Zusammenfassung
Hintergrund
Eingriffe am Kniegelenk sind äußerst schmerzhaft, und eine suffiziente postoperative Schmerztherapie ist nicht unproblematisch. Zur Optimierung der postoperativen Analgesie wurde daher u. a. die lokale Applikation analgetisch wirksamer Medikamente vorgeschlagen. In der vorliegenden Untersuchung wurde eruiert, ob die intraartikuläre Ketamingabe den postoperativen Schmerz nach arthroskopischen Knieoperationen reduziert.
Material und Methoden
Es wurden 68 Patienten, die sich einer arthroskopischen Operation am Kniegelenk unterziehen mussten, doppelblind und randomisiert in 4 Gruppen eingeteilt. Den Patienten wurden folgende Lösungen am Ende der Operation appliziert: 10 ml 0,25%iges Bupivacain intraartikulär (i.a.), 0,25 mg S-(+)-Ketamin/kgKG auf 10 ml in 0,9%iger NaCl-Lösung i.a., 0,25 mg S-(+)-Ketamin/kgKG intravenös (i.v.) und 10 ml 0,9%ige NaCl-Lösung i.a. als Placebo. Die postoperative Schmerztherapie wurde als intravenöse „patient controlled analgesia“ (i.v.-PCA) mit Piritramid durchgeführt. Der Opioidverbrauch und das Schmerzempfinden wurden als Hauptzielkriterien im postoperativen Verlauf gewertet.
Ergebnisse
Die 4 Studiengruppen waren bezüglich der biometrischen Daten vergleichbar. Die Werte der visuellen Analogskala (VAS) zeigten, dass die Schmerzintensität bei Patienten der i.a.-Ketamin- und der i.v.-Ketamin-Gruppe signifikant (p<0,05) geringer war als in den beiden anderen Gruppen. Kurz nach der Operation wurde die stärkste Schmerzreduktion in Ruhe in der i.a.-Ketamin-Gruppe gegenüber der i.a.-Bupivacain- und der Placebogruppe festgestellt. Der postoperative PCA-Opioid-Verbrauch war in der i.a.-Ketamin-Gruppe zu allen Zeiten am geringsten. Eine signifikante Differenz im Piritramidverbrauch (p<0,05) zeigte sich in den ersten 20 min nach der Operation in der i.a.-Ketamin-Gruppe sowohl gegenüber der Placebo- als auch der i.a.-Bupivacain-Gruppe.
Schlussfolgerungen
Die i.a.-Gabe von Ketamin führt nach Knieoperationen zu einer signifikanten Abnahme des postoperativen Schmerzmittelbedarfs und verringert das subjektive postoperative Schmerzempfinden des Patienten gegenüber der i.a.-Gabe von Bupivacain oder Placebo. Vergleichbar kann die i.v.-Ketamin-Gabe wirken, allerdings ist der positive Effekt kürzer nachweisbar.
Abstract
Background
Surgery of the knee can be very painful and sufficient postoperative pain treatment is often problematic. To optimize postoperative analgesia, application of local analgesics has been suggested. In the present study it was investigated whether intra-articular administration of ketamine reduces the level of pain after arthroscopic knee surgery.
Material and methods
A total of 68 patients undergoing arthroscopic knee surgery were randomized into 4 groups. At the end of surgery the following pharmaceuticals were administered: 10 ml 0.25% bupivacaine intra-articular (i.a.), 0.25 mg S-(+)-ketamine/kg body weight to 10 ml in 0.9% NaCl i.a., 0.25 mg S-(+)-ketamine/kg body weight intravenous (i.v.), and 10 ml 0.9% NaCl i.a. as placebo. Postoperative pain therapy was performed as i.v. patient controlled analgesia (PCA) with piritramide. Postoperative opioid consumption and pain intensity were assessed as the main criteria in the postoperative course.
Results
All 4 groups were comparable with respect to biometrical data. The scores of the visual analogue scale (VAS) showed a significantly (p<0.05) lower pain intensity in patients treated with ketamine i.a. or i.v. compared to the other groups. Shortly after surgery the highest reduction of pain was detected in the i.a. ketamine group compared to i.a. bupivacaine or placebo administration. The postoperative opioid consumption was always lowest in the i.a. ketamine group. A significant difference in piritramide consumption (p<0.05) was demonstrated in the first 20 min after operation in the i.a. ketamine group compared to the i.a. administration of placebo and bupivacaine.
Conclusions
The i.a. application of ketamine after arthroscopic knee surgery leads to a significant decrease of postoperative analgesic demand and decreases patients’ subjective level of pain compared to i.a. application of bupivacaine or placebo. Likewise, the i.v. application of ketamine is similarly effective but the effect is of shorter duration.
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Borner, M., Bürkle, H., Trojan, S. et al. Intraartikuläre Ketamingabe bei arthroskopischen Knieoperationen. Anaesthesist 56, 1120–1127 (2007). https://doi.org/10.1007/s00101-007-1249-y
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DOI: https://doi.org/10.1007/s00101-007-1249-y