Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942012000500006
Brazilian Journal of Anesthesiology
Scientific Article

Eficácia analgésica do uso da dextrocetamina intra-articular em pacientes submetidos a artroplastia total do joelho

Analgesic efficacy of the intra-articular administration of S(+)- ketamine in patients undergoing total knee arthroplasty

Hireno Guará Sobrinho; João Batista Santos Garcia; José Wanderley Vasconcelos; José Carlos Amaral Sousa; Letácio Santos Garcia Ferro

http://dx.doi.org/10.1590/S0034-70942012000500006 Braz J Anesthesiol, vol.62, n5, p.670-675, 2012
PDF Português
PDF English
Downloads: 0
Views: 881

Resumo

JUSTIFICATIVA E OBJETIVOS: A artroplastia total do joelho (ATJ) é associada a significativa dor pós-operatória. Muitos agentes de uso intra-articular (IA) têm sido empregados para analgesia pós-operatória com resultados inconsistentes. O enantiômetro cetamina S(+), a dextrocetamina, foi recentemente lançado comercialmente, com maior potência analgésica e menos efeitos indesejáveis do que a forma racêmica. Estudo prospectivo, experimental, aleatório e duplamente encoberto foi conduzido com o objetivo de avaliar a eficácia analgésica do uso da dextrocetamina por via intra-articular em pacientes submetidos à ATJ primária. MÉTODO: Foram avaliados 56 pacientes, alocados em três grupos: Grupo A (n = 19), que recebeu 0,25 mg.kg-1 de peso de dextrocetamina, diluído em 20 mL de solução fisiológica a 0,9%; Grupo B (n = 17), 0,5 mg.kg-1 de peso diluído da mesma forma; e Grupo C (n = 20), somente 20 mL de solução fisiológica a 0,9%, intra-articular, logo após o fim do procedimento e a colocação do dreno. Todos os pacientes tiveram acesso à terapia analgésica de resgate, sendo usada somente morfina endovenosa. Foram feitas avaliações 2, 6, 12 e 24 horas de pós-operatório, com mensuração da intensidade da dor pela Escala Analógica Visual (EAV), o uso da medicação de resgate pela avaliação do tempo decorrido entre a injeção intra-articular da solução e a primeira dose de resgate, o seu consumo total nas 24 horas e os efeitos adversos. RESULTADOS: Os grupos dextrocetamina obtiveram menores escores de dor quando comparados com a solução salina. A menor dose de dextrocetamina intra-articular (Grupo A: 0,25 mg.kg-1) usada resultou em melhores escores de dor e menos analgésico de resgate, com tempo de espera maior para sua solicitação. Os efeitos adversos foram infrequentes. Os resultados com menores escores de dor nos grupos que usaram a dextrocetamina são uma tend&eci+rc;ncia, pois não houve significância estatística entre os grupos. CONCLUSÃO: Neste estudo, com essa amostra, o efeito analgésico da dextrocetamina IA não foi superior à solução salina no período pós-operatório da ATJ.

Palavras-chave

ANALGESIA, Pós-operatório, intra-articular, ANALGÉSICO, Cetamina, CIRURGIA, Ortopédica, artroplastia de joelho, FARMACOLOGIA, Isomeria

Abstract

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) is associated with significant postoperative pain. Many intra-articular (IA) agents have been used for postoperative analgesia with inconsistent outcomes. Ketamine's enantiomer S(+), S(+)- ketamine, was recently introduced commercially, with higher analgesic potency and less side effects than the racemic form. An experimental prospective randomized double-blind study was conducted to evaluate the analgesic efficacy of intra-articular S(+)- ketamine in patients undergoing primary TKA. METHOD: In total, 56 patients were evaluated and allocated into three groups: Group A (n = 19) received 0.25 mg.kg-1 of S(+)- ketamine diluted in 20 mL of saline solution 0.9%; Group B (n = 17) received 0.5 mg.kg-1 of S(+)- ketamine diluted in the same way; and Group C (n = 20) received only 20 mL of intra-articular saline 0.9%, immediately after surgery and drain placement. All patients had access to rescue analgesic therapy, with the use of intravenous morphine alone. Evaluations were made 2, 6, 12, and 24 hours postoperatively, with measurement of pain intensity by Visual Analogue Scale (VAS), use of rescue medication by the evaluation of the time elapsed between the intra-articular injection of the solution and first dose of rescue, total consumption within 24 hours, and adverse effects. RESULTS: The S(+)- ketamine groups had lower pain scores compared with the saline group. The lowest dose of intra-articular S(+)- ketamine (Group A: 0.25 mg.kg-1) resulted in better pain scores and less rescue analgesia, with longer time to first request. Adverse effects were infrequent. The results with lower pain scores in groups using S(+)- ketamine are a trend, as there was no statistical significance between groups. CONCLUSION: In this study, with this sample, the analgesic effect of IA S(+)- ketamine was not superior to saline solution in the postoperative period of TKA.

Keywords

Analgesia, Injections, Intra-articular, Ketamine, Isomerism, Arthroplasty, Replacement, Knee

References

Palmer SH, Cros M. Total knee replacement. .

Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg. 2010;8:55-60.

Klasen J. Intra-articular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Aneaesthesiol Scand. 1999;43:1021-1026.

Tanaka N. The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthristis. J Arthroplasty. 2001;16:306-311.

Pitimana-Aree S. An economic evaluation of bupivacaina plus fentanyl versus ropivacaíne alone for patient-controlled epidural analgesia after total-knee replacement procedure: A double-blinded randomized study. Reg Anesth Pain Med. 2005;30:446-451.

Al-Metwalli RR, Mowafi HA, Ismail SA. Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery. Br J Anaesth. 2008;3:395-399.

Fu P, Wu Y, Wu H. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty: a randomized controlled trial. The Knee. 2009;16:280-284.

Menigaux C, Guignard B, Fletcher D. Intraoperative small-dose ketamine enhances analgesia after outpatient knee arthroscopy. Anesth Analg. 2001;93:606-612.

Dal D, Tetik O, Altunkaya H. The eficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery. Arthroscopy. 2004;20:300-305.

Batra YK, Mhajan R, Bangalia SK. Bupivacaine/ketamine is superior to intra-articular ketamine analgesia following arthroscopic knee surgery. Can J Anesth. 2005;52:832-836.

Borner M, Bürkle H, Trojan S. Intra-articular ketamine after arthroscopic knee surgery: Optimisation of postoperative analgesia. Anaesthesist. 2007;56:1120-1127.

Luft A, Mendes FF. S(+) Cetamina em baixas doses: atualização. Rev Bras Anestesiol. 2005;55:460-469.

Oliveira CMB, Sakata RK, Issy AM. Cetamina e analgesia preemptiva. Rev. Bras. Anestesiol. 2004;54:739-744.

Bondok RS, El-Hady AM. Intra-articular magnesium is effective for postoperative analgesia in arthroscopic knee surgery. Br J Anaesth. 2006;3:389-392.

Elia N, Tramer MR. Ketamine and postoperative pain: a quantitative systematic review of randomised trials. Pain. 2005;113:61-70.

Huskisson EC. Measurement of pain. Lancet. 1974;2:1127-1131.

Parker R, Streem K, Schmitz L. Efficacy of continuous intraarticular bupivacaine infusion for postoperative analgesia after anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35:531-536.

Joshi GP, McCarroll SM, Cooney CM. Intra-articular morphine for pain relief after knee arthroscopy. J Bone Joint Surg. 1992;74-B:749-751.

Reuben SS, Connelly NR. Postoperative Analgesia for Outpatient Arthroscopic Knee Surgery with intra-articular Clonidine. Anesth Analg. 1999;88:729-733.

Castro FE, Garcia JBS. Analgesia preemptiva com S(+) cetamina e bupivacaína peridural em histerectomia abdominal. Rev Bras Anestesiol. 2005;55:28-39.

Carvalho WA, Lemônica L. Mecanismos Centrais de Transmissão e de Modulação da Dor: Atualização Terapêutica. Rev Bras Anestesiol. 1998;48:221-241.

Garcia JBS. Cetamina: uma nova leitura. Prática Hospitalar. 2007;53:1-5.

Schmid RL, Sandler NA, Katz J. Use and efficacy of low-dose ketamine in the management o acute postoperative pain: a review of current techniques and outcomes. Pain. 1999;82:111-125.

Ayesh EE, Jensen TS, Svensson P. Effects of intra-articular ketamine on pain and somatosensory function in temporomandibular joint arthralgia patients. Pain. 2008;137:286-294.

Rosseland LA, Stubhaug A, Sandberg L. Intra-articular (IA) catheter administration of postoperative analgesics: A new trial design allows evaluation of baseline pain, demonstrates large variation in need of analgesics, and finds no analgesic effect of IA ketamine compared with IA saline. Pain. 2003;104:25-34.

Kress HG. The long-term antinociceptive effect of intratecal S(+) Ketamine in a patient with established morphine tolerance. Anaesth Analg. 2001;93:1018-1024.

Convery PN, Milligan KR, Quinn P. Efficacy and uptake of ropivacaine and bupivacaine after single intra-articular injection in the knee joint. Br J Anaesth. 2001;87:570-576.

Sveticic G, Farzanegan F, Zmoos P. Is the Combination of Morphine with Ketamine Better than Morphine Alone for Postoperative Intravenous Patient-Controlled Analgesia?. Int Anesth Res Soc. 2008;106:287-293.

Samoladas EP, Chalids B, Fotiadis H. The intra-articular use of ropivacaine for the control of post knee arthroscopy pain. J Orthop Surg Res. 2006;17:1-4.

Toftdahl K, Nikolajsen L, Haraldsted V. Comparison of peri- and intra-articular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop. 2007;78:172-179.

Vendittoli PA, Makinsen P, Drolet P. A multimodal analgesia protocol for total knee arthroplasty: A randomized, controlled study. J Bone Joint Surg (Am). 2006;88:282-289.

Reilly KA, Beard DJ, Barker KL. Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty: a randomized controlled trial. Knee. 2005;12:351-357.

Ritter MA, Koehler M, Keating EM. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg (Br). 1999;81:301-303.

Busch CA, Shore BJ, Bhandari R. Efficacy of peri-articular multimodal drug injection in total knee arthroplasty: A randomized trial.. J Bone Joint Surg (Am). 2006;88:959-963.

Garcia JBS, Barbosa Neto JO, Vasconcelos JW. Eficácia analgésica do uso de dose alta de morfina intra-articular em pacientes pacientes submetidos à artroplastia total de joelho. Rev Bras Anestesiol. 2010;60:1-6.

Gupta A, Axelsson K, Alvin R. Postoperative pain following knee arthroscopy: The effects of intra-articular ketorolac and/or morphine. Reg Anesth Pain Med. 1999;24:225-230.

Rosseland LA. No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: A qualitative systematic review. Reg Anesth Pain Med. 2005;30:83-98.

Souza RH, Issy AM, Sakata RK. Analgesia intra-articular com morfina, bupivacaína ou fentanil após operação de joelho por videoartroscopia. Rev Bras Anestesiol. 2002;52:34-39.

Carvalho Jr L, Rezende PM, Castro CAC. Bupivacaine, epinephrine and morphine for post-total knee arthroplasty analgesia. Rev Bras Ortop. 2006;41:347-351.

Tuncer B, Babacan A, Arslan M. The pre-emptive analgesic effect of intra-articular bupivacaine in arthroscopic knee surgery. Acta Anaesthesiol Scand. 2005;49:1373-1377.

Andrade MAP, Campos TVO, Silva BFA. Avaliação prospectiva dos pacientes submetidos a artroplastia total do joelho com e sem colocação de dreno de sucção. Rev Bras Ortop. 2010;45:549-553.

5dd29d8d0e8825c34dc63494 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections