Comparison of the effects of clonidine and ketamine added to ropivacaine on stress hormone levels and the duration of caudal analgesia

BACKGROUND: The purpose of this study was to compare the analgesic quality and duration of ropivacaine 0.2% with the addition of clonidine (1 microg.kg(-1)) with that of ropivacaine 0.2% and the addition of ketamine (0.5 mg.kg(-1)) to that of ropivacaine 0.2% and also compare the postoperative cortisol, insulin and glucose concentrations, sampled after induction and 1 h later following caudal administration in children. METHODS: According to the randomization, patients in the ropivacaine group (R; n = 25) received ropivacaine 0.2%, 0.75 ml.kg(-1); those in the clonidine group (RC; n = 25) received ropivacaine 0.2% 0.75 ml.kg(-1) plus clonidine 1 microg.kg(-1) and those in the ketamine/ropivacaine group (RK; n = 25) ropivacaine 0.2% 0.75 ml.kg(-1) plus ketamine 0.5 mg.kg(-1) (10 mg.ml(-1) concentration). Drugs were diluted in 0.9% saline (0.75 ml.kg(-1)) and prepared by a staff anesthesiologist not otherwise involved in the study. In all groups, the duration of analgesia, analgesic requirements, sedation and insulin, glucose, cortisol concentrations were recorded and statistically compared. RESULTS: There were no significant differences among the three study groups with respect to age, weight or duration of surgery. Caudal administration of clonidine 1 microg.kg(-1) or ketamine 0.5 mg.kg(-1) induced a longer duration of analgesia (P < 0.05) compared with ropivacaine alone. Insulin levels were increased and cortisol reduced in all groups. Glucose concentration was increased in all groups and statistically significant (P < 0.05). CONCLUSIONS: Addition of ketamine and clonidine to ropivacaine 0.2% 0.75 ml.kg(-1), when administered caudally in children, prolongs the duration of postoperative analgesia. The need for subsequent postoperative analgesic is also reduced. Caudal analgesia attenuates or allows partial changes to postoperative cortisol, insulin or blood glucose responses to surgery.     

Comparison of caudal ketamine with lidocaine or tramadol administration for postoperative analgesia of hypospadias surgery in children

BACKGROUND: This study was designed to investigate whether the addition of tramadol or lidocaine to ketamine would enhance the quality of intra- and postoperative analgesia for hypospadias surgery in children. METHODS: Sixty-two ASA PS I or II children, between 1 and 10 years of age, scheduled for hypospadias surgery were recruited. Anesthesia was induced with 6-8% sevoflurane and maintained with 0.5-2.5% sevoflurane-50% N2O in oxygen. Children were allocated randomly to receive one of two study drugs. Children in group KL received caudal ketamine (0.25 mg.kg(-1)) plus lidocaine (2%, 2 mg.kg(-1)) and in group KT ketamine (0.25 mg.kg(-1)) plus tramadol (1 mg.kg(-1)). Systemic blood pressure, heart rate, peripheral O2 saturation, sedation, and pain scores (CHEOPS) were recorded at 1, 5, 10, 15, 30, 45 min and 1, 2, 3 h following recovery from anesthesia. RESULTS: Duration of analgesia was similar in the two groups (P > 0.05). CHEOPS in group KL was lower than in group KT during the study period, except at first 15 min. Sedation scores were higher in group KL than group KT in the first 10 min (P < 0.05). Incidence of postoperative nausea and vomiting was similar in the two groups (P > 0.05) Sevoflurane concentration required was significantly lower in group KL than group KT peroperatively (P < 0.001). CONCLUSIONS: Caudal ketamine (0.25 mg.kg(-1)), plus lidocaine (2% 2 mg.kg(-1)) significantly reduced sevoflurane concentration compared with ketamine (0.25 mg.kg(-1)) + tramadol (1 mg.kg(-1)). We suggested that both ketamine + lidocaine and ketamine + tramadol provided very effective and long duration of analgesia, similarly. However, analgesia quality is superior in the ketamine-lidocaine group postoperatively.     

Comparison of caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol administration for postoperative analgesia in children

BACKGROUND: The aim of this study was to compare the effect of single-dose caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol in children for postoperative pain management. METHODS: Following ethics committee approval and informed parental consent, 99 ASA PS I or II children, between 1 and 10 years of age, scheduled for elective inguinal hernia repair with general anaesthesia, were recruited. After induction of anaesthesia and placement of a laryngeal mask airway (LMATM), the patients were randomly divided into three groups to receive either caudal ropivacaine alone (0.4%, 2 mg x kg(-1)) in group R (n = 32) or ropivacaine (0.2%, 1 mg x kg(-1)) plus ketamine (0.25 mg x kg(-1)) in group RK (n = 33) or ropivacaine (0.2%, 1 mg x kg(-1)) plus tramadol (1 mg x kg(-1)) in group RT (n = 34) with a total volume of 0.5 ml x kg(-1). Systemic blood pressure (SBP and DBP), heart rate (HR), peripheral O2 saturation (SpO2), respiratory rate (RR), sedation and pain scores were recorded at 5, 10, 15 and 30 min, 1, 3, 4 and 6 h following recovery from anaesthesia. Pain was evaluated by Children's Hospital of Eastern Ontario Pain Scale, and sedation with a five-point sedation test. RESULTS: No difference was found regarding age, weight and duration of operation between the groups (P > 0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was longer in group RT (1377 +/- 204 min) than group R (1006 +/- 506 min) (P = 0.001). In the tramadol group, fewer patients required supplementary analgesics in the first 24 h (P = 0.005). Sedation scores were below 2 in all groups. Incidence of postoperative nausea and vomiting was higher in group RT (eight patients) and group RK (seven patients) than group R (one patient, P = 0.032). CONCLUSIONS: Ropivacaine (0.4%), ropivacaine (0.2%) plus ketamine (0.25 mg x kg(-1)) and ropivacaine (0.2%) plus tramadol (0.5 mg x kg(-1)) provided sufficient analgesia in children, but the duration of analgesia was longer in the RT group.     

Evaluation of adding preoperative or postoperative rectal paracetamol to caudal bupivacaine for postoperative analgesia in children

BACKGROUND: Our aim was to investigate whether effects of caudal analgesia could be extended by preoperative or postoperative rectal paracetamol administration in children undergoing surgical repair of hypospadias. METHODS: The group consisted of 60 ASA I boys, aged 3-12 years, who were operated for surgical repair of hypospadias. The patients were randomized into three groups: patients in group I received rectal paracetamol (20-25 mg x kg(-1)) just before the operation. Group II received only caudal bupivacaine. Group III patients received rectal paracetamol (20-25 mg x kg(-1)) at the end of the operation. Pain was assessed by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and the degree of sedation was evaluated. During the first 24 h, time to the patients' first analgesic requirement and the number of supplementary analgesics needed were recorded. RESULTS: There was no difference between the demographic and haemodynamic data of the three groups. In addition, the duration of surgery and anaesthesia, pain scores and sedation scores of the groups were not significantly different. CONCLUSIONS : Addition of preoperative or postoperative rectal paracetamol in the doses used did not show an effect on the duration and intensity of postoperative analgesia obtained by caudal bupivacaine.     

Remifentanil vs alfentanil in the total intravenous anaesthesia for paediatric abdominal surgery

BACKGROUNDS: Our aim was to investigate whether total intravenous anaesthesia (TIVA) with remifentanil and alfentanil would ensure appropriate analgesia and recovery conditions in anaesthesia for children undergoing abdominal surgery. METHODS: Sixty children, scheduled for abdominal operations were randomized to receive, in a double-blind manner, either remifentanil (loading dose 1 microg x kg(-1); maintenance infusion, 0.25 microg x kg(-1) min(-1)) or alfentanil (loading dose 50 microg x kg(-1); maintenance infusion, 1 microg x kg(-1) min(-1)) as the analgesic component of TIVA. They were combined with propofol (loading dose, 2 mg x kg(-1); step 1 maintenance infusion, 10 mg x kg(-1) h(-1); step 2 maintenance infusion, 8 mg x kg(-1) h(-1); step 3 maintenance infusion, 6 mg x kg(-1) h(-1)) neuromuscular blockade was with mivacurium. Dose changes of the drugs, the times from cessation of anaesthesia to extubation, verbal responses, recovery of ventilation, orientation, and qualification for discharge from the postanaesthetic care unit (PACU) were recorded. RESULTS: Demographics, duration of surgery and anaesthesia were similar between the two groups. Times to extubation and stay in the PACU were significantly shorter in the remifentanil group compared with the alfentanil group. Quality of emergence (QE) from anaesthesia scale scores were higher in the remifentanil group compared with the alfentanil group. CONCLUSIONS: Remifentanil provides a more rapid recovery and adequate postoperative analgesia after TIVA for paediatric abdominal surgery, compared with alfentanil.     

Efficacy of three doses of ketamine with bupivacaine for caudal analgesia in pediatric inguinal herniotomy

BACKGROUND AND OBJECTIVES: Ketamine administered systemically is a potent analgesic at subanesthetic plasma concentrations. Addition of ketamine to bupivacaine for caudal epidural block significantly prolongs the duration of postoperative analgesia. The purpose of this prospective, randomized double-blind study is to identify the optimal dose of ketamine that produces the maximum duration of caudal analgesia with minimal adverse effects as an adjuvant to bupivacaine for caudal epidural block. METHODS: Sixty children, aged 6 months to 10 years, undergoing inguinal herniotomy were allocated randomly to receive 1 of 3 solutions for caudal epidural block. Group 1 received 0.75 mL/kg of bupivacaine 0.25% with preservative-free ketamine 0.25 mg/kg, group 2 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 0.5 mg/kg, and group 3 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 1 mg/kg. Postoperative pain was assessed using the All India Institute of Medical Sciences pain discomfort scale. Rescue analgesia in the form of pethidine 1 mg/kg intramuscularly was administered when this score exceeded 4. RESULTS: The mean duration of caudal analgesia was 8.8 hours in group 1 compared with 22.1 hours in group 2 (P <.001) and 25.2 hours in group 3 (P <.001). Supplemental analgesia requirements with pethidine were significantly less in group 2 (4 subjects) and group 3 (no subject) when compared with group 1 (18 subjects). There were no differences between the groups in the incidence of motor blockade, urinary retention, emesis, or sedation. Group 3 had a significantly higher incidence of behavioral side effects such as odd behavior, agitation, or restlessness than groups 1 and 2. CONCLUSIONS: The optimal dose of ketamine in our study was 0.5 mg/kg added to 0.75 mL/kg bupivacaine 0.25% for caudal epidural block without an increase in side effects.     

Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine

BACKGROUND: The aim of the present pilot study was to compare the analgesic efficacy of S(+)-ketamine either alone or in combination with neostigmine for caudal blockade in pediatric surgery. METHODS: A total of 40 children were randomly assigned to receive after induction of general anesthesia either caudal S(+)-ketamine 1 mg.kg(-1) (group K, n = 20) or caudal S (+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1) (group KN, n = 20). Anesthesia was maintained with sevoflurane and a laryngeal mask airway (LMA), no additional analgesics were administered. Postoperative pain and sedation were assessed by the Children's Hospital of Eastern Ontario Pain Score and Ramsay scale for 24 h. RESULTS: No statistical difference in duration of analgesia and sedation was found. Mean duration of postoperative analgesia was 18 +/- 9.4 h in group K and 21.8 +/- 6.7 h in group KN. There was a significantly higher incidence of postoperative vomiting after administration of caudal ketamine with neostigmine (30% group KN Vs 0% group K; P < 0.05). CONCLUSIONS: This pilot study demonstrates equianalgesic effects on postoperative pain relief in children with both caudal S(+)-ketamine 1 mg.kg(-1) and caudal S(+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1). Further studies are required to confirm adoption of caudal neostigmine into routine clinical practice.     

Comparison of caudal vs intravenous tramadol administered either preoperatively or postoperatively for pain relief in boys

BACKGROUND: In this study we compared caudal with intravenous (i.v.) tramadol given pre- or postoperatively for pain relief in boys having hypospadias repair. METHODS: The study was approved by the Ethics Committee and informed written consent was obtained from the parents of each patient. Patients (n = 134), aged 1-3 years, American Society of Anesthesiologists (ASA) physical status I, scheduled for hypospadias surgery were recruited. The patients were randomly allocated to one of the four groups: group I (n = 33), received 2 mg.kg(-1) (0.5 ml.kg(-1)) of caudal tramadol after the surgical procedure was completed, group II (n = 33) received 2 mg.kg(-1) (0.5 ml.kg(-1)) of caudal tramadol before incision, group III (n = 34) received 2 mg.kg(-1) tramadol intravenously, after surgery and group IV (n = 34) received 2 mg.kg(-1) tramadol intravenously, after anaesthesia induction. When the patients were fully awake in the recovery area, heart rate, arterial pressure, peripheral oxygen saturation, respiratory rate, pain and sedation scores were recorded at 5, 10, 15, 30, 60 min, and 2, 3, 4, 6, 12 and 24 h postoperatively and side-effects were noted. Pain was assessed using an objective pain score (OPS). RESULTS: The OPS were lower in caudal tramadol groups than in i.v. tramadol groups only at 3 h (P < 0.05). The duration of postoperative analgesia was longer in the caudal groups than in the i.v. groups (P = 0.001). However, the duration of postoperative analgesia was unaffected by the timing of administration. CONCLUSIONS: Caudal tramadol provides better and longer lasting postoperative analgesia than i.v. tramadol. These results also suggest that preoperative caudal tramadol did not provide any clinically perceptible benefits compared with postoperative caudal tramadol.     

The use of midazolam and small-dose ketamine for sedation and analgesia during local anesthesia.

Small-dose ketamine in combination with sedative drugs has increasingly been used for sedation and analgesia in local anesthesia. We compared the clinical efficacy of midazolam with two different ketamine infusion regimens during plastic surgery under local anesthesia. Sixty patients undergoing plastic surgery procedures with local anesthesia were randomly assigned to two groups of 30 patients each in a double-blinded fashion. All patients received a bolus of 0.05 mg/kg midazolam, followed by a stepwise infusion: 1.67 microg x kg(-1) x min(-1) for the first 30 min, then reduced to 1.33 microg x kg(-1) x min(-1) for 90 min and subsequently to 1 microg x kg(-1) x min(-1). Two minutes before the infiltration of local anesthetic solution, a bolus of ketamine 0.3 mg/kg IV was administered, followed by a stepwise infusion of ketamine: Group A, 16.67 microg x kg(-1) x min(-1) for 30 min, 13.3 microg x kg(-1) x min(-1) for 90 min, and subsequently 10 microg x kg(-1) x min(-1); Group B, 8.33 microg x kg(-1) x min(-1) for 30 min, 6.67 microg x kg(-1) x min(-1) for 90 min, and then 5 microg x kg(-1) x min(-1). The level of sedation was evaluated by using the modified Observer's Assessment of Alertness/Sedation scale. We observed the effects of the two ketamine infusion regimens on sedation levels, respiratory and cardiovascular variables, and perioperative side effects. In both groups, midazolam and ketamine produced adequate sedation (with Observer's Assessment of Alertness/Sedation scores of 2-4) without significant respiratory and cardiovascular depression during surgery. However, there were fewer disruptive movements and there was less postoperative vomiting in Group B (P < 0.01). In conclusion, ketamine and midazolam provided satisfactory intraoperative sedation, analgesia, and amnesia in both groups. However, side effects associated with ketamine occurred less often in the smaller-dose ketamine group. IMPLICATIONS: Sedation and analgesia are often provided during local anesthesia. This study demonstrates that a small-dose ketamine infusion in combination with midazolam provided satisfactory intraoperative sedation, analgesia, and amnesia in healthy plastic-surgery patients when it was used to supplement local anesthesia.     

Comparison of caudal epidural bupivacaine with bupivacaine plus tramadol and bupivacaine plus ketamine for postoperative analgesia in children

This study compared the effect of single-dose caudal epidural bupivacaine, bupivacaine plus ketamine and bupivacaine plus tramadol for postoperative pain management in children having surgery for inguinal hernia. Following ethics committee approval and informed parental consent, 75 children ASA PS I and II, between three and nine years of age and scheduled for elective unilateral inguinal hernia repair with general anaesthesia were recruited. The patients were randomly divided into three groups to receive 0.5 ml/kg caudal bupivacaine 0.25% (group B), bupivacaine 0.25% plus tramadol 1 mg/kg (group BT) or bupivacaine 0.25% plus ketamine 0.5 mg/kg (group BK). The injections were performed under general anaesthesia. Mean arterial pressure, heart rate, pulse oximetry, respiratory rate and sedation and pain scores were recorded at defined intervals following recovery from anaesthesia. The groups were similar in age, weight and duration of operation (P >0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was (mean+/-SD) 6.5+/-4.1 h in group B, 9.2+/-3.9 h in group BK, and 8.5+/-3.1 h in group BT (P <0.05). More patients in group B required supplementary analgesics in the first 24 h (P <0.05). Sedation scores were comparable in all groups. Incidence of emesis and pruritus was similar in all the groups. Caudally administered 0.5 ml/kg bupivacaine 0.25% plus ketamine or bupivacaine 0.25% plus tramadol 1 mg/kg provided significantly longer duration of analgesia without an increase in the adverse effects when compared to bupivacaine alone.     

Intraoperative small-dose ketamine enhances analgesia after outpatient knee arthroscopy

Ketamine may prevent postoperative hyperalgesia. In patients undergoing arthroscopic meniscectomy using general anesthesia, we tested whether a single intraoperative dose of ketamine enhanced postoperative analgesia and improved functional outcome compared with a typical multimodal analgesic regimen. After the induction of anesthesia, 50 patients were randomly assigned to ketamine (0.15 mg/kg IV just after the induction of anesthesia) or a vehicle placebo. Standardized general anesthesia included propofol, alfentanil, and nitrous oxide. Bupivacaine (0.5%) and morphine (5 mg) were given intraarticularly at the end of surgery. Postoperative analgesia was initially provided with morphine and subsequently with naproxen sodium (550 mg orally twice daily) and Di-Antalvic (400 mg acetaminophen and 30 mg dextropropoxyphene) as needed. Pain scores, analgesic requirements, side effects, and ability to walk were assessed in the ambulatory unit and at home for three postoperative days. Times to awakening and to discharge were similar in the two groups. However, the Ketamine group had significantly less postoperative pain at rest and during mobilization on Days 0, 1, and 2. Furthermore, they consumed significantly fewer Di-Antalvic tablets than the control group (13 [7-17] vs 27 [16-32], median [25%-75% interquartile range]). Patients given ketamine were also able to walk for longer periods of time on the first postoperative day. In conclusion, adding small-dose ketamine to a multimodal analgesic regimen improved postoperative analgesia and functional outcome after outpatient knee arthroscopy.     

Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine

BACKGROUND: The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic. METHODS: Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg x kg(-1) (group K) or S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h. RESULTS: No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant. CONCLUSIONS: Caudal S(+)-ketamine 1 mg x kg(-1) and S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects.     

Comparing caudal and intravenous ketamine for supplementation of analgesia after Salter innominate osteotomy

Purpose

Previous studies claim that caudal administration of ketamine causes effective analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or intravascular administration in pediatric patients that underwent orthopedic surgery to distinguish between local and systemic analgesia.

Methods

After the induction of general anesthesia, 36 patients, aged 18 months to 10 years, assigned to undergo orthopedic surgery, received a caudal injection of bupivacaine and were randomly blinded into two groups: one group received 1 mg/kg S(+)-ketamine as the caudal group and the other group received 1 mg/kg S(+)-ketamine as the intravascular group. Postsurgical measurements included the effectiveness of postsurgical analgesia, which was assessed by using the observational pain scale (OPS), duration of analgesia, sedation score, and hemodynamic and respiratory monitoring.

Results

The mean time to first analgesia was clearly longer in the caudal ketamine group (13.35 h) than in the intravenous ketamine (9.93 h) group (P < 0.01). During the 24-h observation time, fewer children asked for additional analgesic drugs in the caudal group (8 of 18, 44.4 %) than in the intravenous group (12 of 18, 66.6 %; P = 0.01). The times to first micturation and spontaneous leg movements and the incidence of nausea and vomiting were similar in the two groups. The OPS and sedation scores after operation showed no obvious differences between the groups at any time.

Conclusion

Although caudal ketamine provides good postsurgical analgesia due to its potential neurotoxicity and only small clinical differences with intravenous ketamine, the administration of intravenous ketamine might be a reasonable option to potentially extend the postsurgical analgesic effect of the caudal administration of local anesthetics in children undergoing Salter osteotomy.     

Lack of a pre-emptive effect of low-dose ketamine on postoperative pain following oral surgery

PURPOSE: The aim of this study was to assess the effect of pre- vs postincisional low-dose iv ketamine on postoperative pain in outpatients scheduled for oral surgery under general anesthesia. METHODS: Eighty-four patients were randomly assigned to receive intravenously saline before and after surgery in Group 1, ketamine 300 microg x kg(-1) iv before and saline after surgery in Group 2, saline before and ketamine 300 microg x kg(-1) iv after surgery in Group 3. Postoperative analgesia consisted of iv proparacetamol and ketoprofen. Rescue analgesia consisted of nalbuphine 200 microg x kg(-1) iv. Analgesia at home consisted of oral ketoprofen, and acetaminophen with codeine as rescue analgesia. A telephone interview was conducted on the first and second postoperative days. RESULTS: There were no significant differences between groups with respect to pain scores, the number of patients requiring nalbuphine in the postanesthesia care unit (PACU), (36.7%, 38.7%, and 39.5% for Groups 1, 2, and 3 respectively), or nalbuphine consumption in the PACU (66.5 microg x kg(-1) +/- 16.8, 75.9 microg x kg(-1) +/- 17.5, 66.7 microg x kg(-1) +/- 21.6 for Groups 1, 2, and 3 respectively). The number of rescue analgesic tablets taken at home, and time to first request for rescue analgesia, sedation scores, or side-effects were similar amongst groups. No patient required nalbuphine in the ambulatory care unit. CONCLUSIONS: There was no benefit to pre-emptive administration of ketamine 300 microg x kg(-1) iv whether administered pre- or postoperatively.     

A comparison of two different doses of ketamine with midazolam and midazolam alone as oral preanaesthetic medication on recovery after sevoflurane anaesthesia in children

BACKGROUND: This investigation prospectively evaluated the effect of oral premedication of two different doses of ketamine with midazolam and midazolam alone on the recovery of children after sevoflurane anaesthesia. METHODS: In a randomized, double-blind study, 79 children (aged 1-8 years, ASA physical status I or II) were assigned to receive one of three premedications in a volume of 0.5 ml x kg(-1): group 1 received midazolam 0.5 mg x kg(-1) (MD); group 2 received midazolam 0.5 mg x kg(-1) with ketamine 1.8 mg x kg(-1) (MK-1); and group 3 received midazolam 0.5 mg x kg(-1) with ketamine 3 mg x kg(-1) (MK-2). The reactions of the children during administration were noted. Anaesthesia was induced by facemask with incremental sevoflurane administration. All children received alfentanil (15 micro g x kg(-1)). Tracheal intubation was facilitated by mivacurium (0.2 mg x kg(-1)). Anaesthesia was maintained with sevoflurane and an additional dose of alfentanil, if necessary. During recovery, the time interval between discontinuation of anaesthesia and arousal (spontaneous ventilation, extubation) were recorded. RESULTS: Emergence (spontaneous ventilation, extubation) and recovery times (discharge, Aldrete score=9) did not differ significantly between groups (P=0.24, P=0.59 and P=0.145, respectively). CONCLUSIONS: The combination of midazolam and ketamine as oral preanaesthetic medication did not significantly affect the recovery time of children after sevoflurane anaesthesia.     

Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty

We designed this study to evaluate the effect of small-dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty. Continuous femoral nerve block was started with 0.3 mL/kg of 0.75% ropivacaine before surgery and continued in the surgical ward for 48 h with 0.2% ropivacaine at a rate of 0.1 mL . kg(-1) . h(-1). Patients were randomly assigned to receive an initial bolus of 0.5 mg/kg ketamine followed by a continuous infusion of 3 mug . kg(-1) . min(-1) during surgery and 1.5 mug . kg(-1) . min(-1) for 48 h (ketamine group) or an equal volume of saline (control group). Additional postoperative analgesia was provided by patient-controlled IV morphine. Pain scores and morphine consumption were recorded over 48 h. The maximal degree of active knee flexion tolerated was recorded daily until hospital discharge. Follow-up was performed 6 wk and 3 mo after surgery. The ketamine group required significantly less morphine than the control group (45 +/- 20 mg versus 69 +/- 30 mg; P < 0.02). Patients in the ketamine group reached 90 degrees of active knee flexion more rapidly than those in the control group (at 7 [5-11] versus 12 [8-45] days, median [25%-75% interquartile range]; P < 0.03). Outcomes at 6 wk and 3 mo were similar in each group. These results confirm that ketamine is a useful analgesic adjuvant in perioperative multimodal analgesia with a positive impact on early knee mobilization. No patient in either group reported sedation, hallucinations, nightmares, or diplopia, and no differences were noted in the incidence of nausea and vomiting between the two groups.     

Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy

OBJECTIVES: We compared the quality and duration of analgesia, the effect on perioperative sevoflurane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efficacy of morphine administered caudally in children. METHODS: Patients were randomly divided into three groups to receive 2 mg.kg-1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mg.kg-1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mg.kg-1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia. RESULTS: There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevoflurane concentration was significantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications. CONCLUSION: Caudal tramadol (2 mg.kg-1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mg.kg-1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevoflurane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia.     

A comparison of midazolam, alfentanil and propofol for sedation in oupatient intraocular surgery

PURPOSE: To determine the ideal sedative regimen for intraocular surgery under peribulbar or retrobulbar block. The addition of alfentanil and or propofol to midazolam was evaluated with regard to hemodynamic variables, respiratory rate, pain, anxiety, sedation, postoperative recovery and patient satisfaction. METHODS: Eighty two patients aged between 50 and 85 were recruited into this prospective, randomised, double blind study. Patients, in four groups, received 0.015 mg x kg(-1) midazolam, 5 microg x kg(-1) alfentanil and 0.15 mg x kg(-1) propofol; 0.015 mg x kg(-1) midazolam and 0.15 mg x kg(-1) propofol; 0.015 mg x kg(-1) midazolam and 5 microg x kg(-1) alfentanil or 0.015 mg x kg(-1) midazolam alone. Blood pressure, heart rate, respiratory rate, pain, anxiety and sedation scores were measured. Times to discharge from the Post Anesthesia Care Unit (PACU) and Day Surgery Unit (DSU) were documented. A 24 hr telephone interview was carried out to determine patient satisfaction. RESULT: Systolic blood pressure of patients in groups that had received alfentanil was 6% lower than that of patients who had not (P<0.05) at the time of insertion of intraocular block. Patients in the alfentanil groups also had lower respiratory rates during the first 15 min after drug administration, but all patients were given supplemental oxygen therefore oxygen saturation was unaffected. Pain scores of patients who had been given alfentanil were lower during the first postoperative hour than those who had not. CONCLUSION: The addition of alfentanil to midazolam is advantageous in providing sedation for insertion of intraocular block.     

The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy

BACKGROUND: A few previous studies have suggested the efficacy of i.v. ketamine for postoperative pain relief in children after adenotonsillectomy, but none has investigated the efficacy of peritonsillar infiltration of ketamine in these children. METHODS: This randomized, placebo-controlled study evaluated the effects of peritonsillar infiltration of ketamine in children undergoing adenotonsillectomy. Ninety ASA I-II children were randomized three groups of 30 each. Group I received: 2 ml i.v. saline, group II received i.v. ketamine (0.5 mgxkg(-1)) and group III received a local peritonsillar infiltration of ketamine (0.5 mgxkg(-1)). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding. RESULTS: Group I had higher OPS scores than group II and group III. Group II and group III had comparable scores, which were not statistically significant (P > 0.05). Group II had higher sedation score at 15th min (P = 0.015). Thirty-two children, 19 of whom were in group I had rescue analgesia in postanesthesia care unit (P < 0.05) and the time to first analgesic requirement was significantly shorter in group I than the other groups (P = 0.006). Group II and group III also had less pain than group I at home (P = 0.023). CONCLUSIONS: Low dose ketamine given i.v. or by peritonsillar infiltration perioperatively provides efficient pain relief without side-effects in children undergoing adenotonsillectomy.     

Comparison of the effect of ketamine added to bupivacaine and ropivacaine, on stress hormone levels and the duration of caudal analgesia

BACKGROUND: The aim of this study was to compare bupivacaine 0.25% and ropivacaine 0.2%, singly and in combination with ketamine, for caudal administration in children. Duration of analgesia, the need for other analgesics and the stress response were measured. METHODS: Eighty children were randomized into four groups of twenty. The bupivacaine group received bupivacaine 0.25% and the ketamine/bupivacaine group received bupivacaine 0.25% plus 0.5 mg/kg ketamine. The ropivacaine group received ropivacaine 0.2%, and the ketamine/ropivacaine group received ropivacaine 0.2% plus 0.5 mg/kg ketamine. The duration of analgesia and analgesic requirements were recorded for each group, as were peri-operative and post-operative concentrations of the stress hormones insulin, glucose and cortisol. RESULTS: Ketamine, added to either bupivacaine or ropivacaine for caudal analgesia, gave a longer duration of analgesia (P < 0.05) than bupivacaine or ropivacaine alone. In all groups, blood insulin concentration was increased, and cortisol concentration reduced. Glucose concentration was significantly increased in all groups (P < 0.05). CONCLUSIONS: Ketamine can safely be added to ropivacaine 0.2% or bupivacaine 0.25% for caudal anesthesia in order to prolong duration of analgesia and reduce the need for additional analgesics. Stress hormone levels are partially attenuated.