Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
O R I G I N A L A RT I C L E
ABSTRACT
Background. The aim of this study was to evaluate the benefit of a combination of thiopentone and ketamine over
either of these drugs alone as an induction agent for Cesarean section.
Methods. Randomized prospective study of 3 groups of 20 patients (Group I: thiopentone alone; Group II: ketamine alone; Group III thiopentone and ketamine combination).
Results. Systolic blood pressure (BP) (as measured at baseline, after induction, at intubation, and at 5 min, 10 min,
15 min, 20 min, 25 min, 30 min): baseline BP did not differ significantly across groups. However, postinduction values were significantly higher for Group II (ketamine alone) (P>0.001), but these values normalized by 30 min postinduction. Diastolic BP (as measured at baseline, after induction, at intubation, and at 5 min, 10 min, 15 min, 20 min,
25 min, 30 min): baseline BP did not differ significantly across groups. After induction, diastolic BP increased significantly in all groups. In Group I and Group III, these values returned to baseline after 10 min, and in Group II at the
30 min postinduction stage. Heart rate (measured at the same time as BP): at rest, presented no significant difference
in heart rate across groups. At induction, all groups showed a significant rise in heart rate. At intubation, Group I
showed an increase in heart rate, Group II a decrease in heart rate, and Group III no change. These intergroup variations were statistically significant. Apgar scores and umbilical venous gas measurements: although there were intergroup
variations, these were not statistically significant. Postoperative pain assessment (subjective) VAS scores: the VAS
pain scores 3 h after surgery were significantly higher in Group I, both at rest and coughing, at 24 h after surgery the
difference persisted for scores at rest, but equalized during coughing. Postoperative pain assessment (objective) time
to first analgesic demand: the duration of time to demand for first analgesic was significantly longer in Group II (ketamine only). Postoperative pain assessment (objective) total consumption of analgesic: patients of Group I consumed a significantly higher amount of analgesics than the other groups. Intraoperative event recall, awareness: no
patient reported any adverse events of this nature.
Conclusion. We conclude that though there were no adverse events and a significantly lower analgesic requirement,
the use of ketamine alone as an induction agent in Cesarean section should be avoided, as it causes significant maternal hemodynamic changes. The addition of a reduced dose of ketamine to thiopentone in the induction cocktail confers the benefit of reducing analgesic requirement without side effects. The treatment is safe and effective for the mother and child.
Key words: Cesarean section - Ketamine - Thiopental - Ketamine.
Vol. 75 - No. 4
MINERVA ANESTESIOLOGICA
185
KETAMINE AND THIOPENTONE COMBINATION FOR CESAREAN SECTION VS THIOPENTONE OR KETAMINE ALONE
186
MINERVA ANESTESIOLOGICA
April 2009
150
100
140
90
DBP (mmHg)
SBP (mmHg)
KETAMINE AND THIOPENTONE COMBINATION FOR CESAREAN SECTION VS THIOPENTONE OR KETAMINE ALONE
130
120
110
10
15
20
80
70
60
25
Time (min)
Group 1
Group 2
NAYAR
10
15
20
25
Time (min)
Group 3
Group 1
Group 2
Group 3
Results
130
120
110
HR (bpm)
Descriptive statistics
100
90
80
70
20
Group 2
25
30
Group 3
Maternal parameters
Systolic BP (as measured at baseline, after induction, at intubation, and at 5 min, 10 min, 15 min,
20 min, 25 min, 30 min) (Figure 1).
Preoperatively systolic BP did not differ significantly across groups: F=0.73; df=2.57; P=0.049;
not significant.
However, postinduction values were significantly higher for Group II (Ketamine alone) P>0.001,
The difference between the groups was statistically significant (F=7.13; df=2.57; P=0.002). These
values normalized by 30 min postinduction.
Diastolic BP (as measured at baseline, after
induction, at intubation, and at 5 min, 10 min,
15 min, 20 min, 25 min, 30 min) (Figure 2).
Preoperatively, diastolic BP did not differ significantly between groups (F=0.52; df=2.57; P=0.6).
After induction, diastolic BP increased signifi-
Vol. 75 - No. 4
MINERVA ANESTESIOLOGICA
187
KETAMINE AND THIOPENTONE COMBINATION FOR CESAREAN SECTION VS THIOPENTONE OR KETAMINE ALONE
TABLE I. Changes in fetal parameters (Values are expressed as range, mean and standard deviation [SD]).
Group 1
Apgar 1 min
Apgar 5 min
Umbilical venous blood gas values
pH
PCO2 (mmHg)
PO2 (mmHg)
1-8
7.2 (1.8)
4-8
7.8 (0.9)
(N.=19)
6.8-7.4
7.2 (0.13)
16.7-63.3
40.2 (12.8)
7.8-46.4
25.9 (9.3)
Group 2
6-8
7.8 (0.5)
8
8 (0)
(N.=18)
7.1-7.3
7.2 (0.1)
19.8-61.4
40.7 (11.74)
9.4-47.7
26.7 (11.1)
Group 3
2-8
6.8 (2.1)
6-8
7.8 (0.5)
(N.=20)
7.2-7.3
7.3 (0.04)
32.3-60
40.4 (6.5)
19.2-40.2
23.2 (4.9)
Significance
Kruskall-Wallis test
with 2 df
2=3.63
P=0.16, NS
2=2.96
P=0.23 NS
Not significant (P=0.28)
Not significant (P=0.99)
Not significant (P=0.43)
TABLE II.Maternal analgesia (Values are expressed as range, mean and standard deviation [SD]).
VAS pain scores
Group 1
(N. 20)
Group 2
(N. 20)
Group 3
(N. 20)
Significance
3h
At rest
3-8
6.4 (1.4)
2-7
4 (1.2)
3-8
4.9 (1.5)
F=15.36
df=2.57
P<0.0001
Gp1>(Gp2=Gp3)
On coughing
6-9
7.8 (1.1)
4-9
6.4 (1.4)
4-9
6.9 (1.4)
F=6.7
df=2.57
P<0.0024
Gp1>(Gp2=Gp3)
2-6
4.3 (1)
2-5
2.8 (0.9)
2-5
3.2 (1)
F=12.26,
df=2.57
P<0.0001
Gp1>(GP2=GP3)
On coughing
2-7
4.7 (1.5)
3-6
5 (1)
4-7
5.3 (1)
F=1.29,
df=2.57
P<0.28
Not significant
94-580
216.3
(154.1)
90-1 200
425.6
(303.9)
45-660
363.4
(182.5)
F=4.64
df=2.57
P=0.014
(Gp2=Gp3)>Gp1
Cumulative consumption
of analgesics in 24 h
2.55 (0.82)
1.55 (0.759)
1.8 (1.005)
F=7.16
df=2-57
P value = s0.0016
Gp1>(Gp2=Gp3)
24 h
At rest
188
MINERVA ANESTESIOLOGICA
April 2009
Vol. 75 - No. 4
NAYAR
MINERVA ANESTESIOLOGICA
189
KETAMINE AND THIOPENTONE COMBINATION FOR CESAREAN SECTION VS THIOPENTONE OR KETAMINE ALONE
References
1. Hughes SC, Levinson G, Rosen MA. Anesthesia for Cesarean
section. In: Schneider SM, Levinson G, editors. Anesthesia for
Obstetrics, 3rd ed. Baltimore: William & Wilkes; 2002. p. 201.
2. Clarke RSJ. Intravenous anesthetic agents: induction and
maintenance. In: Wylie, editor. A practice of anesthesia, 6th
ed. London: Churchill Davidson; 1995. p. 97.
3. Baraka A, Louis F, Dalleh R. Maternal awareness and neonatal outcome after ketamine induction of anesthesia for cesarean section. Can J Anaesth 1990;37:641-4.
4. McQuay HJ. Pre-emptive analgesia. Br J Anaesth 1992;69:13.
5. Woolf CJ, Chong MS. Preemptive analgesiatreating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993;77:362-79.
6. Orser BA, Pennefather PS, MacDonald JF. Multiple mechanisms of ketamine blockade of N-methyl-D-aspartate receptors. Anesthesiology 1997;86:903-17.
7. Ito Y, Ichiyanagi K. Post-operative pain relief with ketamine
infusion. Anaesthesia 1974;29:222-6.
8. Clements JA and Mimmao WES Pharmacokinetics and analgesic effect of Ketamine in Man. Br J Anesth 1981;53:27.
9. Ngan Kee WD, Khaw KS, Ma ML, Mainland PA, Gin T.
Postoperative analgesic requirement after cesarean section: a
comparison of anesthetic induction with ketamine or thiopental. Anesth Analg 1997;85:1294-8.
10. Tverskoy M, Oz Y, Isakson A, Finger J, Bradley EL Jr, Kissin
I. Preemptive effect of fentanyl and ketamine on postoperative pain and wound hyperalgesia. Anesth Analg 1994;78:2059.
11. Roytblat L, Korotkoruchko A, Katz J, Glazer M, Greemberg
L, Fisher A. Postoperative pain: the effect of low-dose ketamine
in addition to general anesthesia. Anesth Analg 1993;77:11615.
12. Peltz B, Sinclair DM. Induction agents for Caesarean section. A comparison of thiopentone and ketamine. Anaesthesia
1973;28:37-42.
13. Dich-Nielsen J, Holasek J. Ketamine as induction agent for
caesarean section. Acta Anaesthesiol Scand 1982;26:139-42.
14. Schultetus RR, Hill CR, Dharamraj CM, Banner TE, Berman
LS. Wakefulness during cesarean section after anesthetic induction with ketamine, thiopental, or ketamine and thiopental
combined. Anesth Analg 1986;65:723-8.
15. Baraka A, Louis F, Noueihid R, Diab M, Dabbous A, Sibai A.
Awareness following different techniques of general anaesthesia for caesarean section. Br J Anaesth 1989;62:645-8.
16. Traub E, Knoche E, Dick W, Vlschow E. [Apgar status,
blood gases and acid base balance of neonates after caesarean
sections, using either thiopentone or ketamine for induction
of anaesthesia (authors transl)] Anaesthesist 1977;26:17683.
17. Bernstein K, Gisselsson L, Jacobsson L, Ohrlander S. Influence
of two different anaesthetic agents on the newborn and the correlation between foetal oxygenation and induction-delivery
time in elective caesarean section. Acta Anaesthesiol Scand
1985;29:157-60.
18. Schultetus RR, Paulus DA, Spohr GL. Haemodynamic effects
of ketamine and thiopentone during anaesthetic induction for
caesarean section. Can Anaesth Soc J 1985;32:592-6.
190
MINERVA ANESTESIOLOGICA
April 2009