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Resumen de Análisis de la eficacia clínica de la ketamina en el dolor agudo postoperatorio

Juan Fernando García Henares

  • español

    Estudio A: Efectos de la ketamina en el dolor postoperatorio tras anestesia TIVA basada en remifentanilo en cirugía menor y mayor en Adultos. Una revisión sistematica y metaanálisis.

    La ketamina , un antagonista N-metil -D- aspartato ( NMDA), ha sido postulado con un adyuvante analgésico para prevenir la hiperalgesia inducida por remifentanilo tras la cirugía. Esta revisión sistemática y metanálisis tiene como objetivo comprobar la efectividad de la ketamina ( en su mezcla racémica y forma S-ketamina) para reducir el consumo de morfina y la intensidad del dolor postoperatorio tras una anestesia general con remifentanilo.

    Se realizó una búsqueda bibliográfica en las bases de datos PubMed, Web of Science, Scopus, Cochrane, and EMBASE en Junio de 2017 seleccionando los ensayos clínicos aleatorizados que cumplieran unos criterios de inclusión y exclusión predefinidos. Con el fin de minimizar los posibles factores de confusión y la heterogeneidad, los estudios seleccionados fueron agrupados en las categorías de cirugía menor y mayor.

    la calidad metodológica fue evaluada según las escalas pedro y jada. la extracción de los datos y el metanálisis fue desarrollado cuando se cumplieron criterios de calidad. Doce ensayos clínicos que incluían un total de 156 adultos bajo la categoría cirugía menor y 413 adultos bajo la categoría de cirugía mayor fueron incluidos en el metanálisis.

    La ketamina utilizada como coadyuvante a la morfina redujo el consumo postoperatorio de dicho opioide en las primeras 24h, así como la intensidad del dolor en las primeras 2h tanto en el grupo de cirugía menor como mayor. Además el uso de ketamina se asoció a una reducción significativa del dolor postoperatorio en las primeras 24h en el grupo de cirugía menor. El tiempo hasta el primer rescate fue mayor en aquellos pacientes que recibieron ketamina en el grupo de cirugía mayor. No hubo diferencias significativas en la incidencia de aparición de efectos adversos observados entre los grupos control y ketamina. Esta revisión sistemática y metanálisis nos muestra que la administración de dosis subanestésicas de ketamina (0.5 mg/kg iv en bolo o 5 μg/kg/min iv en perfusión continua) en el intraoperatorio disminuye el consumo postoperatorio de morfina y la intensidad del dolor sin incrementar la incidencia de efectos adversos.

  • English

    ESTUDIO A: Effects of Ketamine on Postoperative Pain After Remifentanil-BasedAnesthesia for Major and Minor Surgery in Adults: A Systematic Review and Meta-Analysis García-Henares JF, Moral-Munoz JA, Salazar A, Del Pozo E. Effects of Ketamine on Postoperative Pain After Remifentanil-Based Anesthesia for Major and MinorSurgery in Adults: A Systematic Review and Meta-Analysis. Front Pharmacol. 2018; 9:921. doi: 10.3389/fphar.2018.00921.

    Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been postulated as an adjuvant analgesic for preventing remifentanil-induced hyperalgesia after surgery. This systematic review and meta-analysis aims to assess the effectiveness of ketamine [racemic mixture and S-(+)-ketamine] in reducing morphine consumption and pain intensity scores after remifentanil-based general anesthesia.

    We performed a literatura search of the PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases in June 2017 and selected randomized controlled trials using predefined inclusion and exclusion criteria. To minimize confounding and heterogeneity, studies of NMDA receptor antagonists other than ketamine were excluded and the selected studies were grouped into those assessing minor or major surgery. Methodological quality was evaluated with the PEDro and JADA scales. The data were extracted and meta-analyses were performed where possible. Twelve RCTs involving 156 adults who underwent minor surgery and 413 adults who underwent major surgery were included in the meta-analysis.

    When used as an adjuvant to morphine, ketamine reduced postoperative morphine consumption in the first 24 h and postoperative pain intensity in the first 2 h in the minor and major surgery groups. It was also associated with significantly reduced pain intensity in the first 24 h in the minor surgery group. Time to the first rescue analgesia was longer in patients who received ketamine and underwent major surgery. No significant differences in the incidence of ketamine-related adverse effects were observed among patients in the intervention group and controls. This systematic review and meta-analysis show that low-dose (0.5 mg/kg for iv bolus or 5 μg/kg/min for iv perfusion) of ketamine reduces postoperative morphine consumption and pain intensity without increasing the incidenceof adverse effects Keywords: remifentanil, ketamine, minor surgery, mayor surgery, NMDA antagonist, meta-analysis ESTUDIO B: Efficacy of Ketamine plus Morphine in Patient-Controlled Analgesia in Spinal Arthrodesis. A Randomized Comparison with Morphine Background: Ketamine, an N-methyl-D-aspartate receptor antagonist, has been postulated as adjuvant analgesic in postoperative multimodal analgesia regimens at sub-anesthetic doses. This study was mainly undertaken to assess the morphine sparing effects of ketamine added to morphine-based iv Patient-Controlled Analgesia (PCA), in patients undergoing elective lumbar spinal surgery.

    Methods: This was a randomized, double-blinded, parallel-group, drug-controlled, clinical trial. Fifty-two patients received postoperative analgesia (iv PCA) with morphine + ketamine (MK group) or morphine + saline (MO group) and were observed for 72 h postoperatively. The primary outcome was morphine consumption. Secondary outcomes were postoperative nausea and vomiting (PONV), pain intensity at rest and on mobilization, and neuropathic pain score.

    Results: Twenty-two patients in each group completed the study. The intention-to-treat adjusted analysis for primary outcome showed that patients in MK group had a significant decrease (P < 0.01) in cumulative morphine doses respect MO group. The analysis of secondary outcomes showed that the incidence of PONV moderate, severe and uncontrollable was significantly lower in the MK group respect to MO group at 24 h postoperatively. VAS scores at rest and on mobilization were lower in MK group (P < 0.035) at all times registered. The groups had no differences in pain DETECT scores.

    Conclusions: Low doses of ketamine as an adjunct to a morphine-based iv PCA reduced the consumption of morphine, the intensity of pain and the incidence of high intensity PONV in the immediate (72 h) postoperative period.


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