title: Pre-incisional epidural ketamine, morphine and bupivacaine combined with epidural and general anaesthesia provides pre-emptive analgesia for upper abdominal surgery.
abstract: BACKGROUND
  Previous studies have shown that N-methyl-D-asparate (NMDA) receptor antagonists provide a pre-emptive analgesic effect in humans. This study investigated the benefits of pre-emptive analgesia for upper abdominal surgery, using pre-incisional epidural ketamine + morphine + bupivacaine (K+M+B) treatment for achieving postoperative pain relief.
  
  
  METHODS
  Sixty ASA 1-2 patients scheduled for upper abdominal surgery were allocated to three groups in a randomized, single-blinded study. Patients in the control group (I) received general anaesthesia followed by an infusion of normal saline. Group II and III patients received general anaesthesia with a continuous epidural infusion of 2% lidocaine. Thirty minutes after the incision in groups I and II, an epidural pain control regimen was administered using ketamine (10 mg) and morphine (1 mg) in 10 ml of 0.085% bupivacaine (K+M+B). Group III patients also received K+M+B, but it was administered 10 min after the 2% lidocaine injection and 30 min before skin incision. All patients received an epidural pain control regimen (q12 h) for 3 days after their first injection. Patient-controlled analgesia (PCA) with morphine was used to control subsequent postoperative pain. During the 3-day period following surgery, duration to PCA trigger (h), morphine consumption (mg), pain intensity at rest and when coughing/moving, and analgesic-related adverse effects were recorded. The VAS scale (0-10) was used to assess pain intensity.
  
  
  RESULTS
  Median times to first PCA trigger were 1.2 (0.5-2.0) h, 3.0 (0.7-4.2) h, and 4.0 (2.5-7.5) h for groups I, II, and III, respectively. Both the incident and resting pain scores were consistently lower for group III patients than groups I and II. The number of PCA triggers (all attempts/successful triggers) during the day following surgery were 14.0 (3-30)/8.0 (3-24) times, 10.0 (3-23)/6.0 (2-20) times, and 7.0 (3-12)/4.5 (1-10) times for groups I, II, and III. Total morphine consumption for the 3-day observation period was 12.5 (3-42) mg, 10.5 (2-29) mg, and 6.0 (1-20) for groups I, II, and III, respectively.
  
  
  CONCLUSIONS
  Pre-incisional epidural K+M+B treatment combined with continuous epidural anaesthesia and general anaesthesia provides an ideal pre-emptive analgesic therapy, exhibiting better postoperative pain relief than general anaesthesia and post-incisional K+M+B treatment.
authors.affiliation: Department of Anesthesiology, Tri-Service General Hospital, Taipei, Taiwan, Republic of China.
authors.forename: C T
authors.initials: CT
authors.lastname: Wu
authors.forename: C C
authors.initials: CC
authors.lastname: Yeh
authors.forename: J C
authors.initials: JC
authors.lastname: Yu
authors.forename: M M
authors.initials: MM
authors.lastname: Lee
authors.forename: P L
authors.initials: PL
authors.lastname: Tao
authors.forename: S T
authors.initials: ST
authors.lastname: Ho
authors.forename: C S
authors.initials: CS
authors.lastname: Wong
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000700:Analgesics / Q000008:administration & dosage*; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002045:Bupivacaine / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007649:Ketamine / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage*; D010149:Postoperative Pain / Q000517:prevention & control*; D011300:Preoperative Care; D016037:Single-Blind Method
chemical_list: D000700:Analgesics; D000779:Anesthetics, Local; D007649:Ketamine; D009020:Morphine; D002045:Bupivacaine