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Alt ekstremite cerrahisinde spinal anestezide levobupivakain ve bupivakaine ketamin ilavesinin etkileri

Yıl 2011, Cilt: 33 Sayı: 1, 80 - 87, 14.03.2011

Ahmet İşbir Caner Mimaroğlu , Cevdet Düger , İclal Özdemir Kol , Kenan Kaygusuz , Hayati Öztürk , Sinan Gürsoy

Öz

Özet

Amaç. Bu çalışmanın amacı, alt ekstremite cerrahilerinde, intratekal levobupivakain ve bupivakain uygulamalarına, ketamin ilavesinin etkilerini araştırmaktır. Yöntem. Çalışma, alt ekstremite operasyonu geçirecek ASA I-II grubuna giren 18-60 yaş arası 120 hasta üzerinde yapıldı. Hastalar otuzar kişilik rastgele 4 gruba ayrıldı. Tüm hastalara lateral dekubitis pozisyonunda, L3-4 veya L4-5 spinal aralıktan 25 G Quincke tipi spinal iğne ile intratekal aralığa girilerek; Grup I’e (n=30); 10 mg %0,5’lik bupivakain, Grup II’ ye (n=30); 10 mg %0,5’lik levobupivakain, Grup III’e (n=30); 10 mg %0,5’lik bupivakain + 25 mg ketamin, Grup IV’e (n=30); 10 mg %0,5’lik levobupivakain + 25 mg ketamin uygulandı. Tüm hastaların sistolik, diastolik ve ortalama kan basınçları kalp atım hızları, oksijen satürasyonları (SpO2), sedasyon skorları, operasyon sureleri, duyusal ve motor blok başlama zamanı, duyusal blok tepe noktaları, duyusal ve motor blok sureleri ve postoperatif vizüel analog skala (VAS) puanları ile ek analjezik ihtiyaçları kaydedildi. Bulgular. Çalışmaya alınan dört gruptaki bireylerin yas, cinsiyet, kalp atım hızı, sistolik ve diastolik kan basıncı, SpO2 değerleri acısından fark yoktu (p>0,05). Ketamin kullanılan gruplarda duyusal ve motor blok başlama zamanı daha kısa, duyusal ve motor blok süreleri daha uzun idi (p<0,05). Duyusal blok tepe noktası yönünden gruplar arası fark yoktu (p>0,05). Ketamin verilen Grup III ve IV deki sedasyon skoru 2/3 olan hasta sayısı Grup I ve II den fazla idi (p<0,05). VAS skorları postoperatif 2. ve 3.saatlerde Grup III ve Grup IV de Grup I ve II‘den anlamlı olarak daha düşüktü (p<0,05). İlk analjezik ihtiyacına kadar geçen süre Grup III ve IV’te Grup I ve II’den anlamlı olarak daha uzundu (p<0,05). Sonuç. Sonuç olarak, intratekal levobupivakain ve bupivakain’e ketamin eklenmesinin, spinal bloğun başlangıcını hızlandırarak süresini uzatacağını düşünüyoruz. Kısa süreli hafif sedasyon yan etkisinin de operasyon sırasındaki anksiyete duygusunu azaltmaya yardımcı olabileceği kanısına vardık.

Anahtar sözcükler: Spinal anestezi, levobupivakain, bupivakain, ketamin

 

Abstract

Aim. The aim of this study is to investigate the effects of the addition of ketamine to levobupivacaine and bupivacaine for lower extremity surgeries. Methods. The study was performed on 120 patients (ASA I-II), aged between 18 and 60 years. All participants were randomized to four groups consisted of 30 patients. In all participants, 25 G Quincke type spinal needles were inserted to the intrathecal cavity, from L3-L4 or L4-L5. Ten miligrams (mg) 0.5% bupivacaine was administered to Group I, 10 mg 0.5% levobupivacaine was administered to Group II, 10 mg. 0.5% bupivacaine plus 25 mg ketamine was administered to Group III and 10 mg 0.5% levobupivacaine plus ketamine was administered to Group IV. Systolic, diastolic, mean arterial pressure values, heart rates, oxygen saturations (SpO2), sedation scores, duration of surgical procedure, starting times of sensorial and motor blockages, maximum levels of sensorial block, sensorial and motor block times, and postoperative visual analog scale (VAS) scores and analgesic request data of all patients were recorded. Results. There were no differences among four groups regarding age, sex, heart rate, systolic and diastolic arterial pressure or SpO2 (p>0.05). The sensorial and motor block times were longer and starting times of sensorial and motor blocks were shorter in the groups given ketamine (p<0.05). There were no differences among the groups regarding maximum levels of sensorial block (p>0.05). The number of the patients with a sedation score of 2/3 in Group III and Group IV were more than Group I and II (p<0.05). The VAS scores at postoperative 2nd and 3rd hours of Group III and IV were significantly lower than those of Group I and II (p<0.05). The time to first analgesic request of Group III and IV was significantly longer than that of Group I and II (p<0.05). Conclusion. In conclusion, we suggest that adding ketamine to levobupivacaine and bupivacaine could fasten spinal block and increase sensorial blockage times. The side effect of short sedation may help in reducing anxiety feeling in patients during the surgical operation.

Keywords: Spinal anesthesia, levobupivacaine, bupivacaine, ketamine

 

Anahtar Kelimeler

-

Kaynakça

  • Bernards CM, Epidural and spinal anesthesia. Barash PG, Cullen BF, Stoelting RK. Ed. Clinical Anesthesia, Lippincott Williams & Wilkins, Philadelphia 2001; 689-713. 2.
  • Morgan GE, Mikhail MS. Clinical Anesthesiology. Appleton & Lange, Connecticut 1996; 211-44. 3.
  • Rosenfeld BA, Beattie C, Christopherson R, Frank SM, Breslow MJ, Rock P, Parker SD, Gottlieb SO, Perler BA, Williams GM, Seidler A, Bell W. The effects of different anesthetic regiments on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia randomized Anesthesia Trial Study Group Anesthesiology 1993; 79: 435-43. 4.
  • Murali Krishna T, Panda NB, Batra YK, Rajeev S. Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery. Eur J Anaesthesiol 2008; 25: 299-306. 5.
  • Choi DH, Ahn HJ, Kim MH. Bupivacaine-sparing effect of fentanyl in spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000; 25: 240-5. 6.
  • Mohammed EM. Selective Spinal Anaesthesia A review EJA 2003; 19: 99-106 7.
  • Liu SS, Hodgson PS, Moore JM, Trautman WJ, Burkhead DL. Dose response effects of spinal neostigmine added to bupivacaine spinal anesthesia in volunteers. Anesthesiology 1999; 90: 710-7. 8.
  • Hirota K, Lambert DG. Ketamine: its mechanism(s) of action and unusual clinical uses. Br J of Anaesth 1996; 77: 441-4. 9.
  • Bion JF. Intrathecal ketamine for war surgery. A preliminary study under field conditions. Anaesthesia 1984; 39: 1023-8.
  • Irifune M, Shimizu T, Nomoto M, Fukuda, T. Ketamine-induced anesthesia involves the N-methyl-D-aspartate receptor-channel complex in mice. Brain Res 1992; 596: 1-9.
  • Kayhan Z. Klinik Anestezi, II. Baskı, Logos Yayıncılık, Ankara 1997; s 477-89.
  • Erdine S. Sinir blokları. Emre Matbaacılık, İstanbul, 1993; s 155-76.
  • Morgan GE Jr, Mikhail MS, Murray MS, Larson CP Jr. Spinal, Epidural ve Kaudal Bloklar. Klinik Anesteziyoloji.(Çev Ed:Tolunay M, Cuhruh H) üçüncü baskı. Ankara, Güneş Kitabevi, 2004, s 253-280.
  • Önder M, Çelebi H. Spinal anestezide % 0,5 hiperbarik bupivakain ve bupivakain-fentanil kombinasyonunun değerlendirilmesi. Türk Anest. ve Rean. Cem 1994; 22: 281-7.
  • Togal T, Demirbilek S, Köroğlu A, Yapıcı E, Ersoy O. Effects of S(+) Ketamine added to bupivacaine for spinal anaesthesia for prostate surgery in elderly patients, Eur J Anaesthesiol 2004; 21: 193-7.
  • Bion JF. Intrathecal ketamine for war surgery,A preliminary study under field conditions Anaesthesia 1984; 39; 1023-8.
  • Lauretti GL, Oliveria AP, Rodrigues AM, Paccola CA. The effect of transdermal nitroglycerine on spinal S(+)-ketamine antinociception following orthopedic surgery. J Clin Anesth 2001; 13: 576-81.
  • Yanlı Y, Eren A. The effect of extradural ketamine on onset time and sensory block in extradural anaesthesia with bupivacaine .Anaesthesia 1996; 51: 84-6.
  • Gantenbein M, Abat C, Attolini L, Pisano P, Emperaire N, Bruguerolle B. Ketamine effects on bupivacaine local anaesthetic activitiy and pharmacokinetics of bupivacaine in mice. Life Sci 1997; 61: 2027-33.
  • Weir PS, Fee JP. Double-blind comparison of ekstradural block with three bupivacaine-ketamine mixtures in knee arthroplasty. Br J Anaesth 1998; 80: 299- 301.
  • Coppejans HC, Vercauteren MP. Low-dose combined spinal-epidural anesthesia for cesarean delivery: a comparison of three plain local anesthetics. Acta Anaesthesiol Belg. 2006; 57: 39- 43.
  • Marhofer P, Krenn CG, Plochl W, Wallner T, Glaser C, Koinig H, Fleischmann E, Höchtl A, Semsroth M. S(+)-ketamine for caudal block in paediatric anaesthesia. Br J Anaesthesia 2000; 84: 341-5.
  • Naguib M, Sharif AM, Seraj M, el Gammal M, Dawlatly AA. Ketamine for caudal analgesia in children: comparison with caudal bupivacaine. Br J Anaesth 1991; 67: 559-64.
  • De Negri P, Ivani G, Visconti C, De Vivo P. How to prolong postoperative analgesia after caudal anaesthesia with ropivacaine in children: S-Ketamine versus clonidine. Paediatr Anaesth 2001;11: 679-83.
  • De Negri P, Visconti C, Ivani G, Borrelli F, De Vivo P. Caudal additives to ropivacaine in children: preservative free S-ketamine versus clonidine. Paediatr Anaesth 2000; 10: 704-5
  • Weber F, Wulf H. Caudal bupivacaine and S(+)-ketamine for postoperative analgesia in children .Paediatr Anaesth 2003; 13: 244-8.
  • Hager H, Marhofer P, Sitzwohl C, Adler L, Kettner S, Semsroth M. Caudal clonidine prolongs analgesia from caudal S(+)-ketamine in children. Anaesth Analg 2002; 94: 1169-72.
  • Benrath J, Scharbert G, Gustorff B, Adams HA, Kress HG. Long-term intrathecal S(+)-ketamine in a patient with cancer related neuropathic pain. Br J Anaesth 2005; 95: 247-9.
  • Suzuki R, Matthews EA, Dickenson AH, Comparison of the effects of MK-801, ketamine and memantine on responses of spinal dorsal horn neurons in a rat model of mononeuropathy.Pain 2001; 91: 101-9.
  • Klepstad P, Borchgrevink P, Hval B, Flaat S, Kaasa S, Long term treatment with ketamine in a 12 year old girl with severe neuropathic pain caused by a cervical spinal tumor. J Pediatr Hematol oncol 2001; 23: 616-9.
  • Schnoebel R, Wolff M, Peters SC, Bräu ME, Scholz A, Hempelmann G, Olschewski H, Olschewski A. Ketamine impairs excitability in superficial dorsal horn neurones by blocking sodium and voltage gated potassium currents. Br J pharmacol 2005 146,826-33.
  • Kathirvel S, Sadhasivam A, Saxena A, Kannan TR, Ganjoo P. Effects of intrathecal ketamine added to bupivacaine for spinal anaesthesia. Anesthesia 2000; 55: 899-910.
  • Wong CS, Lu CC, Cherng CH, Ho ST. Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement. Can J Anaesth 1997; 44: 31-7.
  • Ben-David B, Soloman E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery. Anesth Analg 1997; 85: 560-5.

Orijinal araştırma-Original research

Yıl 2011, Cilt: 33 Sayı: 1, 80 - 87, 14.03.2011

Ahmet İşbir Caner Mimaroğlu , Cevdet Düger , İclal Özdemir Kol , Kenan Kaygusuz , Hayati Öztürk , Sinan Gürsoy

Öz

Amaç. Bu çalışmanın amacı, alt ekstremite cerrahilerinde, intratekal levobupivakain ve bupivakain uygulamalarına, ketamin ilavesinin etkilerini araştırmaktır. Yöntem. Çalışma, alt ekstremite operasyonu geçirecek ASA I-II grubuna giren 18-60 yaş arası 120 hasta üzerinde yapıldı. Hastalar otuzar kişilik rastgele 4 gruba ayrıldı. Tüm hastalara lateral dekubitis pozisyonunda, L3-4 veya L45 spinal aralıktan 25 G Quincke tipi spinal iğne ile intratekal aralığa girilerek; Grup I’e (n=30); 10 mg %0,5’lik bupivakain, Grup II’ ye (n=30); 10 mg %0,5’lik levobupivakain, Grup III’e (n=30); 10 mg %0,5’lik bupivakain + 25 mg ketamin, Grup IV’e (n=30); 10 mg %0,5’lik levobupivakain + 25 mg ketamin uygulandı. Tüm hastaların sistolik, diastolik ve ortalama kan basınçları kalp atım hızları, oksijen satürasyonları (SpO2), sedasyon skorları, operasyon sureleri, duyusal ve motor blok başlama zamanı, duyusal blok tepe noktaları, duyusal ve motor blok sureleri ve postoperatif vizüel analog skala (VAS) puanları ile ek analjezik ihtiyaçları kaydedildi. Bulgular. Çalışmaya alınan dört gruptaki bireylerin yas, cinsiyet, kalp atım hızı, sistolik ve diastolik kan basıncı, SpO2 değerleri acısından fark yoktu (p>0,05). Ketamin kullanılan gruplarda duyusal ve motor blok başlama zamanı daha kısa, duyusal ve motor blok süreleri daha uzun idi (p0,05). Ketamin verilen Grup III ve IV deki sedasyon skoru 2/3 olan hasta sayısı Grup I ve II den fazla idi (p

Anahtar Kelimeler

Spinal anestezi levobupivakain bupivakain ketamin

Kaynakça

  • Bernards CM, Epidural and spinal anesthesia. Barash PG, Cullen BF, Stoelting RK. Ed. Clinical Anesthesia, Lippincott Williams & Wilkins, Philadelphia 2001; 689-713. 2.
  • Morgan GE, Mikhail MS. Clinical Anesthesiology. Appleton & Lange, Connecticut 1996; 211-44. 3.
  • Rosenfeld BA, Beattie C, Christopherson R, Frank SM, Breslow MJ, Rock P, Parker SD, Gottlieb SO, Perler BA, Williams GM, Seidler A, Bell W. The effects of different anesthetic regiments on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia randomized Anesthesia Trial Study Group Anesthesiology 1993; 79: 435-43. 4.
  • Murali Krishna T, Panda NB, Batra YK, Rajeev S. Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery. Eur J Anaesthesiol 2008; 25: 299-306. 5.
  • Choi DH, Ahn HJ, Kim MH. Bupivacaine-sparing effect of fentanyl in spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000; 25: 240-5. 6.
  • Mohammed EM. Selective Spinal Anaesthesia A review EJA 2003; 19: 99-106 7.
  • Liu SS, Hodgson PS, Moore JM, Trautman WJ, Burkhead DL. Dose response effects of spinal neostigmine added to bupivacaine spinal anesthesia in volunteers. Anesthesiology 1999; 90: 710-7. 8.
  • Hirota K, Lambert DG. Ketamine: its mechanism(s) of action and unusual clinical uses. Br J of Anaesth 1996; 77: 441-4. 9.
  • Bion JF. Intrathecal ketamine for war surgery. A preliminary study under field conditions. Anaesthesia 1984; 39: 1023-8.
  • Irifune M, Shimizu T, Nomoto M, Fukuda, T. Ketamine-induced anesthesia involves the N-methyl-D-aspartate receptor-channel complex in mice. Brain Res 1992; 596: 1-9.
  • Kayhan Z. Klinik Anestezi, II. Baskı, Logos Yayıncılık, Ankara 1997; s 477-89.
  • Erdine S. Sinir blokları. Emre Matbaacılık, İstanbul, 1993; s 155-76.
  • Morgan GE Jr, Mikhail MS, Murray MS, Larson CP Jr. Spinal, Epidural ve Kaudal Bloklar. Klinik Anesteziyoloji.(Çev Ed:Tolunay M, Cuhruh H) üçüncü baskı. Ankara, Güneş Kitabevi, 2004, s 253-280.
  • Önder M, Çelebi H. Spinal anestezide % 0,5 hiperbarik bupivakain ve bupivakain-fentanil kombinasyonunun değerlendirilmesi. Türk Anest. ve Rean. Cem 1994; 22: 281-7.
  • Togal T, Demirbilek S, Köroğlu A, Yapıcı E, Ersoy O. Effects of S(+) Ketamine added to bupivacaine for spinal anaesthesia for prostate surgery in elderly patients, Eur J Anaesthesiol 2004; 21: 193-7.
  • Bion JF. Intrathecal ketamine for war surgery,A preliminary study under field conditions Anaesthesia 1984; 39; 1023-8.
  • Lauretti GL, Oliveria AP, Rodrigues AM, Paccola CA. The effect of transdermal nitroglycerine on spinal S(+)-ketamine antinociception following orthopedic surgery. J Clin Anesth 2001; 13: 576-81.
  • Yanlı Y, Eren A. The effect of extradural ketamine on onset time and sensory block in extradural anaesthesia with bupivacaine .Anaesthesia 1996; 51: 84-6.
  • Gantenbein M, Abat C, Attolini L, Pisano P, Emperaire N, Bruguerolle B. Ketamine effects on bupivacaine local anaesthetic activitiy and pharmacokinetics of bupivacaine in mice. Life Sci 1997; 61: 2027-33.
  • Weir PS, Fee JP. Double-blind comparison of ekstradural block with three bupivacaine-ketamine mixtures in knee arthroplasty. Br J Anaesth 1998; 80: 299- 301.
  • Coppejans HC, Vercauteren MP. Low-dose combined spinal-epidural anesthesia for cesarean delivery: a comparison of three plain local anesthetics. Acta Anaesthesiol Belg. 2006; 57: 39- 43.
  • Marhofer P, Krenn CG, Plochl W, Wallner T, Glaser C, Koinig H, Fleischmann E, Höchtl A, Semsroth M. S(+)-ketamine for caudal block in paediatric anaesthesia. Br J Anaesthesia 2000; 84: 341-5.
  • Naguib M, Sharif AM, Seraj M, el Gammal M, Dawlatly AA. Ketamine for caudal analgesia in children: comparison with caudal bupivacaine. Br J Anaesth 1991; 67: 559-64.
  • De Negri P, Ivani G, Visconti C, De Vivo P. How to prolong postoperative analgesia after caudal anaesthesia with ropivacaine in children: S-Ketamine versus clonidine. Paediatr Anaesth 2001;11: 679-83.
  • De Negri P, Visconti C, Ivani G, Borrelli F, De Vivo P. Caudal additives to ropivacaine in children: preservative free S-ketamine versus clonidine. Paediatr Anaesth 2000; 10: 704-5
  • Weber F, Wulf H. Caudal bupivacaine and S(+)-ketamine for postoperative analgesia in children .Paediatr Anaesth 2003; 13: 244-8.
  • Hager H, Marhofer P, Sitzwohl C, Adler L, Kettner S, Semsroth M. Caudal clonidine prolongs analgesia from caudal S(+)-ketamine in children. Anaesth Analg 2002; 94: 1169-72.
  • Benrath J, Scharbert G, Gustorff B, Adams HA, Kress HG. Long-term intrathecal S(+)-ketamine in a patient with cancer related neuropathic pain. Br J Anaesth 2005; 95: 247-9.
  • Suzuki R, Matthews EA, Dickenson AH, Comparison of the effects of MK-801, ketamine and memantine on responses of spinal dorsal horn neurons in a rat model of mononeuropathy.Pain 2001; 91: 101-9.
  • Klepstad P, Borchgrevink P, Hval B, Flaat S, Kaasa S, Long term treatment with ketamine in a 12 year old girl with severe neuropathic pain caused by a cervical spinal tumor. J Pediatr Hematol oncol 2001; 23: 616-9.
  • Schnoebel R, Wolff M, Peters SC, Bräu ME, Scholz A, Hempelmann G, Olschewski H, Olschewski A. Ketamine impairs excitability in superficial dorsal horn neurones by blocking sodium and voltage gated potassium currents. Br J pharmacol 2005 146,826-33.
  • Kathirvel S, Sadhasivam A, Saxena A, Kannan TR, Ganjoo P. Effects of intrathecal ketamine added to bupivacaine for spinal anaesthesia. Anesthesia 2000; 55: 899-910.
  • Wong CS, Lu CC, Cherng CH, Ho ST. Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement. Can J Anaesth 1997; 44: 31-7.
  • Ben-David B, Soloman E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery. Anesth Analg 1997; 85: 560-5.
Toplam 34 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Bölüm Cerrahi Tıp Bilimleri Araştırma Yazıları
Yazarlar

Ahmet İşbir

Caner Mimaroğlu

Cevdet Düger

İclal Özdemir Kol

Kenan Kaygusuz

Hayati Öztürk

Sinan Gürsoy

Yayımlanma Tarihi 14 Mart 2011
Yayımlandığı Sayı Yıl 2011Cilt: 33 Sayı: 1

Kaynak Göster

AMA İşbir A, Mimaroğlu C, Düger C, Özdemir Kol İ, Kaygusuz K, Öztürk H, Gürsoy S. Alt ekstremite cerrahisinde spinal anestezide levobupivakain ve bupivakaine ketamin ilavesinin etkileri. CMJ. Mart 2011;33(1):80-87.