Nesher Nachum, Ekstein Margaret P, Paz Yoseph, Marouani Nissim, Chazan Shoshana, Weinbroum Avi A
Department of Cardiothoracic Surgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Department of Anesthesia and Intensive Care Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Chest. 2009 Jul;136(1):245-252. doi: 10.1378/chest.08-0246. Epub 2008 Aug 27.
Thoracotomy is associated with severe pain. We hypothesized that the concomitant use of a subanesthetic dose of ketamine plus a two-third-standard morphine dose might provide more effective analgesia with fewer side effects than a standard morphine dose for early pain control.
We conducted a 6-month randomized, double-blind study in patients undergoing thoracotomy for minimally invasive direct coronary artery bypass or for lung tumor resection. After extubation, when objectively awake (>or= 5/10 visual analogue scale [VAS]) and complaining of pain (>or= 5/10 VAS), patients were connected to patient-controlled IV analgesia delivering 1.5 mg of morphine plus saline solution (MO) or 1.0 mg of morphine plus a 5-mg ketamine bolus (MK), with a 7-min lockout time. Rescue IM diclofenac, 75 mg, was available. Follow-up lasted 4 h.
Forty-one patients completed the study. MO patients (n = 20) used 6.8 +/- 1.9 mg/h (mean +/- SD) and 5.5 +/- 3.6 mg/h of morphine during the first and second hours, respectively; MK patients (n = 21) used 3.7 +/- 1.2 mg/h and 2.8 +/- 2.3 mg/h, respectively (p < 0.01). The 4-h activation rate of the device was double in the MO patients than in the MK patients (66 +/- 54 vs 28 +/- 20, p < 0.001). The maximal self-rated pain score was 5.6 +/- 1.0 for the MO group vs 3.7 +/- 0.7 for the MK group (p < 0.01). Four MO patients vs one MK patient required diclofenac; 6 MO patients but no MK patients had oxygen saturation by pulse oximetry < 94% on a fraction of inspired oxygen of 0.4 (p < 0.01); two MO patients required reintubation. Paco(2) was higher in the MO group (40 +/- 6 mm Hg vs 33 +/- 5 mm Hg, p < 0.05). Heart rate, BP, and incidence of nausea/vomiting were similar; no ketamine-related hallucinations were detected.
Subanesthetic ketamine combined with a 35%-lower morphine dose provided equivalent pain control compared to the standard morphine dose alone, with fewer adverse side effects and a 45% reduction in morphine consumption.
ClinicalTrials.gov Identifier: NCT00625911.
开胸手术会带来剧痛。我们假设，与标准吗啡剂量相比，同时使用亚麻醉剂量的氯胺酮加三分之二标准吗啡剂量可能在早期疼痛控制方面提供更有效的镇痛效果，且副作用更少。
我们对接受微创直接冠状动脉搭桥术或肺肿瘤切除术的开胸手术患者进行了一项为期6个月的随机双盲研究。拔管后，当患者客观清醒（视觉模拟评分[VAS]≥5/10）且主诉疼痛（VAS≥5/10）时，将患者连接到患者自控静脉镇痛装置，该装置输送1.5毫克吗啡加生理盐水（MO组）或1.0毫克吗啡加5毫克氯胺酮推注（MK组），锁定时间为7分钟。可使用75毫克双氯芬酸进行肌内注射急救。随访持续4小时。
41例患者完成了研究。MO组患者（n = 20）在第一小时和第二小时分别使用了6.8±1.9毫克/小时和5.5±3.6毫克/小时的吗啡；MK组患者（n = 21）分别使用了3.7±1.2毫克/小时和2.8±2.3毫克/小时（p < 0.01）。MO组患者装置的4小时激活率是MK组患者的两倍（66±54对28±20，p < 0.001）。MO组的最大自评疼痛评分为5.6±1.0，而MK组为3.7±0.7（p < 0.01）。4例MO组患者与1例MK组患者需要使用双氯芬酸；6例MO组患者但无MK组患者在吸入氧分数为0.4时经脉搏血氧饱和度测定氧饱和度<94%（p < 0.01）；2例MO组患者需要重新插管。MO组的动脉血二氧化碳分压更高（40±6毫米汞柱对33±5毫米汞柱，p < 0.05）。心率、血压和恶心/呕吐发生率相似；未检测到与氯胺酮相关的幻觉。
与单独使用标准吗啡剂量相比，亚麻醉剂量的氯胺酮联合降低35%的吗啡剂量可提供同等的疼痛控制，副作用更少，吗啡消耗量减少45%。
ClinicalTrials.gov标识符：NCT00625911。
