The Role of Ketamine and Dexmedetomidine in Opioid-Sparing Analgesia
Condition: Ketamine-Induced Mood Disorder
MeSH terms: Mood Disorders
Study type: Interventional

Summary: 
      Optimal multimodal opioid-sparing analgesic technique is considered as one of the most
      important Enhanced recovery pathways (ERPs) or enhanced recovery after surgery (ERAS)
      interventions that mitigate the undesirable effects of surgical stress response.
      Implementation of ERP has been shown to reduce postoperative complications and shorten the
      hospital LOS.
    

Detailed description: 
      In this study, the investigator hypothesizes that by using continuous infusion of ketamine or
      dexmedetomidine in addition to NSAIDs, the investigator can reduce or completely eliminate
      opioid use in adult patients after cardiac surgery.

      The anesthesia technique was composed of the following 10 steps:

        1. Premedication with oral Pregabalin 75 mg the night before surgery;

        2. For induction and maintenance of anesthesia: - Midazolam 0.02- 0.05 mg/kg bolus,
           -Fentanyl (cumulative dose 5-15 μg/kg), followed by continuousInfusion of Fentanyl; 2-3
           μg/kg /h as a maintenance dose, Rocuronium: (0.6-1.0 mg/kg - intubation dose, followed
           by continuous Infusion of Rocuronium; 0.075-0.15 mg/kg/h as a maintenance dose, and
           Sevoflurane in a dose of 0.8-1.0 (MAC).

        3. Ventilation: Lung protective ventilation (Vt 6 ml/kg predicted body weight, + PEEP 5, +
           FiO2 60%), and we conducted a recruitment maneuver in order to prevent atelectasis.

        4. Monitoring: Routine monitors (ECG, SpO2, arterial line inserted using local anesthesia
           for pressure monitor and repeated ABG, Central line inserted after induction of
           anesthesia for monitoring CVP, ETCO2, core temperature through urinary catheter, and
           Activated Clotting Time (ACT) for monitoring of coagulation). Cerebral oximetry, and
           Bispectral Index (BIS) as an indicator of depth anesthesia was kept between 40 and 60.
           (5) Cardiopulmonary Bypass (CPB): Goal directed perfusion maintaining MAP ≥ 60, using
           Phenylephrine and Norepinephrine infusion. Additional propofol infusion (25 -
           50µg/kg/min) was administered during CPB to maintain BIS between 40 and 60. Smooth
           conduct of CPB, with Mild hypothermia (28°C 32°C). Rewarming at the end of the
           procedure, Goal postop temperature >36 °C.

      (6) Perioperative Glycemic Control: Insulin infusion, and the perioperative Goal glucose ≤
      150 - 180.

      (7)Perioperative hemoglobin concentration: Goal hemoglobin transfusion trigger: 7.5
      regardless of patient Age and Comorbidity. (8) Protamine: Post CPB protamine (heparin
      reversal) given up to the full dose (5 mg/kg after test dose) to return to baseline ACT.

      (9) Multimodal analgesia: In addition to continuous infusion of Fentanyl, at the end of the
      surgery, Paracetamol: 1 gm IV infusion over 15 min was administered with the sternum closure,
      and Surgical Incision Field Block using 30 ml of Bupivacaine 0.5% just before dressing. The
      patient will then be transferred intubated to Surgical ICU (SICU). (10) In SICU:
      Postoperative analgesia will be carried out for all groups. All patients will receive IV
      fentanyl via patient-controlled analgesia (PCA) with (10 µg.mL-1, with a bolus of 15 µg, and
      lockout 10 minutes, maximum cumulative dose of 90µ.hr-1 and no background dose). Before
      extubation, analgesia will be given as nurse-controlled analgesia (NCA) with the same
      regimen, depending on the sudden rise in HR or MABP ≥20% of the baseline. The total of 24 h.
      opioid consumption will be recorded.

      At this step, and for opioid-sparing analgesia and sedation, using the sealed envelope
      technique, patients will be randomly divided into three groups: Group (K): (n=30) will
      receive ketamine infusion of 1-2 μg/kg/min (0.12 mg/kg/h) titrated to the desired level of
      sedation. Group (D): (n=30) will receive Dexmedetomidine infusion 0.1- 0.2 μg/kg/hour
      titrated to desired level of sedation. Group (C): (n=30) will receive fentanyl only. All
      hemodynamic monitors used intraoperatively are continued in SICU, and in addition, the
      following parameters are used to monitor the level of analgesia and sedation -During
      mechanical ventilation: Richmond Agitation-Sedation Scale
    

Intervention name(s): Ketamine
Intervention type(s): Drug
Intervention description(s): drug
Other intervention name(s): dexmedetomidine
Intervention MeSH terms: Dexmedetomidine; Ketamine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: ketamine; dexmedetomidine; Analgesia; Cardiac Surgery; Sedation