Perbandingan Ketamin dosis 0.5 mg/kgBB/IV dan 1 mg/kgbb/IV Sebagai Preemptif Analgesia pada Pascaoperasi Ginekologi Dengan Anestesi Umum

Abstract

Background: Excitatory amino acids participate in the activation of nociceptive dorsal horn neurons as agonists of the N-methyl-D-aspartate (NMDA) receptor. A series of experimental data provides evidence that NMDA receptors play a significant role in neuronal plasticity and processes leading to central sensitization to pain. The concept of preemptive analgesia on the assumption that the administration of an analgesic drug before the occurrence of nociceptive input can prevent sensitization and thus improve postoperative analgesia. Objectives: The aim of our study was to test the hypothesis that preemptive ketamine administration would further reduce postoperative pain in gynecology surgery. Method: After institutional review board approved the study protocol, all patients gave informed, written consent. 60 patients were randomized to a preemptive Ketamine 0,5 mg/kg (Group A) or Ketamine 1 mg/kg (Group B). Preoperatively visual analog scale (VAS) for pain assessment. Patient received premedication with midazolam 0,1 mg/kg iv, sulfas atropin 0,01 mg/kg at the operating room. Anesthesia was induced with propofol 2 mg/kg iv, fentanyl 2 μg/kg iv, and rocuronium 1 mg/kg iv was administered to facilitate tracheal intubation. Maintenance of anesthesia consisted of O2:N2O = 50%:50% and isoflurane 1%. In both groups, ketamine bolus IV was administered after induction of general anesthesia and 10 minute before incision. HR and BP was recorded during operation. Post operative pain assessed with VAS at 0,5, 1, 2, 8, 16, and 24 hour. Time first analgesic (TFA) was recorded, and if VAS pain scores > 3 cm (0= no pain, 10 = worst pain imaginable). Total fentanyl consumption were recorded for the post surgery. Result: The first analgesic required time was significantly shorter in groups A as compared with group B (p=0,0001). Group B had significantly decreased postoperative pain scores (VAS) at 0,5, 1, and 2 hours (p<0,05). There were no statistically significant differences VAS score between the two grups at 8, 16, and 24 hours post surgery (p>0,05). Conclusion: Ketamine 1 mg/kg intravena provide better preemptive analgesia in the first 2 hours post surgery, but both groups perform the same preemptive analgesia within 24 hours of post gynecology operation, and there were statistically significant diferences between the two grups in the first analgesia required time.

Latar belakang: Asam amino eksitatori berperan dalam aktivasi saraf nosisepsi kornu medula spinalis pada reseptor N-methyl-D-aspartate (NMDA). Data penelitian melaporkan reseptor NMDA berperan dalarn proses sensitisasi sentral terhadap nyeri. Analgesia preemptif berdasar bahwa pemberian obat analgesia sebelum input nosisepsi dapat mencegah sensitisasi dan memperbaiki nyeri pascabedah. Tujuan: Mengetahui efektifitas ketamin sebagai analgesia preemptif, terhadap derajat nyeri pascabedah ginekologi. Metode: Merupakan penelitian eksperimental randomized tersamar ganda. 60 pasien yang menjalani operasi elektif ginekologi dengan anestesi umum dibagi dalam 2 kelompok preemptif ketamin dosis 0,5 mg/kgBB/IV (kelompok A) dan dosis 1 mg/kgBB/IV (kelompok B) di RSUP H. Adam Malik Medan dan Rumah Sakit jejaring kota Medan; memenuhi kriteria inklusi dan eksklusi dibagi dalam dua kelompok dicatat tanda vital pra bedah. Premedikasi dengan midazolam 0,1 mg/kgBB/IV, Sulfas atropin 0,01 mg/kgBB/IV. Induksi dengan propofol 2 mg/kgBB/IV, rocuronium 1 mg/kgBB/IV, fentanyl 2 μg/kgBB/IV dilakukan intubasi. Rumatan anestesi dengan N2O:O2=50%: 50%, isofluran 1%, rocuronium intermiten. Selesai operasi pasien diekstubasi, dilakukan observasi di ruang pemulihan. Bila skor nyeri atau nilai Visual Analog Scale (VAS) >3 cm diberi fentanyl 1 μg /kgBB/IV. Dicatat tanda vital pascabedah, waktu pertama kali diberikan analgetik di ruangan, diberi analgetik fentanyl 1 μg /kgBB/IV bila VAS > 3 cm. Dicatat jumlah total kebutuhan fentanyl. Efek samping yang terjadi dicatat. Hasil: Secara statistik kelompok B memiliki waktu permintaan analgesia pertama kali lebih lama (p=0,0001), nilai VAS yang lebih rendah pada 0,5, 1, dan 2 jam pascabedah (p<0,05), dibandingkan dengan kelompok A. Nilai VAS pada jam 8, 16, dan 24 pascabedah berbeda tidak bermakna pada kedua kelompok preemptif ketamin (p>0,05). Simpulan: Ketamin dosis 1 mg/kgBB intravena memberikan waktu permintaan analgesia pertama yang lebih lama, nilai VAS yang lebih rendah pada 2 jam pertama pascabedah tetapi efek analgesia preemptif sama dengan ketamin dosis 0,5 mg/kgBB intravena dalam 24 jam pascabedah ginekologi.