RESUMO
BACKGROUND: Low-dose ketamine infusion (LDKI) has shown effectiveness for treating acute pain associated with surgical and nonsurgical (traumatic, neuropathic, and acute cancer-related) origin as an adjuvant to opioids. The increasing use of LDKI as an opioid-sparing agent in multimodal analgesia requires a better understanding of its effects on the cardiovascular response, a known dose-dependent side effect of ketamine administration. We investigated the cardiovascular response of acute pain patients treated with LDKI. OBJECTIVES: The aim of the present study was to evaluate the effect of LDKI in hemodynamic variables (blood pressure [BP] and heart rate [HR]) during LDKI analgesia for up to 48 hours of treatment in an acute pain setting. Secondary objectives were to evaluate psychomimetic effects. STUDY DESIGN: Retrospective unicentric cohort design. SETTING: The study was conducted at an academic university hospital. METHODS: We conducted a single-center retrospective cohort analysis of adult patients who underwent LDKI to treat surgical and nonsurgical acute pain. We obtained data from the Hospital San Vicente Fundación Health Documentation System database and evaluated the medical records of 318 patients with surgical and nonsurgical pain. Patients received a 0.1 mg/kg/h ketamine infusion as part of a multimodal analgesic plan. Baseline systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and HR values were compared with those measured after 24 and 48 hours of treatment. Pain level and psychomimetic effects were measured at 24 and 48 hours. Cardiovascular complications and treatment duration were also recorded. Patients with a history of psychiatric, cardiovascular, or cognitive disease were excluded from the study. This study was registered in the clinicaltrials.gov database (identifier: NCT03979105). RESULTS: No statistical differences in SBP, DBP, MAP, or HR were observed when baseline and post-LDKI treatment values were compared (P < 0.05). When comparing hemodynamic variables after exposure to LDKI in patients with and without hypertension, we did not observe statistically significant differences in mean HR, systolic arterial pressure, diastolic arterial pressure, or MAP values at 24 and 48 hours. The frequency of severe pain was reduced from 72% on day 0 to 4.4% on day 1 and 6.2% on day 2 post-LDKI. Observed psychomimetic effects were confusion 4.39%, hallucinations 2.51%, and nightmares 1.25%. No major cardiovascular events were observed. LIMITATIONS: This study was limited by its retrospective design, the lack of a comparative matching cohort, and the good general condition of the majority of patients included in the study. CONCLUSIONS: LDKI (0.1 mg/kg/h) was not associated with significant changes in baseline BP or HR. Our results suggest that as an adjuvant in multimodal analgesia for surgical and nonsurgical acute pain, LDKI has a low impact on the cardiovascular response. KEY WORDS: Ketamine, adverse effects, tachycardia, hypertension, postoperative pain, chronic postsurgical pain.
Assuntos
Dor Aguda , Hipertensão , Ketamina , Adulto , Humanos , Estudos Retrospectivos , Dor Aguda/tratamento farmacológico , Analgésicos , Analgésicos Opioides/uso terapêutico , Hipertensão/induzido quimicamente , Hipertensão/tratamento farmacológico , Dor Pós-Operatória/tratamento farmacológicoRESUMO
Introducción. La tolerabilidad a la analgesia epidural puede comprometerse por efectos adversos derivados del opioide usado. Este estudio compara la tolerabilidad y eficacia de hidromorfona o morfina en combinación con bupivacaína, en analgesia epidural postoperatoria. Métodos. Ensayo prospectivo, aleatorizado y doble ciego en el Hospital Universitario San Vicente de Paul; 147 pacientes fueron aleatorizadosen dos grupos: 73 pacientes del grupo MB recibieron 30 mcg/ml de morfina más bupivacaína 0,1 %, y 74 pacientes del grupo HB recibieron hidromorfona 10 mcg/ml más bupivacaína 0,1 %. Resultados. El desenlace principal fue tolerabilidad, definida por la frecuencia de náusea, vómito, sedación, retención urinaria y prurito entre los grupos a las 24 horas. Se analizaron 142 pacientes: 71 en el grupo MB y 71 en el grupo HB. La frecuencia de náusea fue de 36,6 % y 31 %, (p = 0,54); vómito, 19,7 % y 25,4 % (p = 0,42); sedación 15,5 % y 14,1 % (p = 0,81); retención urinaria 11,3 % y 7 % (p = 0,38); y prurito 43,7 % y 31 % (p = 0,11) para los grupos MB y HB, respectivamente. Cinco pacientes fueron retirados del estudio debido a migración o desconexión del catéter. No se hallaron diferencias estadísticamente significativas entre los grupos. La escala verbal numérica (EVN) de dolor dinámico a las 24 horas fue de 3,42 (+/- 2,8) y 2,82 (+/- 2,5) para los grupos MB y HB, respectivamente (p = 0,16). Conclusión. La escogencia entre morfina 30 mcg/ml o hidromorfona 10 mcg/ml no influye en la tolerabilidad o eficacia de esta técnica.
Introduction. The acceptance (tolerability) of epidural analgesia can be compromised by the side effects of opioids. This study compares theside effects and efficacy of hydromorphone or morphine combined with bupivacaine in postoperativeepidural analgesia. Methods. Double-blind prospective randomizedcontrolled trial at Hospital Universitario San Vicente de Paul; 147 patients were randomized in two groups: 73 patients of the MB Group received 30 μg per ml of morphine with bupivacaine 0.1 % and 74 patients of the HB group received10 μg per ml of hydromorphone with bupivacaine 0.1 %. Results. The main outcome was the tolerability defined by the frequency of nausea and vomitingsedation urinary retention and pruritus between the groups at 24 hours. 142 patients were analyzed: 71 in group MB and 71 in group HB. The incidence of nausea was 36.6 % and 31 % (p = 0.54); vomiting 19.7 % and 25.4 % (p = 0.42); sedation 15.5 % and 14.1 % (p = 0.81); urinary retention 11.3 % and 7 % (p = 0.38); and pruritus 43.7 % and 31 % (p = 0.11) for groups MB and HB respectively. Five patients were excluded either because of catheter migration or disconnection. No statistically significant differences werefound between the groups. The verbal numerical scale (VNS) of dynamic pain at 24 hours was 3.42 (+/- 2.8) y 2.82 (+/- 2.5) for groups MB and HBrespectively (p = 0.16) Conclusions. The choice between 30 μg per ml of morphine or 10 mcg per ml of hydromorphone does not influence the incidence of side effects or the efficacy of this technique.
Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Pessoa de Meia-Idade , Analgesia , Analgésicos Opioides , Sistema Nervoso Central , Dor Pós-Operatória , Analgesia Epidural , Anestesia Epidural , Tolerância a Medicamentos , Sistema NervosoRESUMO
Objetivo: determinar la prevalencia de dolor agudo posoperatorio moderado o severo y la calidad de la recuperación en pacientes atendidos en un hospital universitario. Diseño: estudio prospectivo, observacional, de corte transversal, en el Hospital Universitario San Vicente de Paúl (HUSVP), Medellín, Colombia. Muestra: 112 pacientes hospitalizados, mayores de 18 años, en posoperatorio de cirugía ortopédica, torácica o abdominal. Métodos y resultados: se evaluaron el dolor posoperatorio dinámico y en reposo mediante la Escala Numérica Verbal (ENV) y la Calidad de la Recuperación por medio de una encuesta para determinar el bienestar y la funcionalidad física y mental de los pacientes. También se tuvieron en cuenta los efectos adversos asociados a la analgesia. La tasa de prevalencia del dolor moderado en reposo fue de 31,3% y la del dolor severo, 22,3%. Para el dolor dinámico moderado y severo, las tasas de prevalencia fueron de 27,6% y 48,2%, respectivamente. La calidad de la recuperación fue buena en el 80,4% de los pacientes. Se halló relación entre el dolor severo y la peor calidad de la recuperación. Los efectos adversos reportados fueron somnolencia (44,6%), náuseas (25%), epigastralgia (17%), retención urinaria (17%) y vómito (13,4%). Conclusiones: la tasa de prevalencia del dolor posoperatorio severo en el grupo de pacientes estudiado fue elevada y se asoció con resultados desfavorables en la calidad de la recuperación, lo cual motiva a poner en práctica estrategias que optimicen su control.
Objective: To determine the prevalence of acute moderate or severe postoperative pain and the quality of recovery at a university-affiliated hospital. Design: Prospective, observational, cross-sectional study at Hospital Universitario San Vicente de Paúl in Medellín, Colombia. Patients: 112 hospitalized patients, older than 18 years, in the postoperative period of orthopedic, thoracic or abdominal surgery. Methods and results: The static and dynamic postoperative pains were evaluated by means of a Verbal Numeric Rate Pain scale. The Quality of Recovery was measured with an instrument to determine the well-being and mental and physical functionality of the patients during the postoperative period. The adverse effects associated with analgesia were also taken into account. The prevalence rates of moderate and severe static postoperative pain were, respectively, 31.3% and 22.3%. For moderate and severe dynamic postoperative pain, the prevalence rates were 27.6% and 48.2%, respectively. The Quality of Recovery was good in 80.4% of the patients. An increase in the intensity of postoperative pain was correlated with a decrease in the quality of recovery. Adverse effects of analgesia were as follows: somnolence (44.6%), nausea (25%) epigastralgia (17%), urinary retention (17%) and vomit (13.4%). Conclusions: The prevalence rate of severe postoperative pain was high in this group of patients and it correlated with a decrease in the quality of recovery. Strategies to improve control of postoperative pain should be implemented in our milieu.
