title: Is the combination of morphine with ketamine better than morphine alone for postoperative intravenous patient-controlled analgesia?
abstract: BACKGROUND
  The addition of ketamine to morphine for patient-controlled analgesia (PCA) is supported by previous basic and clinical research, but has been challenged by subsequent negative studies. Important limitations of previous studies are the low number of patients analyzed, the use of morphine-ketamine combinations that may not the optimal, and that not all the relevant outcomes have been analyzed. In this study, we compared the combination of morphine and ketamine with morphine alone for postoperative PCA in large patient groups. We used a morphine-ketamine combination identified by an optimization procedure in our previous study.
  
  
  METHODS
  After major elective orthopedic surgery, 352 patients received either PCA with morphine bolus 1.5 mg (Group M, n = 176) or a bolus of morphine plus ketamine 1.5 mg each (Group MK, n = 176) in a randomized, double-blind fashion. Unsatisfactory treatment was defined as the occurrence of either inadequate analgesia or unacceptable side effects. In addition, total consumption of PCA drugs, duration of PCA use, direct medical costs, and number of patients with chronic postoperative pain 3 and 6 mo after operation were recorded.
  
  
  RESULTS
  The incidence of unsatisfactory treatment was 33.0% in Group M and 36.9% in Group MK (P = 0.50). No significant differences were found between the groups with respect to secondary end points.
  
  
  CONCLUSIONS
  Small-dose ketamine combined with morphine for PCA provides no benefit to patients undergoing major orthopedic surgery and cannot be recommended for routine use.
authors.affiliation: Department of Anesthesiology, Inselspital, Bern, Switzerland. gorazd.sveticic@insel.ch
authors.forename: Gorazd
authors.initials: G
authors.lastname: Sveticic
authors.forename: Farzan
authors.initials: F
authors.lastname: Farzanegan
authors.forename: Patrick
authors.initials: P
authors.lastname: Zmoos
authors.forename: Sandra
authors.initials: S
authors.lastname: Zmoos
authors.forename: Urs
authors.initials: U
authors.lastname: Eichenberger
authors.forename: Michele
authors.initials: M
authors.lastname: Curatolo
mesh_terms: D000328:Adult; D000368:Aged; D016058:Analgesia, Patient-Controlled; D000700:Analgesics / Q000008:administration & dosage* / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007649:Ketamine / Q000008:administration & dosage* / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects; D019637:Orthopedic Procedures; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control*; D017060:Patient Satisfaction; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D007649:Ketamine; D009020:Morphine