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450: Nmda Antagonist: Ketamine for “balanced Analgesia” in the Perioperative Period What Is the Preferential Route?
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448. Postoperative cognitive dysfunction and cerebral oximetry in patients undergoing total knee arthroplasty under spinal anaesthesia F. Salazar1, M. Don˜ate2, T. Boget3, A. Bogdanovich1, M. Basora1, N. Fabregas4 1Hospital Clinic. Universidad de Barcelona, Anaesthesiology, Barcelona, Spain, 2Hospital Clinic. Universidad de Barcelona, Neuropsychology, Barcelona, Spain, 3Hospital Clinic, Neuropsychology, Barcelona, Spain, 4Hospital Clinic, Anaesthesiology, Barcelona, Spain Background and Aims: Postoperative cognitive dysfunction(POCD) is a decline in cognitive function detected days or weeks after cardiac and major non-cardiac surgery. Cerebral oximetry noninvasively measures regional cerebral oxygen saturation(rSO2) and significant correlation has been reported between intraoperative cerebral desaturation and POCD. We investigated the correlation between early postoperative cognitive performance and intraoperative rSO2 in a prospective observational setting. Methods: After institutional approval and informed consent, 150 patients undergoing elective total knee arthroplasty under spinal anaesthesia and 50 controls, all over 65 years, were included. Neurocognitive assessment was performed during the preoperative and postoperative period with both executive and learning/memory functions. Patients were classified according to the presence or absence of postoperative cognitive dysfunction. Cognitive dysfunction was defined when individual test score decreased 1.5 standard deviation in two or more of the eleven tests. The anaesthetic and surgical techniques were performed as usual. During surgery and in the early postoperative period, bilateral rSO2 was continuously measured using an INVOS4100 device. The decrease of rSO2 values was compared between the patients with and without cognitive dysfunction. Results: 130 patients completed the study but five patients were excluded because of a second surgery. 34%(27,2%) of the patients showed postoperative cognitive dysfunction at 3 months. We did not observe significant differences in the incidence or duration of decrease in rSO2 values between patients with and without POCD. Preoperative baseline values of right/left rSO2 were 65,61⫾7,75/ 65,79⫾5,49 and 65,04⫾7,28/64,98 ⫾6,01 respectively. The decrease and extent of rSO2 values was similar in patients with and without cognitive dysfunction: (right: ⫺13,48%⫾7,30 vs ⫺14,09%⫾6,66) and (left: ⫺13,80%⫾7,44 vs ⫺13,94⫾6,70) respectively. Only 7(20,6%) of the patients with POCD and 25% (27,5%) without had recovered the baseline values at the end of procedure. Conclusions: Postoperative cognitive dysfunction could not be predicted with cerebral oximetry in patients undergoing total knee arthroplasty under spinal anaesthesia.
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Miscellaneous
237
450. Nmda antagonist: ketamine for “balanced analgesia” in the perioperative period what is the preferential route? M. Hafez1, N. Helmy2 1Cairo University, Anesthesiology, Cairo, Egypt, 2Cairo University, Anesthesiology, Giza, Egypt Background and Aims: Ketamine is an anesthetic agent with potent analgesic properties. Its mode of action includes non competitive antagonism at (NMDA) receptorsand alocal anaesthetic effect. We investigated whether intraoperative sub-anesthetic doses of ketamine could represent an efficient constituent of “balanced analgesia”, and which is the preferential routeof administration,either systemic(intravenous) or epidural. Methods: Fifty patients scheduled for upper abdominal operations under combined epidural/general anesthesia were included. Before skin incision all patients received an epidural bolus followed by an infusion of continuous bupivacaine / fentanyl / clonidine mixture. The patients were randomly assigned to receive no ketamin(group 1); i.v . ketamine at a bolus dose of 0.25mg/kg followed by an infusion of 0.125mg/kg/h(group 2); 0.5mg/kg and 0.25mg/kg/h (group 3); epidural ketamine 0.25 mg/kg and 0.125 mg/kg/ h,(group 4); or epidural ketamine 0.5mg/kg and 0.25 mg/kg/ h(group 5). all i.v. and epidural anesthesia stopped at the end of surgeryand patients were connected to an i.v. morphine patientcontrolled analgesia(PCA) device. Intraoperative changes in plasma cortisol levels were determined with radioimmunoassay. Short term post-operative analgesia was assessed by pain anaogue scale (VAS) scores at rest, cough, and movements as well as by PCA requirements . residual pain was assessed by asking the patients at 2 weeks, 1 month, and 6 months. Results: Plasma cortisol levels were significantly lower in group m3 compared to other groups. Morphine PCA requirements were significantly reduced in group 3. These patients reported significantly less residual pain untill the sixth postoperative month. Conclusions: Our observations support the theory that sub-anesthetic doses of i. v. ketamine(0.5mg/kg bolus followed by 0.25 mg /kg/h )given during anesthesia are useful adjuvant in perioperative balanced analgesia. Moreover they showed that the systemic route clearly is the perferential route.
448. Postoperative cognitive dysfunction and cerebral oximetry in patients undergoing total knee arthroplasty under spinal anaesthesia F. Salazar1, M. Don˜ate2, T. Boget3, A. Bogdanovich1, M. Basora1, N. Fabregas4 1Hospital Clinic. Universidad de Barcelona, Anaesthesiology, Barcelona, Spain, 2Hospital Clinic. Universidad de Barcelona, Neuropsychology, Barcelona, Spain, 3Hospital Clinic, Neuropsychology, Barcelona, Spain, 4Hospital Clinic, Anaesthesiology, Barcelona, Spain Background and Aims: Postoperative cognitive dysfunction(POCD) is a decline in cognitive function detected days or weeks after cardiac and major non-cardiac surgery. Cerebral oximetry noninvasively measures regional cerebral oxygen saturation(rSO2) and significant correlation has been reported between intraoperative cerebral desaturation and POCD. We investigated the correlation between early postoperative cognitive performance and intraoperative rSO2 in a prospective observational setting. Methods: After institutional approval and informed consent, 150 patients undergoing elective total knee arthroplasty under spinal anaesthesia and 50 controls, all over 65 years, were included. Neurocognitive assessment was performed during the preoperative and postoperative period with both executive and learning/memory functions. Patients were classified according to the presence or absence of postoperative cognitive dysfunction. Cognitive dysfunction was defined when individual test score decreased 1.5 standard deviation in two or more of the eleven tests. The anaesthetic and surgical techniques were performed as usual. During surgery and in the early postoperative period, bilateral rSO2 was continuously measured using an INVOS4100 device. The decrease of rSO2 values was compared between the patients with and without cognitive dysfunction. Results: 130 patients completed the study but five patients were excluded because of a second surgery. 34%(27,2%) of the patients showed postoperative cognitive dysfunction at 3 months. We did not observe significant differences in the incidence or duration of decrease in rSO2 values between patients with and without POCD. Preoperative baseline values of right/left rSO2 were 65,61⫾7,75/ 65,79⫾5,49 and 65,04⫾7,28/64,98 ⫾6,01 respectively. The decrease and extent of rSO2 values was similar in patients with and without cognitive dysfunction: (right: ⫺13,48%⫾7,30 vs ⫺14,09%⫾6,66) and (left: ⫺13,80%⫾7,44 vs ⫺13,94⫾6,70) respectively. Only 7(20,6%) of the patients with POCD and 25% (27,5%) without had recovered the baseline values at the end of procedure. Conclusions: Postoperative cognitive dysfunction could not be predicted with cerebral oximetry in patients undergoing total knee arthroplasty under spinal anaesthesia.
•
Miscellaneous
237
450. Nmda antagonist: ketamine for “balanced analgesia” in the perioperative period what is the preferential route? M. Hafez1, N. Helmy2 1Cairo University, Anesthesiology, Cairo, Egypt, 2Cairo University, Anesthesiology, Giza, Egypt Background and Aims: Ketamine is an anesthetic agent with potent analgesic properties. Its mode of action includes non competitive antagonism at (NMDA) receptorsand alocal anaesthetic effect. We investigated whether intraoperative sub-anesthetic doses of ketamine could represent an efficient constituent of “balanced analgesia”, and which is the preferential routeof administration,either systemic(intravenous) or epidural. Methods: Fifty patients scheduled for upper abdominal operations under combined epidural/general anesthesia were included. Before skin incision all patients received an epidural bolus followed by an infusion of continuous bupivacaine / fentanyl / clonidine mixture. The patients were randomly assigned to receive no ketamin(group 1); i.v . ketamine at a bolus dose of 0.25mg/kg followed by an infusion of 0.125mg/kg/h(group 2); 0.5mg/kg and 0.25mg/kg/h (group 3); epidural ketamine 0.25 mg/kg and 0.125 mg/kg/ h,(group 4); or epidural ketamine 0.5mg/kg and 0.25 mg/kg/ h(group 5). all i.v. and epidural anesthesia stopped at the end of surgeryand patients were connected to an i.v. morphine patientcontrolled analgesia(PCA) device. Intraoperative changes in plasma cortisol levels were determined with radioimmunoassay. Short term post-operative analgesia was assessed by pain anaogue scale (VAS) scores at rest, cough, and movements as well as by PCA requirements . residual pain was assessed by asking the patients at 2 weeks, 1 month, and 6 months. Results: Plasma cortisol levels were significantly lower in group m3 compared to other groups. Morphine PCA requirements were significantly reduced in group 3. These patients reported significantly less residual pain untill the sixth postoperative month. Conclusions: Our observations support the theory that sub-anesthetic doses of i. v. ketamine(0.5mg/kg bolus followed by 0.25 mg /kg/h )given during anesthesia are useful adjuvant in perioperative balanced analgesia. Moreover they showed that the systemic route clearly is the perferential route.