Analgesia for spinal anesthesia positioning in elderly patients with proximal femoral fractures: Dexmedetomidine-ketamine versus dexmedetomidine-fentanyl
Ki Hwa Lee, Soo Jee Lee, Jae Hong Park, Se Hun Kim, Hyunseong Lee, Dae Seok Oh, Yong Han Kim, Yei Heum Park, Hyojoong Kim, Sang Eun Lee, Ki Hwa Lee, Soo Jee Lee, Jae Hong Park, Se Hun Kim, Hyunseong Lee, Dae Seok Oh, Yong Han Kim, Yei Heum Park, Hyojoong Kim, Sang Eun Lee
Abstract
Elderly patients with femoral fractures are anticipated to endure the most pain caused by positional changes required for spinal anesthesia. To improve pain relief, we compared the analgesic effects of intravenous dexmedetomidine-ketamine and dexmedetomidine-fentanyl combinations to facilitate patient positioning for spinal anesthesia in elderly patients with proximal femoral fractures. Forty-six patients were randomly assigned to two groups and received either 1 mg/kg of intravenous ketamine (group K) or 1 μg/kg of intravenous fentanyl (group F) concomitant with a loading dose of dexmedetomidine 1 μg/kg over 10 minutes, then dexmedetomidine infusion only was continued at 0.6 μg/kg/h for following 20 minutes, and titrated at a rate of 0.2 to 0.6 μg/kg/h until the end of surgery. After completion of the infusion of either ketamine or fentanyl, the patients were placed in the lateral position with the fracture site up. The pain score (0 = calm, 1 = facial grimacing, 2 = moaning, 3 = screaming, and 4 = unable to proceed because of restlessness or agitation) was used to describe the pain intensity in each step during the procedure (lateral positioning, hip flexion, and lumbar puncture), and quality score (0 = poor hip flexion, 1 = satisfactory hip flexion, 2 = good hip flexion, and 3 = optimal hip flexion) was used to describe the quality of posture. Group K showed a median pain score of 0 (0-1), 0 (0-0) and 0 (0-0) in lateral positioning, hip flexion and lumbar puncture, respectively, while group F showed a score of 3 (2.75-3), 3 (2-3) and 0 (0-1), respectively. The pain score in lateral positioning (P < .0001) and hip flexion (P < .0001) was significantly lower in group K than group F. Group K showed the significantly higher quality scores of spinal anesthesia positioning (P = .0044) than group F. Hemodynamic adverse effects, such as bradycardia, hypotension, and desaturation, were not significantly different between the groups. The administration of dexmedetomidine-ketamine showed a greater advantage in reducing pain intensity and increasing the quality with patient positioning during spinal anesthesia in elderly patients with proximal femoral fractures, without any serious adverse effects.
Conflict of interest statement
The authors have no conflicts of interest to disclose.
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References
- Roche J, Wenn RT, Sahota O, et al. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005;331:1374.
- Miller CP, Buerba RA, Leslie MP. Preoperative factors and early complications associated with hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures. Geriatr Orthop Surg Rehabil 2014;5:73–81.
- Lee DJ, Elfar JC. Timing of hip fracture surgery in the elderly. Geriatr Orthop Surg Rehabil 2014;5:138–40.
- Bech RD, Lauritsen J, Ovesen O, et al. The verbal rating scale is reliable for assessment of postoperative pain in hip fracture patients. Pain Res Treat 2015;2015:676212.
- Sandby-Thomas M, Sullivan G, Hall J. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur. Anaesthesia 2008;63:250–8.
- Yun M, Kim Y, Han M-K, et al. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block. Acta Anaesthesiologica Scandinavica 2009;53:1282–7.
- Iamaroon A, Raksakietisak M, Halilamien P, et al. Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur. Local Reg Anesth 2010;3:21.
- Bhana, Bhana N, Goa KL, et al. Dexmedetomidine. Drugs 2000;59:263–8.
- Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Pediatric Critical Care Medicine 2012;13:423–7.
- Erdil F, Demirbilek S, Begec Z, et al. The effects of dexmedetomidine and fentanyl on emergence characteristics after adenoidectomy in children. Anaesth Intensive Care 2009;37:571–6.
- Neuman MD, Silber JH, Elkassabany NM, et al. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology 2012;117:72–92.
- Dahanl A, Olofsenl E, Sigtermans M, et al. Population pharmacokinetic—pharmacodynamic modeling of ketamine-induced pain relief of chronic pain. Eur J Pain 2011;15:258–67.
- Levanen J, Makela M-L, Scheinin H. Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology 1995;82:1117–25.
- Kose EA, Honca M, Yılmaz E, et al. Comparison of effects of dexmedetomidine-ketamine and dexmedetomidine-midazolam combinations in transurethral procedures. Urology 2012;79:1214–9.
- Chun EH, Han MJ, Baik HJ, et al. Dexmedetomidine-ketamine versus Dexmedetomidine-midazolam-fentanyl for monitored anesthesia care during chemoport insertion: a Prospective Randomized Study. BMC anesthesiology 2015;16:49.
- Yu C, Li S, Deng F, et al. Comparison of dexmedetomidine/fentanyl with midazolam/fentanyl combination for sedation and analgesia during tooth extraction. Int J Oral Maxillofac Surg 2014;43:1148–53.
- Taheri R, Seyedhejazi M, Ghojazadeh M, et al. Comparison of ketamine and fentanyl for postoperative pain relief in children following adenotonsillectomy. Pak J Biol Sci 2011;14:572.
- Frey TM, Florin TA, Caruso M, et al. Effect of intranasal ketamine vs fentanyl on pain reduction for extremity injuries in children: the PRIME randomized clinical trial. JAMA Pediatr 2019;173:140–6.
- Stanley TH. The fentanyl story. J Pain 2014;15:1215–26.
- Jonkman K, Dahan A, van de Donk T, et al. Ketamine for pain. F1000Res 2017;6.
- Lötsch J. Pharmacokinetic–pharmacodynamic modeling of opioids. J Pain Symptom Manage 2005;29:90–103.
- Chau DL, Walker V, Pai L, et al. Opiates and elderly: use and side effects. Clin Interv Aging 2008;3:273–8.
- Sia S, Pelusio F, Barbagli R, et al. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: a comparison between femoral nerve block and intravenous fentanyl. Anesth Analg 2004;99:1221–4.
- Mei B, Meng G, Xu G, et al. Intraoperative sedation with dexmedetomidine is superior to propofol for elderly patients undergoing hip arthroplasty. Clin J Pain 2018;34:811–7.
- Su X, Meng Z-T, Wu X-H, et al. Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. Lancet 2016;388:1893–902.
- Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014;383:911–22.
- Kim KH. Safe Sedation and Hypnosis using Dexmedetomidine for Minimally Invasive Spine Surgery in a Prone Position. Korean J Pain 2014;27:313–20.
- Sengupta S, Ghosh S, Rudra A, et al. Effect of ketamine on bispectral index during propofol--fentanyl anesthesia: a randomized controlled study. Middle East J Anaesthesiol 2011;21:391–5.
- Hans, Hans P, Dewandre PY, et al. Comparative effects of ketamine on Bispectral Index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth 2005;94:336–40.
Source: PubMed