Ketamine analgesia before spinal anesthesia for fractured femur

Transcription

1 analgesia before spinal anesthesia for fractured femur Amal A Mohammed, MD *, Mayada M Ali, MD ** Assistant Professor of Anaesthesia, Faculty of Medicine, University of Alzaiem Alazhari, Sudan *, Anaesthesiologist Soba Teaching Hospital, Sudan ** أثشعمبس انك زبي ف إصان األنى ع ذ خه ط يش ط عظى انفخز ان كس سنهزخذ ش ان صف د.أ بي ػجذهللا ؾ ذ,د. ١ بد ؾ ذ ػ يهخص انجحث وغ س ػظب ا فخز ا ىغ س ا ؾبئؼخ وغ س ئ خ رؾزبط ؼ ١ بد عشاؽ ١ خ رؾذ ا زخذ ٠ ش ا قف. ر ذف ز ا ذساعخ ؼشفخ ف ائذ ػمبس ا ىزب ١ ػ ذ اػطبئ س ٠ ذ ٠ ب ف رغى ١ األ ف مغ ا ىغش اص بء اعشاء ا زخذ ٠ ش ا قف ش ٠ ل عب ظ. اعش ٠ ذ ز ا ذساعخ ػ 60 ش ٠ نب ا غ غ ١ ف ا فزشح اغغطظ 2011 ا بسط 2012 ف غزؾف ١ بد ا خشه ا زؼ ١ ا دس ب ا زؼ ١ ثؾش ا زؼ ١. اخز ١ شد األػ بس ع ا خب غخ ا ؼؾش ٠ ف ب ف ق لغ ا ؼذد ا ى شم ا غ ػز ١ زغب ٠ ز ١. ا غ ػخ اال )أ( غ ػخ ا زؾى ا غ ػخ ا ضب ١ خ )ة( غ ػخ ا ىزب ١. أ مؾذ ا ذساعخ ا اػطبء ا ى ١ زب ١ س ٠ ذ ٠ ب لج اعشاء ا زخذ ٠ ش ا قف شم ا ز ٠ ٠ ؼب وغ س ف ػظ ا فخز ٠ م األ ف مغ ا ىغش. %30 فمو غ ػخ ا ىزب ١ ػب ا ا ف لغ ا ىغش. ث ١ ب ػب %76,7 غ ػخ ا زؾى ا ف مغ ا ىغش. رى ب ه آصبس عب ج ١ خ العزخذا ا ىزب ١ ث ز ا غشػخ ا قغ ١ شح. رخف ١ ف األ ع ػ ١ خ ا زخذ ٠ ش ا قف ل ص اعشاء ا زخذ ٠ ش ؽ ١ ش ل ػذد ؾب الد ؽم ا ش ٠ ل ثؼمبس ا زخذ ٠ ش و ب ٠ ؾزبط ا ش ٠ ل ا ث ظ مؼ ف ىب ا ؾم. Abstract Objectives Fracture femur is a painful injury occurs in different age s. Regional anaesthesia compared to general anaesthesia has many advantages in terms of decreased morbidity and mortality. This study was set to detect the effect of giving a small dose of ketamine in preventing pain at the fracture site when given before performing spinal anaesthesia in the sitting position for patients complaining femur bone fracture. Methods This is an interventional cross-sectional study conducted in Khartoum Teaching Hospital, Corresponding author Amal Abdalla Mohamed, ssistant Professor of Anaesthesia, Faculty of Medicine, University of Alzaiem Alazhari amalos@live.com Omdurman Teaching Hospital and Khartoum North Teaching Hospital during the period from August 2011 to March Results Sixty-patients including males and females, aged 25 and above The American Society of Anesthesiology(ASA) classification I and II, divided patients into two equal s. Group A the control and B the ketamine. Patients who experienced pain at the fracture site in the ketamine were 30%, while those in control were 76.7%. P. value Conclusion A small dose of ketamine before performing spinal anaesthesia in sitting position for patients having fracture femur has a valuable effect in reducing patient pain at the site of fracture. It facilitates the procedure, reducing its time, reducing the number of trials of spinal injection and requires no local infiltration at site of injection. Sudan Med J 2015;April 50(1) 17

2 Keywords: femur fracture, spinal anaesthesia bupivacaine,ketamine. Introduction Fracture femur is a painful bone injury occurs in different age s. The causative trauma ranges from minor to severe one that occurs during the involvement in road traffic accident, which becomes now a days a leading cause of morbidity and mortality (1). Regional anaesthesia compared to general anaesthesia have many advantages in decreasing morbidity and mortality (2). Spinal anaesthesia can be performed in the sitting or the lateral position, the former is more common because the midline anatomy often easier to palpate than when the patient is in the lateral position (3). However, the patient who complains of lower limb fracture may experience severe pain especially during the time taken in changing the position from lying flat to sitting up or to the lateral position, throughout the time of performing the block until the effect of spinal anaesthesia is established. Some investigators as Morad El Taweel used ketamine with midazolam for both analgesia and sedation (4) while Salvatore Sia, Remo Barbogli and Calogero Rivituso (5) studied the effect of femoral nerve block compared to opioid. In our study, we investigate the effect of small iv dose of ketamine which is available and cheap drug in reducing pain at the site of the fractured femur bone to facilitate the sitting position for spinal anaesthesia. Patients and Methods The study was carried out in Khartoum Teaching Hospital, Omdurman Teaching Hospital and Khartoum North Teaching Hospital. It was performed on sixty patients including males and females, presented for elective orthopedic operations done for different types of fractured femur (fracture head, neck and shaft). All the operations were done under spinal anaesthesia performed in the sitting 18 position using bupivacaine 0.5% hyperbaric in a doze of 10-15mg. Patients were divided into two equal s; (A) the control and (B) the ketamine. Inclusion criteria:- Patients of ASA class I and II. Patients age 25 years and above. Patients sustained fracture femur less than 10 days duration. Exclusion criteria :- Impacted fracture. Patients tolerated pain prior to operation. Patients who received strong analgesics (opioid) less than 6 hours prior to surgery. Unco-operative patients or patients with dementia. The procedure was explained to the patients in details and a written consent was taken. All patients were monitored using pulse oximeter, non-invasive blood pressure sphygmomanometers, and ECG. Base line vital were recorded (HR, SPO2, BP and RR) and monitored continuously. Iv cannula size 18 was inserted and all patients received 750ml of normal saline before performing spinal anaesthesia. Oxygen 4L/ min via nasal cannula was supplied. For the ketamine ( B) those 25 to > 70 years old received ketamine in a dose of 0.25mg/kg iv and those < 70 years old received ketamine in a dose of 0.15mg/ kg i.v. Spinal anaesthesia was performed under aseptic technique using spinal needle G23 or G25 at the vertebral level (L3- L4) without local infiltration of the skin mg of hyperbaric bupivacaine, 0.5% was injected into the sub-arachnoid space, and then the patient was placed back in the supine position. Patients were inquired about pain at fracture site and at the site of the spinal needle injection. Severity of pain at the fracture site was assessed by the (0-10) verbal descriptive scale.

3 0 = no pain 1 3 = mild pain 4 6 = moderate pain 7 9 = severe pain 10 = very severe (worst imaginable pain) Data statistical analysis was conducted using Software Package for Social science (SPSS). Results All patients aged not less than 25 years received the last dose of analgesia 6 hours or more before operation as an inclusion criteria (Figures 1,2). Fig 1: Distribution of age Fig 2: Distribution of last dose of Analgesia compared to 30% in the ketamine, P. value Table 1: Pain at fracture site during positioning: Yes No Total (9) 30% (21) 70% (23) 76.7% (7) 23.3% Total P. value In Table2 9 patients in ketamine experienced pain, Whereas in the control 23 patients complained of pain, where 33.3% of them had mild pain, while 66.7% had moderate pain, 21.7% had mild pain, 47.8% had moderate pain, 26.2% had severe pain and 4.3% had very severe pain. P. value Table 2: Severity of pain Mild Moderate Severe Very severe (3) 33.3% (5) 21.7% (6) 66.7% (11) 47.8% (6) 26.2% (1) 4.3% Total (9) (23) Total P. value Only 13.3% of ketamine experienced pain at site of spinal needle injection compared to 63.3% of the control. P. value (Table 3) Table 3: Pain at site of spinal injection Yes No Total (4) 13.3% (19) 63.3% (26) 86.7% (11) 36.7% Total P. value In Table 1,76.7% of the patients in the control experienced pain at the fracture site while positioned for spinal anaesthesia P. value More time was consumed in performing spinal block in the control, compared to ketamine. 19

4 P. value, most of the ketamine patients were done in < 5 min 66.7%, while only 26.7% in the control took < 5 min. (Table 4). Table 4: Time spent for performing spinal anesthesia: < 5 min Total min min (20) 66.7% (6) 33.3% (8) 26.7% (18) 60% (4) 13.3% Total P. value Regarding the patients vital signs there were insignificant changes in pulse rate, blood pressure and oxygen saturation. (Table 5) Table 5: Vital signs: pulse rate, blood pressure, SO2%: P. value Normal (10) 33.3% (10) 33.3% Pulse rate Bradycardia % 10% Tachycardia (18) 60% (17) 56.7% Blood pressure Normal 12 60% % Hypotension (6) 20% (11) 36.7% Hypertension (12) 40% (9) 30% Oxygen saturation Normal (28) 93.9% (29) 96.7% Desaturation (2) 26.7% (1) 3.3% Insignificant changes with regard to patients changes of behavior. P. value (Table 6) Table (6): Changes in patients behavior: Awake Sedated Other Total and cooperative (28) 93.3% (2) 6.7% (28) 93.3% (2) 6.7% Total P. value Discussion Operations for fracture femur such as Austin Moore, dynamic hip screw or intra-medullary nail were performed commonly under regional anaesthesia especially spinal anaesthesia (6). As this type of fractures are very painful an optimal conditions for performing spinal anaesthesia in the sitting positions are needed. In this study, we investigated the analgesic effect of small doses of ketamine before rendering the patient sitting for spinal anaesthesia. Analgesic drugs in the majority of our patients were administered before 24 hours (46.7%) and (33.3%) before 12 hours from starting the procedure, by this result we eliminated the contribution of other modalities of analgesia in our study (Fig 1); this is consistent with Arissara Lamiron and Manne Rasakietesak study (7). There was a significant difference between the two s in accordance to the presence or absence of pain at the fracture site during sitting position. In the ketamine 70% did not experience pain while 23.3% in control did not have pain. Patients experienced pains at fracture site were 30% in ketamine, 76.7% in control. P=0.00 significant value (Table 1), and it is consistent with the studies conducted by Moataz Morad El- Tawil (8), Suzuki M, Tsueda K (9) and Sandby- Thomas M, Sullivan G (10) who reported that when considering the technique used to aid positioning patients for spinal block, the most frequently used agents were ketamine, midazolam and propofol. Regarding severity of pain among patients in ketamine, it varies between moderate 66.7% to mild pain 33.3%, no patient had severe or very severe pain. Severity of pain was assessed by the verbal descriptor scale because it is an easy method for the patients to express the severity of pain especially for the elderly. In control, those who expressed pain as mild21.7%, moderate 47.8%, severe 20

5 pain 26.2% and very severe 4.3% were only observed in this (Table 2). As for the pain at the site of spinal injection 63.3% had pain in the control compared to only 13.3% in ketamine. P = (Table 3).This result showed that there is no need for local infiltration if ketamine in the analgesic dose was given before spinal anaesthesia. The time taken for performing spinal anaesthesia was shorter in ketamine ; the procedure was performed in less than 10 minutes in all patients of the. In 66.7% the time taken was less than 5 minutes, while 33.3% was conducted in the period from 5-10 minutes and no procedure was performed in more than 10 minutes. In the control, 60% procedures were performed in the period from 5-10 minutes 26.7% in less than 5 minutes and 13.3% conducted in more than 15 minutes P. = (Table 4). This result implies that comfortable position during performing spinal anaesthesia aids in reducing number of failed trials, minimizing time and resources. Changes in the vital signs produced by ketamine such as tachycardia and hypertension, increased systemic vascular resistance which are indirect cardio-vascular effects due to central stimulation of the sympathetic nervous system and inhibition of the re-uptake of norepinephrine (11) were monitored pre- and post positioning. Changes in pulse rate after positioning the patient for spinal anaesthesia in the ketamine were found to be; normal pulse rate in 33.3% compared to 33.3% in control. Those who developed tachycardia in ketamine were 60% compared to 56.7% from control. As for those who had bradycardia were 6.7% in study compared to 10% in control, p = 0.892, this was an insignificant difference in change in the pulse rate between the two s, so from this result we can conclude that the use of a small dose of ketamine will not alter the pulse rate significantly (Table 5). Regarding blood pressure we considered the patient base line reading as normal, if it increased by 20% or more it was taken as hypertension, and if it is decreased by 20% or more it was considered hypotension. The changes in blood pressure after positioning the patient for spinal anaesthesia also were insignificant. Normal blood pressure values were 40% in ketamine and 30% in control. Hypertension occurred in 20% in ketamine and 36.7% in control (Table 5). We noticed that more patients in the control developed hypotension and this was attributed to the side effect, of ketamine as it causes elevation in blood pressure even in small dose (12) so it can balance the haemodynamic instability caused by spinal anaesthesia. Oxygen saturation taken as an indicator of adequacy of ventilation and tissue hypoperfusion as seen with hypotensive episodes was normal in all patients prepositioning. After positioning patients who had normal saturation in ketamine were 93.3% compared to 96.6% in the control, this may be due to the sedation caused by ketamine. P = i.e no significant difference in saturation between the two s (Table 5). Patients behavior was not changed significantly, after the use of ketamine 93.3% in both ketamine and control patients were awake and co-operative. In ketamine 6.7% were sedated and 6.7 in control showed other behavioral changes. P = insignificant (Table 6). 21

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