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EFFECT OF INTRAOPERATIVE LOW DOSE KETAMINE INFUSION ON POSTOPERATIVE PAIN MANAGEMENT FOLLOWING MASTECTOMY
ABSTRACT
BACKGROUND: Postoperative pain control has remained a major challenge to most
practitioners and patients despite the availability of an array of pharmacologically active agents
and techniques. The Multimodal approach to postoperative pain management is the current
trend of achieving better postoperative analgesia with minimal or no side effects of analgesic
drugs. Considering the pharmacology of ketamine, the availability, accessibility, cost and
relatively minimal undesirable side effects when used as a low dose therapy, makes ketamine
a good option in the management of post operative pain in Nigeria.
OBJECTIVE: The aim of this study is to determine the effect of continuous intra-operative
infusion of low–dose ketamine (analgesic dose) on post-operative analgesia following
mastectomy.
PATIENTS AND METHODS: The study was a prospective, double blind, randomized
controlled study. After the approval of the Oyo State Research Ethical Review Committee
(OYSRERC), verbal and written consent were obtained from the patients. The patients were
randomized into either: (a) Fentanyl-ketamine (FK) group (the study group), which received
intravenous continuous infusion of 2 µg/kg/hr of fentanyl + 0.5 mg/kg/hr of ketamine. Or (b)
Fentanyl-Normal saline (FN) group (the control group), which received intravenous continuous
infusion of 2 µg/kg/hr of fentanyl and normal saline only. All patients had non-invasive arterial
blood pressure, oxygen saturation, ECG, end tidal carbon dioxide and temperature monitored
perioperatively.
The primary outcome was time to first request for analgesia after surgery. Secondary outcomes
were pain scores in the first six hours and at the twenty-fourth hour, postoperative analgesic
consumption and overall satisfaction with pain control. Pain score were assessed using the
numerical rating scale.
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RESULTS: The two groups were comparable with respect to socio-demographic
characteristics, duration of surgery and doses of fentanyl administered intraoperatively. The
time to first request for analgesia was longer and statistically significant in the ketamine group
245.61± 160.46 minutes versus 179.42 ± 161.46 minutes in the control group (p=0.0217). Both
groups had mean NRS less than 3 within the first six hours post surgery. The mean NRS pain
assessment in the first 6 hours at rest and at deep inspiration showed no statistical difference.
The worst pain in 24 hours and the average level of pain in 24 hours were not statistically
significant either. The postoperative analgesic (tramadol) consumption was lower for the
ketamine group at all measured points during the 24 hour postoperative period. The reduction
in tramadol consumption was also statistically significant at the 3rd, 4th and 5th hour
postoperatively in the ketamine group. Interference with mood and relationship with people by
pain was lower in the ketamine group (p value were 0.034 and 0.021 respectively). The level
of satisfaction with overall pain control was better in the ketamine group (p=0.030). There was
no observed statistically significant undesirable effect or complication in either group.
CONCLUSION: The administration of intraoperative low dose ketamine infusion with
fentanyl to patients during mastectomy enhances postoperative analgesia and overall
satisfaction with pain control. It reduces postoperative analgesic requirement in the immediate
postoperative period, causes less interference with mood, relationship with people. These were
observed with minimal side effect.
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