Does a Single Intravenous Dose of Ketamine Reduce the Need for Supplemental Opioids in Post-Cesarean Section Patients?
Pain control after cesarean delivery is associated with improved breastfeeding and infant rooming-in times. In addition, inadequate analgesia leads to elevated plasma catecholamine concentrations, which negatively affect every organ system. There is growing evidence that ketamine, N-methyl-D-aspartate receptor antagonist, is efficacious when used as an adjuvant in postoperative pain control. A 2006 Cochrane Collaboration systemic review and meta-analysis concluded, "Ketamine in subanesthetic doses….is effective in reducing morphine requirements in the first 24 hours after surgery."
Ketamine's prolonged analgesic effect, despite its short half-life and its use in low doses, is theorized to be due to blockade of spinal cord central sensitization. Central sensitization is a phenomenon whereby repeated painful stimulus leads to more severe pain perception over time despite no change in the intensity of the painful stimulus.Ketamine may also prevent the development of acute opioid tolerance. Ketamine's analgesic effects have also demonstrated in the obstetric population. Post-cesarean delivery morphine requirements in women who received ketamine as part of a general anesthesia technique were decreased. Similary, low-dose ketamine in conjunction with bupivacaine-only spinal anesthesia reduced postoperative analgesic requirements compared to bupivacaine-only spinal anesthesia and bupivacaine-fentanyl spinal anesthesia.
In the United States, healthy women scheduled for elective cesarean delivery commonly receive spinal anesthesia with bupivacaine-fentanyl-morphine. To our knowledge, IV ketamine has not been studied as an adjuvant to this regimen in the analgesic management in post-cesarean delivery patients. Multimodal therapy for postoperative pain control is widely practiced due to the advantage it provides in blocking multiple pain pathways while minimizing side effects of each individual pain medication. We hypothesize that low dose intravenous ketamine will improve multi-modal post-cesarean analgesia compared to placebo. The purpose of this study is to evaluate this hypothesis and study the possible side effects of this regimen in combination with bupivacaine-fentanyl-morphine spinal anesthesia.
Ketamine Adverse Reaction
Effects of; Anesthesia, Spinal and Epidural, in Pregnancy
Complication of Labor and/or Delivery
|Study Design:||Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
|Official Title:||Does a Single Intravenous Dose of Ketamine Reduce the Need for Supplemental Opioids in Post-Cesarean Section Patients?|
- Number of Subjects Requiring Supplemental Analgesia in the First 24 Hours Following Cesarean Delivery [ Time Frame: 24 hours ] [ Designated as safety issue: No ]Request for oral hydrocodone/acetaminophen for pain not controlled by around the clock non-steroidal antiflammatory drugs in the first 24 hours following cesarean delivery.
- Verbal Pain Scores (0 to 10) at First Analgesia Request [ Time Frame: 24 hours ] [ Designated as safety issue: No ]Numeric rating of pain scores (NRS) scale (0 to 10) at time of supplemental analgesia request. Zero is no pain and 10 is worst pain imaginable.
- Cumulative Hydrocodone/Acetaminophen for Supplemental Analgesia to Treat Breakthrough Pain [ Time Frame: 72 hours ] [ Designated as safety issue: No ]Cumulative hydrocodone/acetaminophen for supplemental analgesia to treat breakthrough pain for 72 hours following cesarean delivery
- Postoperative Nausea [ Time Frame: 24 hours ] [ Designated as safety issue: No ]Number of subjects reporting nausea in first 24 hours following cesarean delivery
- Postoperative Vomiting [ Time Frame: 24 hours ] [ Designated as safety issue: No ]Number of subjects that vomited in the first 24 hours following cesarean delivery
- Postperative Pruritus [ Time Frame: 24 hours ] [ Designated as safety issue: No ]Number of subjects with pruritus in the first 24 hours following cesarean delivery
- Disturbing Dreams [ Time Frame: 72 hours ] [ Designated as safety issue: No ]Number of subject reporting disturbing dreams at 72 hours post cesarean delivery
|Study Start Date:||July 2006|
|Study Completion Date:||October 2008|
|Primary Completion Date:||October 2008 (Final data collection date for primary outcome measure)|
Subjects receive IV ketamine 10 mg 5 minutes after infant delivery.
Ketamine 10 mg diluted to 20 mL delivered over 10 minutes via an infusion pump set at 2ml/minute
Other Name: N-methyl-D-aspartate (NMDA)
Placebo Comparator: Placebo
Subjects receive IV Saline 20 mL 5 minutes after infant delivery
Saline 20 mL IV infusion delivered over 10 minutes via an infusion pump set at 2ml/minute
Other Name: 0.9% Saline
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|United States, Illinois|
|Chicago, Illinois, United States, 60611|
|Principal Investigator:||Cynthia A Wong, M.D.||Northwestern University|