title: Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement.
abstract: OBJECTIVE
  Pre-emptive analgesia can improve postoperative pain management. The purpose of this study was to examine the effectiveness of ketamine as a pre-emptive analgesic as previous studies have shown the involvement of N-methyl-D-Aspartate (NMDA) receptor in neuroplasticity.
  
  
  METHODS
  Forty-five ASA 1-2 patients, undergoing unilateral total knee replacement were studied. In the study groups, epidural lidocaine was used as the primary anaesthestic. Patients received ketamine + morphine epidurally 30 min either before (group EB) or after skin incision (group EA). Group G patients received general anaesthesia and ketamine + morphine were given 30 min after skin incision via an epidural catheter used for postoperative pain control. Epidural morphine and ketamine in lidocaine was given to all patients at the end of surgery and every 12 hr for three days for analgesia supplemented with PCA morphine. The time until first PCA trigger, morphine consumption, pain scores, satisfaction scores, and morphine related side effects were recorded at 6, 12, 24, 48 and 72 hr after surgery.
  
  
  RESULTS
  Epidural ketamine plus morphine with lidocaine before surgical incision produced better pain relief and patient satisfaction than when given after incision. A longer time to PCA and decreased morphine consumption were observed in group EB than in group G. In group EA, epidural anaesthesia also produced some pre-emptive analgesic effect compared with general anaesthesia shown by decreased morphine consumption.
  
  
  CONCLUSIONS
  Administration of ketamine plus morphine with epidural lidocaine anesthesia before surgery provided improved postoperative analgesia compared with general anaesthesia alone or when analgesics were given after skin incision.
authors.affiliation: Department of Anesthesiology, National Defense Medical Center, Taipei, Taiwan, Republic of China.
authors.forename: C S
authors.initials: CS
authors.lastname: Wong
authors.forename: C C
authors.initials: CC
authors.lastname: Lu
authors.forename: C H
authors.initials: CH
authors.lastname: Cherng
authors.forename: S T
authors.initials: ST
authors.lastname: Ho
mesh_terms: D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D000778:Anesthetics, Dissociative / Q000008:administration & dosage / Q000627:therapeutic use*; D000779:Anesthetics, Local / Q000008:administration & dosage; D062109:Dermatologic Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007649:Ketamine / Q000008:administration & dosage / Q000627:therapeutic use*; D007720:Knee Prosthesis; D008012:Lidocaine / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D009473:Neuronal Plasticity / Q000187:drug effects; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control; D017060:Patient Satisfaction; D011292:Premedication; D016194:Receptors, N-Methyl-D-Aspartate / Q000187:drug effects
chemical_list: D000701:Analgesics, Opioid; D000778:Anesthetics, Dissociative; D000779:Anesthetics, Local; D016194:Receptors, N-Methyl-D-Aspartate; D007649:Ketamine; D009020:Morphine; D008012:Lidocaine