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REGIONAL ANESTHESIA AND PAIN MEDICINE

Small-Dose S(+)-Ketamine Reduces Postoperative Pain When Applied with Ropivacaine in Epidural Anesthesia for Total Knee Arthroplasty

Klinik für Anaesthesiologie, Technische Universität München, München, Germany

Address correspondence and reprint requests to Sabine Himmelseher, Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 München, Germany. Address e-mail to S.Himmelseher{at}lrz.tu-muenchen.de

Reduction of nociceptive input through blockade of N-methyl-D-aspartate (NMDA) receptors has been reported. We compared the effects of epidural S(+)-ketamine versus placebo on postoperative pain in a randomized, double-blinded study in 37 patients undergoing unilateral knee arthroplasty. After lumbar epidural anesthesia with ropivacaine (10 mg/mL, 10–20 mL), 19 patients received 0.9% epidural saline, and 18 patients received 0.25 mg/kg epidural S(+)-ketamine 10 min before surgical incision. After surgery, patient-controlled epidural analgesia with ropivacaine was provided. During the first 8 h after surgery, visual analog scale pain rating was similar between groups. Twenty-four and 48 h after surgery, patients anesthetized with ropivacaine had higher visual analog scale ratings at rest and during movement (P < 0.05) than patients anesthetized with S(+)-ketamine and ropivacaine. Forty-eight hours after surgery, patients anesthetized with ropivacaine also consumed more ropivacaine (558 ± 210 mg) (P < 0.01) than those anesthetized with S(+)-ketamine and ropivacaine (319 ± 204 mg). Adverse events were similar between groups. Patients who received S(+)-ketamine and ropivacaine rated the quality of their pain therapy better than those who received ropivacaine alone (P < 0.05). We conclude that the combination of S(+)-ketamine and ropivacaine in epidural anesthesia increases postoperative pain relief when compared with ropivacaine.

Implications: Epidural S(+)-ketamine applied with ropivacaine before surgery is a rational approach to decrease injury-induced pain sensitization. Epidural blockade with an N-methyl-D-aspartate receptor antagonist and a local anesthetic may provide better analgesia in the postoperative period than a local anesthetic alone.

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