.
• Malmberg AB, Yaksh TL. Voltage sensitive calcium channels in spinal nociceptive pro- cessing. J Neurosci 1994;14:4882-90.
• Lynch C, Pancrazio JJ. Is there a role for calcium channels in anesthetic mecha- nisms? Anesthesiology 1994;81:1-5.
• Huganir RL, Jhan R. Signalling mecha- nisms. Current Opinion in Neurobiology 2000; 10: 289-292. modulation. Current Opinion in Neurobi- olgy 1999; 9: 436-441.
• Pockett S. Spinal cord synaptic plasticity and cronic pain. Anesth Analg 1995; 80: 173-9.
• Hawksworth C, Serpell M. İntrathecal an- esthesia with ketamine. Regional Anesthe- sia and Pain Medicine 1998;23:283-8.
• Eide PK, Stubhaug A, Oye I, Breivik H. Continuous subcutaneous administration of N-methyl-D-aspartic acid (NMDA) receptor antagonist ketamine in the treat- ment of postherpetic neuralgia. Pain 1995;61:221-8.
• Nikolajsen L, Hansen CL, Nielsen J, Keller J, Arend-Nielsen L, Jensen TS. The effect of ketamine on phantom pain: A central neu- rophatic disorder maintained by peripheral input. Pain 1996;67:69-77.
• Andersen OK, Felsby S, Nicolaisen L, Bjerring P, Jensen TS, Arendt-Nielsen L. The effect of ketamine on stimulation of primary and secondary hyperalgesic ar- eas induced by capsaicin- a double blind, placebo-controlled, human experimental study. Pain 1996;66:51-62.
• Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical ex- perience. Can J Anaesth 1989;36:186-97.
• Young ER, Mac Kenzie TA. The pharmacol- ogy of local anesthetics. A review of the litera- ture. J Can Dent Assoc 1992;58:34-42.
• Bowersox SS, Gadbois T, Singh T, Pettus M, Wang YX, Luther RR. Selective N-type neuronal voltage sensitive calcium channel blocker, SNX-111, produces spinal antino- ciception in rat models of acute, persistent and neurophatic pain. J Pharmacol Exp Ther 1996;279:1243-9.
• Hora K, Saito Y, Kirihara Y, Sakura S, Ko- saka Y. Antinociceptive effects of intrathe- cal L-type calcium channel blockers on vis- ceral and somatic stimuli in the rat. Anesth Analg 1998;87:382-7.
• Sluka KA. Blockade of calcium channels can prevent the onset of secondary hy- peralgesia and allodinia induced by intra- dermal injection of capsaicin in rats. Pain 1997;71:157-64.
• Richmond CE, Bromley LM, Woolf CJ. Preoperative morphine pre-empts postop- erative pain. The Lancet 1993; 342: 73-75.
• Kissin I. Preemptive analgesia, why its ef- fect is not always obvious? Anesthesiology 1996;84:1015-9.
• Kurt E, Toker T. Ağrının Taksonomi ve Fi- zyopatolojisi. Turkiye Klinikleri J Surg Med Sci 2007, 3(45):1-8.