Advertisement

Utilization of Ketamine in Total Knee and Hip Joint Arthroplasty: An Evidence-Based Review

Published:August 16, 2022DOI:https://doi.org/10.1016/j.jopan.2022.04.019

      Abstract

      Purpose

      To evaluate the efficacy of ketamine in total knee and hip arthroplasty.

      Design

      Evidence-based review.

      Methods

      Following the guidelines outlined in the PRISMA statement, a comprehensive search was conducted using Google Scholar, PubMed, CINAHL, Cochrane Collaboration, and other grey literature. Only randomized controlled studies and pre-appraised evidence such as systematic review and meta-analysis examining the effects of ketamine in total knee and hip arthroplasty were included. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide.

      Findings

      Three systematic reviews and meta-analyses and 2 randomized controlled trials involving 1284 patients were included in this review. The use of ketamine reduced pain scores within the 24 hours after surgery. In addition, evidence suggests that patients who were treated with ketamine consumed fewer opioids 24 and 48 hours after surgery. Furthermore, ketamine reduced the incidence of postoperative nausea and vomiting with no effects on the incidence of hallucinations and central nervous system side effects. All studies included in the review were categorized as Level I and rated Grade A implying strong confidence in the true effects of ketamine in all outcome measures in the review.

      Conclusions

      The current evidence demonstrates the viability of ketamine as a safe and effective alternative to opioids in the perioperative setting with major total joint arthroplasty surgery. Decreased pain scores and opioid consumption up to 48 hours into the postoperative period were observed in a number of the appraised articles.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of PeriAnesthesia Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Anger M
        • Valovska T
        • Beloeil H
        • et al.
        PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations.
        Anaesthesia. 2021; 76: 1082-1097https://doi.org/10.1111/anae.15498
        • Li J
        • Ma Y
        • Xiao L
        Postoperative pain management in total knee arthroplasty.
        Orthop Surg. 2019; 11: 755-761https://doi.org/10.1111/os.125353
        • Singh J
        • Lemay C
        • Nobel L
        • et al.
        Association of early postoperative pain trajectories with longer-term pain outcome after primary total knee arthroplasty.
        JAMA Netw Open. 2019; 2e1915105https://doi.org/10.1001/jamanetworkopen.2019.15105
        • Gan T.
        Poorly controlled postoperative pain: prevalence, consequences, and prevention.
        J Pain Res. 2017; 10: 2287-2298https://doi.org/10.2147/jpr.s144066
        • Stephan B
        • Parsa F.
        Avoiding opioids and their harmful side effects in the postoperative patient: exogenous opioids, endogenous endorphins, wellness, mood, and their relation to postoperative pain.
        Hawaii J Med Public Health. 2016; 75: 63-67
        • Wick E
        • Grant M
        • Wu C.
        Postoperative multimodal analgesia pain management with non-opioid analgesics and techniques.
        JAMA Surg. 2017; 152: 691https://doi.org/10.1001/jamasurg.2017.0898
        • Memtsoudis S
        • Poeran J
        • Zubizarreta N
        • et al.
        Association of multimodal pain management strategies with perioperative outcomes and resource utilization.
        Anesthesiology. 2018; 128: 891-902https://doi.org/10.1097/aln.0000000000002132
        • Laskowski K
        • Stirling A
        • McKay W
        • Lim H.
        A systematic review of intravenous ketamine for postoperative analgesia.
        Can J Anaesth. 2011; 58: 911-923https://doi.org/10.1007/s12630-011-9560-0
        • Jouguelet-Lacoste J
        • La Colla L
        • Schilling D
        • Chelly J
        The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature.
        Pain Med. 2015; 16: 383-403https://doi.org/10.1111/pme.12619
        • Gorlin A
        • Rosenfeld D
        • Ramakrishna H.
        Intravenous sub-anesthetic ketamine for perioperative analgesia.
        J Anaesthesiol Clin Pharmacol. 2016; 32: 160https://doi.org/10.4103/0970-9185.182085
        • Brinck E
        • Tiippana E
        • Heesen M
        • et al.
        Perioperative intravenous ketamine for acute postoperative pain in adults.
        Cochrane Database Syst Rev. 2018; https://doi.org/10.1002/14651858.cd012033.pub4
      1. American Joint Arthroplasty Registry (AJRR). The seventh annual report of the AJRR on hip and knee arthroplasty; 2021. Available at: https://www.aaos.org/globalassets/registries/2020-aaos-ajrr-annual-report-preview_final.pdf. Accessed December 17, 2021.

        • Zaslansky R
        • Meissner W
        • Chapman C.
        Pain after orthopaedic surgery: differences in patient reported outcomes in the United States vs internationally. An observational study from the PAIN OUT dataset.
        Br J Anaesth. 2018; 120: 790-797https://doi.org/10.1016/j.bja.2017.11.109
        • Seo S
        • Kim O
        • Seo J
        • Kim D
        • Kim Y
        • Park B.
        Comparison of the effect of continuous femoral nerve block and adductor canal block after primary total knee arthroplasty.
        Clin Orthop Surg. 2017; 9: 303https://doi.org/10.4055/cios.2017.9.3.303
        • Riddell J
        • Trummel J
        • Onakpoya I.
        Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis.
        Br J Anaesth. 2019; 123: 325-334https://doi.org/10.1016/j.bja.2019.05.043
        • Pan L
        • Shen Y
        • Ma T
        • Xue H.
        The efficacy of ketamine supplementation on pain management for knee arthroscopy.
        Medicine (Baltimore). 2019; 98: e16138https://doi.org/10.1097/md.0000000000016138
        • Page MJ
        • McKenzie JE
        • Bossuyt PM
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71https://doi.org/10.1136/bmj.n71
        • Dang D
        • Dearholt S.
        Johns Hopkins Nursing Evidence-Based Practice.
        3rd ed. Sigma Theta Tau International, Indianapolis, IN2017
        • Wang P
        • Yang Z
        • Shan S
        • Cao Z
        • Wang Z.
        Analgesic effect of perioperative ketamine for total hip arthroplasties and total knee arthroplasties: a PRISMA-compliant meta-analysis.
        Medicine (Baltimore). 2020; 99: e22809https://doi.org/10.1097/MD.0000000000022809
        • Xu B
        • Wang Y
        • Zeng C
        • et al.
        Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies.
        BMJ Open. 2019; 9e028337https://doi.org/10.1136/bmjopen-2018-028337
        • Li Z
        • Chen Y.
        Ketamine reduces pain and opioid consumption after total knee arthroplasty: a meta-analysis of randomized controlled studies.
        Int J Surg. 2019; 70: 70-83https://doi.org/10.1016/j.ijsu.2019.08.026
        • Paulin VS
        • Bakshi SG
        • Hegde PC
        • et al.
        Inkk Trial - Intraoperative ketamine for perioperative pain management following total knee endoprosthetic arthroplasty in oncology: a double-blinded randomized trial.
        Braz J Anesthesiol. 2021; (S0104-0014(21)00295-5)https://doi.org/10.1016/j.bjane.2021.07.014
        • Koh HJ
        • In Y
        • Kim ES
        • et al.
        Does central sensitization affect hyperalgesia after staged bilateral total knee arthroplasty? A randomized controlled trial.
        J Int Med Res. 2020; 48 (300060520938934)https://doi.org/10.1177/0300060520938934
        • Tan TL
        • Longenecker AS
        • Rhee JH
        • et al.
        Intraoperative ketamine in total knee arthroplasty does not decrease pain and narcotic consumption: a prospective randomized controlled trial.
        J Arthroplasty. 2019; 34: 1640-1645https://doi.org/10.1016/j.arth.2019.04.017
        • Zhang J
        • Shi K
        • Jia H.
        Ketamine and bupivacaine attenuate postoperative pain following total knee arthroplasty: a randomized clinical trial.
        Exp Ther Med. 2018; 15: 5537-5543https://doi.org/10.3892/etm.2018.6104
        • Ji S
        • Yao F
        • Huang L
        • et al.
        Outcomes of postoperative analgesia with ketamine combined with sufentanyl in patients after total knee arthroplasty.
        Jiangsu Med J. 2015; 41: 1786-1788
        • Liu M
        • Liao R
        • Yu J
        • et al.
        The effect of small dose ketamine for postoperative analgesia after total knee arthroplasty under unilateral spinal anesthesia.
        J Guangdong Med Coll. 2015; 33: 205-207
        • Cengiz P
        • Gokcinar D
        • Karabeyoglu I
        • et al.
        Intraoperative low-dose ketamine infusion reduces acute postoperative pain following total knee arthroplasty surgery: a prospective, randomized double-blind placebo controlled trial.
        J Coll Physicians Surg Pak V. 2014; 24: 299-303
        • Martinez V
        • Cymerman A
        • Ben Ammar S
        • et al.
        The analgesic efficiency of combined pregabalin and ketamine for total hip arthroplasty: a randomised, double-blind, controlled study.
        Anaesthesia. 2014; 69: 46-52https://doi.org/10.1111/anae.12495
        • Chen J
        • Li J
        • Wang D.
        Effect of small dose ketamine combined with morphine used for postoperative analgesia in elderly patients undergoing total knee arthroplasty surgery.
        Chin J Geriatr. 2013; 32: 1322-1325
        • Guara Sobrinho H
        • Garcia JB
        • Vasconcelos JW
        • et al.
        Analgesic efficacy of the intra-articular administration of S(+)- ketamine in patients undergoing total knee arthroplasty.
        Rev Bras Anestesiol. 2012; 62: 665-675
        • Zhao T.
        Application of intravenous low-dose ketamine for preemptive analgesia in total knee arthroplasty.
        China Modern Med. 2012; 19: 86-87
        • Wang S
        • Li Y
        • Tan P
        • et al.
        Low-dose ketamine combined with sufentanil PCIA for postoperative analgesia after hip arthroplasty.
        Chin Manip Rehab Med. 2011; 2: 113
        • Zhai Q.
        Comparison of the effects of low-dose ketamine and tramadol on hip arthroplasty in elderly patients.
        Chin J Prim Med Pharm. 2010; 17: 1395-1396
        • Aveline C
        • Gautier JF
        • Vautier P
        • et al.
        Postoperative analgesia and early rehabilitation after total knee arthroplasty: a comparison of continuous low-dose intravenous ketamine versus nefopam.
        Eur J Pain. 2009; 13: 613-619https://doi.org/10.1016/j.ejpain.2008.08.003
        • Cagla Ozbakis Akkurt B
        • Inanoglu K
        • Kalaci A
        • et al.
        Effects on intravenous small dose ketamine and midazolam on postoperative pain following knee arthroscopy.
        Pain Pract. 2009; 9: 289-295https://doi.org/10.1111/j.1533-2500.2009.00278.x 37
        • Perrin SB
        • Purcell AN.
        Intraoperative ketamine may influence persistent pain following knee arthroplasty under combined general and spinal anaesthesia: a pilot study.
        Anaesth Intensive Care. 2009; 37: 248-253https://doi.org/10.1177/0310057X0903700202
        • Remerand F
        • Le Tendre C
        • Baud A
        • et al.
        The early and delayed analgesic effects of ketamine after total hip arthroplasty: a prospective, randomized, controlled, double-blind study.
        Anesth Analg. 2009; 109: 1963-1971https://doi.org/10.1213/ANE.0b013e3181bdc8a0
        • Liu D
        • Lv Z
        • Liu M.
        Epidural ketamine and clonidine in preemptive analgesia for total hip arthroplasty.
        Pain Clin J. 2008; 2: 35-39
        • Wang F.
        Low-dose ketamine improves analgesia quality and rehabilitation after total knee arthroplasty.
        J North China Univ Sci Technol (Health Sciences Edition). 2007; 9: 779-781
        • Adam F
        • Chauvin M
        • Du Manoir B
        • et al.
        Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty.
        Anesth Analg. 2005; 100: 475-480https://doi.org/10.1213/01.ANE.0000142117.82241.DC
        • Lauretti GR
        • Rodrigues AM
        • Paccola CA
        • et al.
        The combination of epidural clonidine and S(+)-ketamine did not enhance analgesic efficacy beyond that for each individual drug in adult orthopedic surgery.
        J Clin Anesth. 2005; 17: 79-84https://doi.org/10.1016/j.jclinane.2004.04.006
        • Ma H
        • Wang G.
        The postoperative analgesic effects of epidural ketamine in patients undergoing total knee arthroplasty surgery.
        Hebei Med J. 2005; 27: 579-580
        • Himmelseher S
        • Ziegler-Pithamitsis D
        • Argiriadou H
        • et al.
        Small-dose S (+)-ketamine reduces postoperative pain when applied with ropivacaine in epidural anesthesia for total knee arthroplasty.
        Anesth Analg. 2001; 92: 1290-1295https://doi.org/10.1097/00000539-200105000-00040
        • Wong CS
        • Liaw WJ
        • Tung CS
        • et al.
        Ketamine potentiates analgesic effect of morphine in postoperative epidural pain control.
        Reg Anesth. 1996; 21: 534-541
        • Baratta JL
        • Schwenk ES
        • Viscusi ER.
        Clinical consequences of inadequate pain relief: barriers to optimal pain management.
        Plast Reconstr Surg. 2014; 134: 15S-21Shttps://doi.org/10.1097/PRS.0000000000000681
        • Manion J
        • Waller M
        • Clark T
        • Massingham J
        • Neely G.
        Developing modern pain therapies.
        Front Neurosci. 2019; 13https://doi.org/10.3389/fnins.2019.01370
        • Goode V
        • Morgan B
        • Muckler V
        • Cary M
        • Zdeb C
        • Zychowicz M.
        Multimodal pain management for major joint arthroplasty surgery.
        Orthopaedic Nursing. 2019; 38: 150-156https://doi.org/10.1097/nor.0000000000000525
        • Dave S
        • Shriyan D
        • Gujjar P.
        Newer drug delivery systems in anesthesia.
        J Anaesthesiol Clin Pharmacol. 2017; 33: 157-163https://doi.org/10.4103/joacp.JOACP_63_16
      2. Opioid Overdose Crisis | National Institute on Drug Abuse. National Institute on Drug Abuse. Published 2021. Available at: https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis. Accessed February 7, 2021.

        • Nahin R.
        Estimates of pain prevalence and severity in adults: United States, 2012.
        J Pain. 2015; 16: 769-780https://doi.org/10.1016/j.jpain.2015.05.002
        • Seymour RB
        • Ring D
        • Higgins T
        • Hsu JR.
        Leading the way to solutions to the opioid epidemic: AOA critical issues.
        J Bone Joint Surg Am. 2017; 99: e113
        • Schoenfeld AJ
        • Jiang W
        • Chaudhary MA
        • Scully RE
        • Koehlmoos T
        • Haider AH.
        Sustained prescription opioid use among previously opioid-naive patients insured through TRICARE (2006-2014).
        JAMA Surg. 2017; 152: 1175-1176https://doi.org/10.1001/jamasurg.2017.2628
        • Ladha KS
        • Gagne JJ
        • Patorno E
        • et al.
        Opioid overdose after surgical discharge.
        JAMA. 2018; 320: 502-504https://doi.org/10.1001/jama.2018.6933
        • Fink BC
        • Uyttebrouck O
        • Larson RS.
        An effective intervention: limiting opioid prescribing as a means of reducing opioid analgesic misuse, and overdose deaths.
        J Law Med Ethics. 2020; 48: 249-258https://doi.org/10.1177/1073110520935336
        • Rosero E
        • Joshi G.
        Preemptive, preventive, multimodal analgesia.
        Plast Reconstr Surg. 2014; 134: 85S-93Shttps://doi.org/10.1097/PRS.0000000000000671
        • Wainwright T
        • Gill M
        • McDonald D
        • et al.
        Consensus statement for perioperative care in total hip arthroplasty and total knee arthroplasty surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
        Acta Orthop. 2019; 91: 3-19https://doi.org/10.1080/17453674.2019.1683790
        • Zhu S
        • Qian W
        • Jiang C
        • Ye C
        • Chen X.
        Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis.
        Postgrad Med J. 2017; 93: 736-742https://doi.org/10.1136/postgradmedj-2017-134991
        • Vadivelu N
        • Schermer E
        • Kodumudi V
        • Belani K
        • Urman RD
        • Kaye AD.
        Role of ketamine for analgesia in adults and children.
        J Anaesthesiol Clin Pharmacol. 2016; 32: 298-306https://doi.org/10.4103/0970-9185.168149
        • Radvansky BM
        • Shah K
        • Parikh A
        • Sifonios AN
        • Le V
        • Eloy JD.
        Role of ketamine in acute postoperative pain management: a narrative review.
        Biomed Res Int. 2015; 2015749837https://doi.org/10.1155/2015/749837
        • Bell RF
        • Kalso EA.
        Ketamine for pain management.
        Pain Rep. 2018; 3: e674https://doi.org/10.1097/PR9.0000000000000674
        • Abdullatif E
        • Amin M
        • Lotfy S.
        Comparative study between preoperative ketamine bolus dose versus ketamine bolus plus infusion for perioperative analgesia in orthopedic surgery.
        Sci J Al-Azhar Med Fac Girls. 2020; 4: 660-666https://doi.org/10.4103/sjamf.sjamf_129_20
        • Dahmardeh A
        • Keykha A
        • Bamerian N.
        Effect of using low-dose Ketamine after spinal anesthesia on the severity of postoperative pain in patients with orthopedic surgery.
        Arch Anesthesiolog Crit Care. 2017; 3: 378-381
        • Rosenbaum SB
        • Gupta V
        • Palacios JL
        Ketamine.
        ([Updated 2021 Feb 19])StatPearls [Internet]. StatPearls Publishing, Treasure Island (FL)2021 (Available at:) (Accessed December 10, 2021)
        • Pendi A
        • Field R
        • Farhan S
        • Eichler M
        • Bederman S.
        Perioperative ketamine for analgesia in spine surgery: a meta-analysis of randomized controlled trials.
        Spine (Phila Pa 1976). 2018; 43: E299-E307https://doi.org/10.1097/BRS.0000000000002318
        • Wylde V
        • Sayers A
        • Lenguerrand E
        • et al.
        Preoperative widespread pain sensitization and chronic pain after hip and knee arthroplasty.
        Pain. 2015; 156: 47-54https://doi.org/10.1016/j.pain.0000000000000002
        • Krishna Prasad G
        Post-operative analgesia techniques after total knee arthroplasty: a narrative review.
        Saudi J Anaesth. 2020; 14: 85https://doi.org/10.4103/sja.sja_494_19