Tawfic Qutaiba A, Faris Ali S, Kausalya Rajini
Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
J Pain Symptom Manage. 2014 Feb;47(2):334-40. doi: 10.1016/j.jpainsymman.2013.03.012. Epub 2013 Jul 12.
Acute pain is one of the main causes of hospital admission in sickle cell disease, with variable intensity and unpredictable onset and duration.
We studied the role of a low-dose intravenous (IV) ketamine-midazolam combination in the management of severe painful sickle cell crisis.
A retrospective analysis was performed with data from nine adult patients who were admitted to the intensive care unit with severe painful sickle cell crises not responding to high doses of IV morphine and other adjuvant analgesics. A ketamine-midazolam regimen was added to the ongoing opioids as an initial bolus of ketamine 0.25mg/kg, followed by infusion of 0.2-0.25mg/kg/h. A midazolam bolus of 1mg followed by infusion of 0.5-1mg/h was added to reduce ketamine emergence reactions. Reduction in morphine daily requirements and improvement in pain scores were the determinants of ketamine-midazolam effect. The t-tests were used for statistical analysis.
Nine patients were assessed, with mean age of 27±11 years. Morphine requirement was significantly lower after adding the IV ketamine-midazolam regimen. The mean±SD IV morphine requirement (milligram/day) in the pre-ketamine day (D0) was 145.6±16.5, and it was 112±12.2 on Day 1 (D1) of ketamine treatment (P=0.007). The Numeric Rating Scale scores on D0 ranged from eight to ten (mean 9.1), but improved to range from five to seven (mean 5.7) on D1. There was a significant improvement in pain scores after adding ketamine-midazolam regimen (P=0.01).
Low-dose ketamine-midazolam IV infusion might be effective in reducing pain and opioid requirements in patients with sickle cell disease with severe painful crisis. Further controlled studies are required to prove this effect.
急性疼痛是镰状细胞病患者住院的主要原因之一，其强度各异，发作和持续时间不可预测。
我们研究了低剂量静脉注射氯胺酮-咪达唑仑联合用药在重度镰状细胞疼痛危象管理中的作用。
对9例成年患者的数据进行回顾性分析，这些患者因重度镰状细胞疼痛危象入住重症监护病房，对高剂量静脉注射吗啡和其他辅助镇痛药无反应。在持续使用阿片类药物的基础上，添加氯胺酮-咪达唑仑方案，初始静脉注射氯胺酮0.25mg/kg，随后以0.2 - 0.25mg/kg/h的速度输注。添加1mg咪达唑仑静脉推注，随后以0.5 - 1mg/h的速度输注，以减少氯胺酮的苏醒反应。吗啡每日需求量的减少和疼痛评分的改善是氯胺酮-咪达唑仑疗效的决定因素。采用t检验进行统计分析。
评估了9例患者，平均年龄为27±11岁。添加静脉注射氯胺酮-咪达唑仑方案后，吗啡需求量显著降低。氯胺酮治疗前一天（D0）静脉注射吗啡的平均需求量（毫克/天）为14,5.6±16.5，氯胺酮治疗第1天（D1）为112±12.2（P = 0.007）。D0时数字评分量表评分范围为8至10分（平均9.1分），但在D1时改善为5至7分（平均5.7分）。添加氯胺酮-咪达唑仑方案后疼痛评分有显著改善（P = 0.01）。
低剂量静脉输注氯胺酮-咪达唑仑可能有效减轻镰状细胞病重度疼痛危象患者的疼痛并减少阿片类药物的需求量。需要进一步的对照研究来证实这种效果。
