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CARDIOVASCULAR ANESTHESIA

S(+)-Ketamine as an Analgesic Adjunct Reduces Opioid Consumption After Cardiac Surgery

Pasi Lahtinen, MD^*, Hannu Kokki, MD PhD^*,, Tapio Hakala, MD, and Markku Hynynen, MD PhD

Departments of *Anesthesiology and Intensive Care and Surgery, Kuopio University Hospital, Kuopio, Finland; Department of Pharmacology and Toxicology, Clinical Pharmacology, University of Kuopio, Kuopio, Finland; and Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

Address correspondence and reprint requests to Pasi Lahtinen, MD, Department of Anesthesiology and Intensive Care, Kuopio University Hospital, FIN-70210 Kuopio, Finland. Address e-mail to pasi.lahtinen{at}kuh.fi

There are no studies evaluating S(+)-ketamine for pain management after sternotomy. In this prospective, randomized, double-blind, placebo-controlled clinical trial, we evaluated the efficacy and feasibility of S(+)-ketamine as an adjunctive analgesic after cardiac surgery. Ninety patients scheduled for elective coronary artery bypass grafting (CABG) were randomized to receive either a 75 µg/kg bolus of S(+)-ketamine followed by a continuous infusion of 1.25 µg · kg^–1 · min^–1 for 48 h (n = 44) or placebo (normal saline bolus and infusion) (n = 46). From the time of tracheal extubation, patients could access an opioid (oxycodone) via a patient-controlled analgesia device, and the cumulative oxycodone doses were measured over 48 h. Pain was evaluated on a visual analog scale three times daily. The quality of recovery, patient satisfaction with pain management, and adverse effects were recorded. The cumulative oxycodone consumption during the first 48 postoperative hours was less in the S(+)-ketamine group (103 ± 44 mg) than in the placebo group (125 ± 45 mg; mean difference, 22 mg; 95% confidence interval for the difference, 3–40 mg; P = 0.023). Pain scores did not differ between the groups at rest (P = 0.17) or during a deep breath (P = 0.23). Patient satisfaction was superior in S(+)-ketamine-treated patients: 26 (60%) of 44 in the S(+)-ketamine group compared with 16 (35%) of 46 in the placebo group were very satisfied with the analgesic management (P = 0.032). Nausea and vomiting were the most common adverse events, with similar frequencies in both groups. Four patients in the S(+)-ketamine group developed transient hallucinations during the infusion, versus none in the placebo group. In conclusion, small-dose S(+)-ketamine decreased opioid consumption in CABG patients during the first 48 h after surgery.

IMPLICATIONS: This is the first placebo-controlled study to evaluate the efficacy and feasibility of S(+)-ketamine as a complementary analgesic to opioid after sternotomy in cardiac surgery patients. A small-dose S(+)-ketamine bolus followed by a continuous infusion for 48 h decreased cumulative opioid consumption and resulted in improved patient satisfaction with pain management. However, a few patients developed transient hallucinations.

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