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Original Research: THORACIC SURGERY |

Morphine With Adjuvant Ketamine vs Higher Dose of Morphine Alone for Immediate Postthoracotomy Analgesia:

Nachum Nesher, MD; Margaret P. Ekstein, MD; Yoseph Paz, MD; Nissim Marouani, MD; Shoshana Chazan, RN; Avi A. Weinbroum, MD
Author and Funding Information

From the Department of Cardiothoracic Surgery (Dr. Nesher), Department of Anesthesia and Intensive Care Medicine (Drs. Ekstein and Weinbroum), Department of Cardiothoracic Surgery (Dr. Paz), and Acute Pain Service (Dr. Marouani and Ms. Chazan), Department of Anesthesia and Intensive Care Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Correspondence to: Avi A. Weinbroum, MD, Professor of Anesthesiology and CCM, Director, Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel; e-mail: draviw@tasmc.health.gov.il


Parts of this study were presented at the Euroanaesthesia 2003 Meeting, Glasgow, Scotland May 31–June 3, 2003; and at the fifth International Congress on Coronary Artery Disease, Florence, Italy, October 19–22, 2003.

No financial support was received for this clinical trial.

The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(1):245-252. doi:10.1378/chest.08-0246
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Background:  Thoracotomy is associated with severe pain. We hypothesized that the concomitant use of a subanesthetic dose of ketamine plus a two-third–standard morphine dose might provide more effective analgesia with fewer side effects than a standard morphine dose for early pain control.

Methods:  We conducted a 6-month randomized, double-blind study in patients undergoing thoracotomy for minimally invasive direct coronary artery bypass or for lung tumor resection. After extubation, when objectively awake (≥ 5/10 visual analogue scale [VAS]) and complaining of pain (≥ 5/10 VAS), patients were connected to patient-controlled IV analgesia delivering 1.5 mg of morphine plus saline solution (MO) or 1.0 mg of morphine plus a 5-mg ketamine bolus (MK), with a 7-min lockout time. Rescue IM diclofenac, 75 mg, was available. Follow-up lasted 4 h.

Results:  Forty-one patients completed the study. MO patients (n = 20) used 6.8 ± 1.9 mg/h (mean ± SD) and 5.5 ± 3.6 mg/h of morphine during the first and second hours, respectively; MK patients (n = 21) used 3.7 ± 1.2 mg/h and 2.8 ± 2.3 mg/h, respectively (p < 0.01). The 4-h activation rate of the device was double in the MO patients than in the MK patients (66 ± 54 vs 28 ± 20, p < 0.001). The maximal self-rated pain score was 5.6 ± 1.0 for the MO group vs 3.7 ± 0.7 for the MK group (p < 0.01). Four MO patients vs one MK patient required diclofenac; 6 MO patients but no MK patients had oxygen saturation by pulse oximetry < 94% on a fraction of inspired oxygen of 0.4 (p < 0.01); two MO patients required reintubation. Paco2 was higher in the MO group (40 ± 6 mm Hg vs 33 ± 5 mm Hg, p < 0.05). Heart rate, BP, and incidence of nausea/vomiting were similar; no ketamine-related hallucinations were detected.

Conclusions:  Subanesthetic ketamine combined with a 35%-lower morphine dose provided equivalent pain control compared to the standard morphine dose alone, with fewer adverse side effects and a 45% reduction in morphine consumption.

Trial registration:  ClinicalTrials.gov Identifier: NCT00625911

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