A randomized controlled trial of infraorbital block using ketamine 1% for intra- and postoperative analgesia in children for ambulatory cleft lip correction
Abstract
BACKGROUND In Indonesia, cleft lip correction surgery is often done as a social program in remote areas with limited resources. This study aimed to assess the effectiveness of ketamine, a cheaper and more accessible alternative, as a local analgesia in infraorbital block and to determine the possibility of ketamine as an alternative local analgesic drug for intraoperative and postoperative periods.
METHODS This was a randomized controlled trial in children aged 2 months to 5 years who underwent cleft lip correction surgery at Cipto Mangunkusumo Hospital in 2016. Subjects were randomly divided into two groups: ketamine and bupivacaine. Standard general anesthesia with endotracheal intubation was performed in each group. Bilateral intraoral infraorbital block was performed using ketamine 1% 0.5 ml or bupivacaine 0.25% 0.5 ml. Postoperative evaluation includes pain scores based on the face, leg, activity, cry, and consolability (FLACC) scale and analgesic duration.
RESULTS A total of 36 subjects were enrolled in this study, with 18 in each group. Both groups received the same total amount of fentanyl addition intraoperatively (p = 1). The postoperative FLACC pain scale scores between the two groups were not different, with p>0.05 in every measurement. The mean duration of postoperative analgesia in the ketamine group was longer than the bupivacaine group (15–13.49 hours, p = 0.031).
CONCLUSIONS Infraorbital block with 1% ketamine 0.5 mg/kg was similarly effective for intraoperative and postoperative analgesia but had a longer duration than that with 0.25% bupivacaine 0.5 ml in ambulatory cleft lip correction.
References
Deshpande JK, Kelly KJ, Baker M. Anesthesia for pediatric plastic surgery. In: Motoyama EK, Davis PJ. Smith's anesthesia for infants and children. 9th ed. St. Louis: Mosby Elsevier; 2016.
Kwari DY, Chinda JY, Olasoji HO, Adeosun OO. Cleft lip and palate surgery in children: anaesthetic considerations. Afr J Paediatr Surg. 2010;7(3):174-7. https://doi.org/10.4103/0189-6725.70420
Reena, Bandyopadhyay KH, Paul A. Postoperative analgesia for cleft lip and palate repair in children. J Anaesthesiol Clin Pharmacol. 2016;32(1):5−11. https://doi.org/10.4103/0970-9185.175649
Singam A, Rallabhandi S, Dhumey T. Comparison of greater palatine nerve block with intravenous fentanyl for postoperative analgesia following palatoplasty in children. J Evol Med Dent Sci. 2020;9(35):2526−31. https://doi.org/10.14260/jemds/2020/549
Russell P, von Ungern-Sternberg BS, Schug SA. Perioperative analgesia in pediatric surgery. Curr Opin Anesthesiol. 2013;26(4):420−7. https://doi.org/10.1097/ACO.0b013e3283625cc8
Bosenberg A. Benefits of regional anesthesia in children. Paediatr Anaesth. 2011;22(1):10−8. https://doi.org/10.1111/j.1460-9592.2011.03691.x
Persson J. Ketamine in pain management. CNS Neurosci Ther. 2013;19(6):396−402. https://doi.org/10.1111/cns.12111
Pai A, Heining M. Ketamine. Continuing Educ Anaesthesia Crit Care Pain. 2007;7(2):59−63. https://doi.org/10.1093/bjaceaccp/mkm008
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Paediatr Nurs. 1997;23(3):293−7.
Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010;19(1):55−61. https://doi.org/10.4037/ajcc2010624
Sawynok J. Topical and peripheral ketamine as an analgesic. Anesth Analg. 2014;119(1):170−8. https://doi.org/10.1213/ANE.0000000000000246
Grewal G, Garg K, Grewal A. Bilateral infraorbital nerve block versus intravenous pentazocine: a comparative study on postoperative pain relief following cleft lip surgery. J Clin Diagn Res. 2015;9(5):UC04−6. https://doi.org/10.7860/JCDR/2015/11953.5984
Dahmani S, Michelet D, Abback PS, Wood C, Brasher C, Nivoche Y, et al. Ketamine for perioperative pain management in children: a meta-analysis of published studies. Pediatr Anaesth. 2011;21(6):636−52. https://doi.org/10.1111/j.1460-9592.2011.03566.x
Eikermann M, Grosse-Sundrup M, Zaremba S, Henry ME, Bittner EA, Hoffmann U, et al. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116(1):35−46. https://doi.org/10.1097/ALN.0b013e31823d010a
Li K, Yang J, Han X. Ketamine attenuates sepsis-induced acute lung injury via regulation of HMGB1-RAGE pathways. Int Immunopharmacol. 2016;34:114−28. https://doi.org/10.1016/j.intimp.2016.01.021
Abdel-Ghaffar HS, Abdel-Aziz NGE, Mostafa MF, Osman AK, Thabet NM. Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair. Braz J Anesthesiol. 2018;68(3):266−73. https://doi.org/10.1016/j.bjane.2018.01.011
Copyright (c) 2021 Andi Ade Wijaya Ramlan, Apriliana Ratnaningrum, Arif Hari Martono Marsaban
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors who publish with Medical Journal of Indonesia agree to the following terms:
- Authors retain copyright and grant Medical Journal of Indonesia right of first publication with the work simultaneously licensed under a Creative Commons Attribution-NonCommercial License that allows others to remix, adapt, build upon the work non-commercially with an acknowledgment of the work’s authorship and initial publication in Medical Journal of Indonesia.
- Authors are permitted to copy and redistribute the journal's published version of the work non-commercially (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in Medical Journal of Indonesia.
