PERİOPERATİF DÜŞÜK-DOZ KETAMİN SPİNAL ANESTEZİ UYGULANAN GEBELERDE POSTOPERATİF SEZERYAN AĞRISINI, BULANTI VE KUSMA SIKLIĞINI AZALTIR MI?

Öz

Amaç: Postoperatif ağrı sezaryen operasyonlarını takiben karşımıza çıkan en büyük sorunlardan birisi olmaya devam etmektedir. Akut ağrı tedavisindeki gelişmelere rağmen kişisel farklılıklar nedeniyle hastaları yeterince memnun etmek her zaman mümkün olamamaktadır. Ketamin 1960 yıllardan beri güçlü bir anestetik ve etkin bir analjezik olarak kullanılmaktadır. Bu çalışmada amacımız, sezaryen operasyonu için, spinal anestezi yapılmış gebelerde, uygulanan düşük doz ketaminin, postoperatif ağrı, bulantı ve kusma üzerine etkilerini incelemektir.

Gereç ve Yöntem: Çalışmaya, 120 hasta retrospektif olarak dahil edildi. Hastaların ağrı durumlarını değerlendirmek için Vizüel Analog Skala değerlerini 1., 2., 3., 4., 12., 24. ve 48. saatlerde inceledik. Bununla birlikte, postoperatif dönemdeki bulantı & kusma, ilk analjezik talep sürelerini ve ketamine bağlı oluşabilecek yan etkileri de kayıt altına aldık.

Bulgular: Vizüel Analog Skala değerlerinde 2., 4., ve 12. saatlerde ketamin grubunda anlamlı azalmalar olduğunu tespit ettik. Bu anlamlılığın 30. dakikada 1., 24. ve 48. saatlerde olmadığını gözlemledik. Hastaların postoperatif ilk analjezik talep sürelerinde ve bulantı & kusma oranlarında ketamin grubunda kontrol grubuna göre anlamlı azalma olduğunu saptadık. Psikodisleptik bulgularda ise ketamin grubunda anlamlı olmayan bir artış gördük.

Sonuç: Bu sonuçlar ışığında, düşük doz ketaminin, sezaryen operasyonlarında, spinal anestezi yapılan gebelerde, mevcut ağrı tedavilerini desteklemek için, etkin bir ilaç olduğunu düşünüyoruz. Aynı zamanda ketaminin postoperatif bulantı ve kusma oranlarında azalma sağlamasının da, önemli bir konu olduğu kanaatindeyiz.

Anahtar kelimeler: Ketamin; VAS; analjezi.

Anahtar Kelimeler

• Ketamin,VAS,analjezi

PERIOPERATIVE LOW-DOSE KETAMINE DIMINISHES POST-OPERATIVE CAESAREAN PAIN, NAUSEA & VOMITING AFTER SPINAL ANAESTHESIA

Öz

Objective: Despite various developments in the treatment of post-operative caesarean pain, there are still difficulties in satisfying patients due to individual differences. Ketamine is used as a potent anaesthetic and an effective analgesic since 1960’s. The purpose of our study is to observe the effects of low-dose ketamine applied following spinal anaesthesia for postoperative analgesia and  nausea & vomiting in pregnant patients.

Materıal and Method: We examined the Visual Analogue Scales values of 120 patients at the 1^st, 2^nd, 4^th, 12^th, 24^th, and 48^th hours and evaluated nausea & vomiting. We also recorded the first additional analgesic demands and ketamine associated adverse events.

Results: We detected significant differences between the visual analogue scale values of ketamine and control group in the 2^nd, 4^th and 12^th hours. Significant differences were also seen in the first analgesic demand periods. We found a significant decrease in nausea and vomiting and insignificant elevation of psychodysleptic findings in ketamine group.

Conclusion: We believe that low-dose ketamine can be effectively used to sustain analgesia in pregnant patients who received spinal anaesthesia. We further believe that the effect of ketamine in decreasing nausea and vomiting, in exchange of low levels of neuropsychiatric symptoms, is a remarkable subject.

Keywords: Ketamine; VAS; analgesia.

Anahtar Kelimeler

• Ketamine,VAS,analgesia

Kaynakça

1. 1. Pan PH. Post cesarean delivery pain management: multimodal approach. Editorial. Int J Obstet Anesth 2006; 15:185–8.
2. 2. Turk D C, Okifuji A. Assessment of patients’ reporting of pain: An integrated perspective. Lancet 1999; 352:1784–8.
3. 3. Pan PH, Coghill R, Houle TT, Seid MH, Lindel WM, Parker RL, Washburn SA, Harris L, Eisenach JC. Multifactorial preoperative predictors for post caesarean section pain and analgesic requirement. Anesthesiology 2006; 104: 417–25.
4. 4. Dolin S T, Cashman J N, Bland J M. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002; 89: 409–23.
5. 5. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014; 30:149-160.
6. 6. Bell RF, Dahl JB, Moore RA, Kalso EA. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 2006;1:CD004603. doi: 10.1002/14651858.
7. 7. Bilgen S, Köner O, Türe M. Effect of three different doses of ketamine prior to general anaesthesia on postoperative pain following caesarean delivery: a prospective randomized study. Minerva Anestesiol 2012; 78:442-9. 8. Lavand’homme P. Chronic pain after vaginal and caesarean delivery: a reality questioning our daily practice of obstetric anaesthesia. Int J Obstet Anesth 2010; 19:1-2.
8. 9. Minoshima R, Kosugi S, Nishimura D, Ihara N, Seki H, Yamada T, Watanabe K, et all. Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: A randomized controlled trial. Acta Anaesthesiol Scand. 2015; 59(10):1260-8. doi: 10.1111/aas.12571.

9. 10. Sen S, Ozmert G, Aydin ON, Baran N, Caliskan E. The persisting analgesic effect of low-dose intravenous ketamine after spinal anaesthesia for caesarean section. Eur J Anaesthesiol. 2005; 22:518–23.
10. 11. Menkiti ID, Desalu I, Kushimo OT. Low-dose intravenous ketamine improves postoperative analgesia after caesarean delivery with spinal bupivacaine in African parturients. Int J Obstet Anesth 2012; 21:217–21.
11. 12. Mion G, Villevieille T. Ketamine Pharmacology: An Update (Pharmacodynamics and Molecular Aspects, Recent Findings). CNS Neurosci Ther 2013; 19:370–80.
12. 13. Kohrs R, Durieux ME. Ketamine: Teaching an old drug new tricks. Anesth Analg 1998; 87:1186–93.
13. 14. Han SY, Jin HC, Yang WD, Lee JH, Cho SH, Chae WS, Lee JS, Kim YI. The effect of low-dose ketamine on post-caesarean delivery analgesia after spinal anesthesia. Korean J Pain. 2013; 26: 270–6.
14. 15. Behaeen K, Soltanzadeh M, Nesioonpour S, Ebadi A, Olapour A, Aslani SMM. Analgesic effect of low dose subcutaneous ketamine administration before and after cesarean section. Iran Red Crescent Med J. 2014; 16(3):15506. doi: 10.5812/ircmj.15506.
15. 16. Dahl V, Ernoe PE, Steen T, Raeder JC, White PF. Does ketamine have preemptive effects in women undergoing abdominal hyster-ectomy procedures? Anesth Analg. 2000; 90: 1419–22.
16. 17. Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: A randomized controlled trial. Int J Obstet Anesth.2011; 20: 3–9.
17. 18. Aubrun F, Gaillat C, Rosenthal D, Dupuis M, Mottet P, Marchetti F, Coriat P, Riou B. Effect of a low-dose ketamine regimen on pain, mood, cognitive function and memory after major gynaecological surgery: a randomized, double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2008; 25: 97–105.
18. 19. Karaman S, Kocabaş S, Zincircioğlu C, Firat V. Has ketamine preemptive analgesic effect in patients undergoing abdominal hysterectomy? Agri. 2006 Jul; 18: 36-44.
19. 20. Heesen M, Böhmer J, Brinck EC, Kontinen VK, Klöhr S, Rossaint R, Straube S. Intravenous ketamine during spinal and general anaesthesia for caesarean section: systematic review and meta-analysis. Acta Anaesthesiol Scand 2015; 59: 414–26.
20. 21. Noppers I, Olofsen E, Niesters M, Aarts L, Mooren R, Dahan A, Kharasch E, Sarton E. Effect of Rifampicin on S-ketamine and S-norketamine Plasma Concentrations in Healthy Volunteers after Intravenous S-ketamine Administration. Anesthesiology 2011; 114: 1435-45.
21. 22. Malinovsky JM, Servin F, Cozian A, Lepage JY, Pinaud M. Ketamine and norketamine plasma concentrations after IV, nasal and rectal administration in children. Br J Anaesth 1996;77: 203–7.
22. 23. Pai A, Heining M. Ketamine. Contin Educ Anaesthesia, Crit Care Pain. 2007; 7: 59–63.
23. 24. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anesth. 2011; 58: 911–23.
24. 25. Kose EA, Honca M, Dal D, Akinci SB, Aypar U. Prophylactic ketamine to prevent shivering in parturients undergoing Cesarean delivery during spinal anesthesia. J Clin Anesth 2013; 25:275–80.
25. 26. Remérand F, Le Tendre C, Baud A, Couvret C, Pourrat X, Favard L, Laffon M, Fusciardi J. The early and delayed analgesic effects of ketamine after total hip arthroplasty: A prospective, randomized, controlled, double-blind study. Anesth Analg. 2009; 109: 1963–71.
26. 27. Kwok RFK, Lim J, Chan MT V, Gin T, Chiu WKY. Preoperative ketamine improves postoperative analgesia after gynaecologic laparoscopic surgery. Anesth Analg. 2004; 98: 1044–49.
27. 28. Shabana AM, Nasr ES, Moawad HE. Effect of ketamine on intraoperative nausea and vomiting during elective caesarean section under spinal anaesthesia: A placebo-controlled prospective randomized double blinded study. Egypt J Anaesth 2012;28:169–74.
28. 29. Chandrakantan A, Glass PSA. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth 2011;107(1): 27–40.