Journal of PeriAnesthesia Nursing 37 (2022) 820−826

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Journal of PeriAnesthesia Nursing

jo urn al h ome p ag e: ww w.jop a n.org

Research

Comparison of Ketamine, Dexmedetomidine and Lidocaine in Multimodal

Analgesia Management Following Sleeve Gastrectomy Surgery: A
Randomized Double-Blind Trial
Yasemin Burcu Ustun, MDa, Esra Turunc, MDa, Gokhan Selcuk Ozbalci, MDb,
Burhan Dost, MDa,*, Sezgin Bilgin, MDa, Ersin Koksal, MDa, Cengiz Kaya, MDa
a
Department of Anaesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
b
Department of General Surgery, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey

A B S T R A C T

Keywords: Purpose: The aim of this study was to compare the effects of ketamine, dexmedetomidine, and lidocaine infu-
dexmedetomidine sions added to the multimodal analgesia regimen on pain scores and analgesic requirement in laparoscopic
ketamine sleeve gastrectomy.
lidocaine Design: A prospective randomized double-blind trial. Seventy-three patients aged 18 to 65 years (ASA II-III)
obesity, morbid undergoing laparoscopic sleeve gastrectomy were included. The patients were divided into 3 groups. Intrave-
pain, postoperative
nous (IV) ketamine (0.5 mg/kg/h), dexmedetomidine (0.5 mcg/kg/h), and lidocaine (2 mg/kg/h) were admin-
istered to Groups K, D and L, respectively. Postoperative infusions were continued for 12 hours.
Methods: Visual Analog Scale (VAS) scores (during rest and movement) in the admission to postanesthesia
care unit, 1, 3, 6, 12, 24, 48 hours, and on day 15 were assessed postoperatively. Rescue analgesia require-
ment, the number of patients with nausea, retching, and vomiting, time to mobilization, and hospital length
of stay (LOS) were recorded.
Findings: VASrest values during all measurements in the first 24 hours, and VASmovement values in the first
6 hours and at 24 hours were lower in Group L when compared to Group K and Group D (P < .001, P < .001,
P = .008, respectively). VASrest at 48 hours and VASmovement at 12 and 48 hours were lower in Group L when
compared to Group K (P = .044, P = .001 and P = .011, respectively). There was no statistically significant dif-
ference between Group D compared to the other two groups at these times (P > .05). The requirement of res-
cue analgesia on postoperative day 1 was significantly higher in Group K (P < .001). Hospital LOS was shorter
in Group L than in the other groups (P = .002).
Conclusions: IV lidocaine added to multimodal analgesia provided better pain control in the early postopera-
tive period compared to dexmedetomidine and ketamine and decreased the hospital LOS.
© 2022 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Obesity continues to be a global problem despite campaigns about
healthy life style and diet programs.1 Laparoscopic bariatric surgery is
an effective treatment for obesity. However, there are some chal-
lenges that affect the postoperative outcome of patients undergoing
bariatric surgery. One of these is postoperative pain management.2
Opioids are the principal drugs used in the postoperative pain man-
agement for non-obese patients. However, the use of this group of
drugs in obese patients is restricted due to the risk of opioid-induced
airway obstruction and respiratory depression, urinary retention,
nausea-vomiting, constipation, itching, opioid-induced hyperalgesia,
Conflict of Interest: None to report.
* Address correspondence to Burhan Dost, Department of Anesthesiology, Ondokuz
Mayis University, School of Medicine, Kurupelit, Samsun TR55139, Turkey.
E-mail address: burhandost@hotmail.com (B. Dost).
tolerance, and addiction.3 Due to these undesirable effects, the need
to develop opioid-sparing and opioid-free anesthesia strategies in
the perioperative period has arisen. Following laparoscopic bariatric
surgery, multimodal analgesia is recommended to avoid the adverse
effects of opioids by reducing their use.
Opioid-sparing effects of lidocaine, ketamine, and dexmedetomi-
dine infusions as components of multimodal analgesia following bar-
iatric surgery have been previously reported.4 As a sodium channel
blocker, lidocaine has analgesic and anti-inflammatory effects. Peri-
operative infusion of intravenous lidocaine reduces the postoperative
pain score and consumption of analgesics.5 Dexmedetomidine is a
potent and highly selective a-2 adrenoreceptor agonist with sedative,
anxiolytic, sympatholytic, and opioid-sparing properties. It reduces
the need for anesthetics and opioids without causing respiratory
depression.6 Ketamine is an NMDA (N-Methyl-D-Aspartate) receptor

https://doi.org/10.1016/j.jopan.2021.12.012
1089-9472/© 2022 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Y.B. Ustun et al.
antagonist and has analgesic, antidepressant, and bronchodilator
properties. It reduces opioid-induced hyperalgesia while preserving
respiratory drive, making it a reliable choice for multimodal
analgesia.7
Although lidocaine, ketamine, and dexmedetomidine have been
used as adjuvant analgesics, there are no studies in literature com-
paring intra- and postoperative infusions of these three agents.
Our primary outcome was the postoperative pain scores in the
first 12 hours, while secondary outcomes were the need for rescue
analgesia, the incidence of nausea, retching and vomiting, mobiliza-
tion time, and hospital length of stay (LOS).
Methods
Study Design
This prospective, randomized, double-blind study was conducted
after receiving the Local Ethics Committee and Ministry of Health
approval (Ondokuz Mayis University Clinical Research Ethics Com-
mittee, approval no: 2020/743) in accordance with the principles
outlined in the Declaration of Helsinki. Prior to enrollment, written
informed consent was obtained from all participants for inclusion
and publication of data. The study was registered at ClinicalTrials.
gov, Identifier NCT04836819 prior to the enrollment of any subject.
The study was carried out between April 2021 and July 2021 and
reporting was in accordance with the 2010 Consolidated Standards
of Reporting Trials (CONSORT) statement. Patients aged between 18
and 65 years with obesity (body mass index >35) for which they
were to undergo laparoscopic sleeve gastrectomy were included in
the study. Exclusion criteria included refusal to participate, allergy to
the study drugs, chronic kidney disease (creatinine >150 mmol/L),
mental illness, liver, respiratory or oncological disease, cardiac dys-
function (ejection fraction <40%), uncontrolled hypertension, preop-
erative analgesic use, chronic pain, and a history of alcohol or drug
addiction.
Randomization
Patients were randomly assigned before surgery to the K, D or L
groups (1:1:1 ratio) using opaque sealed envelopes. Randomization
was performed using a computer-generated random number list
(Microsoft Office 365 Excel, Microsoft, Redmond, WA). The patient
codes were kept in opaque, sealed, and sequentially numbered enve-
lopes by an independent doctor. Each patient was asked to choose an
envelope, and the patients were assigned to the study according to
the group mentioned in the envelope. All drugs were prepared 30
minutes before the surgical procedure in the drug preparation room
by a nurse who was not involved in the study. The intraoperative
anesthesia team and outcome assessors were blinded to the group
assignments.
Interventions
All patients were monitored for standard noninvasive blood
pressure, heart rate, electrocardiogram findings, end-tidal carbon
dioxide, peripheral pulse oximeter findings, core body temperature,
and the Bispectral index (BIS). Anesthesia was induced with propo-
fol (1.5 to 2.5 mg/kg) and remifentanil (1 mcg/kg IV bolus for 30 to
60 seconds followed by 0.25 mcg/kg/min) and rocuronium (1.2 mg/
kg). Before the surgery started, 1 g paracetamol, 100 mg tramadol,
100 mg ketoprofen, and 4 mg dexamethasone were administered
to all patients pre-emptively. Intermittent doses of rocuronium
were administered as necessary to maintain controlled ventilation.
Desflurane and remifentanil infusion (0.1 to 0.25 mcg/kg/min) were
administered to all patients with 50% oxygen and air to maintain
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Journal of PeriAnesthesia Nursing 37 (2022) 820−826
anesthesia within 20% of preoperative levels according to the BIS
values (40 to 50) and hemodynamic variables. Drug dosages were
calculated based on lean (LBW)/ideal (IBW)/actual (ABW) body
weight.8-12 All study drugs were administered immediately after
induction of anesthesia. Intravenous lidocaine (2 mg/kgLBW/h) was
initiated for patients in Group L, and it was continued for 12 hours
postoperatively after decreasing the dose to 1 mg/kgLBW/h at the
end of surgery. In Group K, intravenous ketamine (0.5 mg/kgIBW/h)
was initiated, and it was continued for 12 hours postoperatively
after decreasing the dose to 0.3 mg/kgIBW/h at the end of surgery.
In Group D, intravenous dexmedetomidine (0.5 mcg/kgABW/h) was
initiated, and it was continued for 12 hours postoperatively after
decreasing the dose to 0.3 mg/kgABW/h at the end of surgery. All
patients received i.v. granisetron (3 mg) 30 minutes before the end
of surgery and neuromuscular blockage was reversed with i.v. neo-
stigmine (0.03 mg/kg) and atropine (0.015 mg/kg).
Postoperative pain assessment of the patients in all groups was
performed using the visual analog scale (VAS). The VAS is an 11-point
scale consisting of integers from 0 to 10: 0 indicates “no pain” and 10
indicates “the worst pain ever possible.” One day before the surgery,
all patients were informed about VAS. In the ward, the study groups
were monitored by the blinded anesthesia provider. Paracetamol was
administered regularly IV at 8-hour intervals, and as rescue analgesia
in case of the pain score ≥ 4/10 on the VAS, 25 mg meperidine i.v.
was administered. Vomiting was defined as forceful expulsion of the
contents of the stomach, while retching was defined as the attempt
to vomit without bringing anything up. Postoperative nausea and
vomiting was evaluated with verbal descriptive scale (0 = None,
1 = Mild nausea, 2 = Moderate nausea, 3 = Vomiting once, 4 = Multiple
vomiting). In case of the verbal scale ≥ 3 granisetron (3 mg) was used
as a rescue antiemetic therapy. Mobilization time was defined as the
patient’s extubation to the time patients spontaneously requested to
ambulate in the ward. Our hospital discharge instructions were used
to determine readiness for discharge.
Outcomes
The primary outcome of the study was to evaluate the postopera-
tive pain scores in the first 12 hours. The secondary outcomes were
postoperative rescue analgesic requirement, the number of patients
with nausea, retching and vomiting, mobilization time, and hospital
length of stay (LOS).
Sample Size and Statistical Analysis
Calculations of sample size were conducted using Minitab 16.0
software considering data of 12th-hour VAS scores in the pilot study,
which included seven patients in each of the three groups. Using the
following: 5% Type I error margin, power of 80%, expected standard
deviation 0.84 and the maximum difference between the three group
averages 0.85, the sample size for each group was calculated to be at
least 20. However, a sufficient sample size was determined to be 25
in each group, considering potential dropouts.
The data were analyzed using IBM SPSS V23. Compliance with
normal distribution was examined using the Shapiro-Wilk Test. Chi-
square test was used for the comparison of categorical variables
according to groups. One-way analysis of variance was used to com-
pare the normal distributed quantitative data according to the three
groups, while the Kruskal Wallis test with Dunn’s correction was
used to compare the non-normally distributed data. Friedman test
was used to compare the data that was not normally distributed
according to the intra-groups time. The categorical data are pre-
sented as frequency (percentage), and the quantitative data as mean
§ standard deviation, median (Q1-Q3). P < .05 was considered as the
level of significance.
Y.B. Ustun et al.
Results
The study included 78 patients; two patients who underwent cho-
lecystectomy at the same session and one patient who did not meet
inclusion criteria were excluded. Seventy-five patients were random-
ized (25 in each group). In groups, K and L, one patient, for each
group, declined to continue the study. Finally, 73 patients were ana-
lyzed (Figure 1). There was no difference between the groups’ demo-
graphic data and clinical characteristics at baseline (Table 1).
In the lidocaine group, VASrest was lower at all-time points in the
first 24 hours and VASmovement in the first 6 hours and at 24 hours
than in the dexmedetomidine and ketamine groups (P < .001, P <
.001, P = .008, respectively). VASrest scores at 48 hours VASmovement
scores at 12 and 48 hours were lower in the lidocaine group than in
the ketamine group (P = .044, P = .001, P = .011, respectively). There
was no statistically significant difference between lidocaine and dex-
medetomidine groups with regard to VASrest and VASmovement scores
at this times (P > .05). There was no difference between the VASmove-
ment and VASrest scores of the patients on the 15th day (P = 1.00,
Figure 1. Flow diagram showing the distribution of patient data.
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Journal of PeriAnesthesia Nursing 37 (2022) 820−826
P = .360, respectively) (Tables 2 and 3). Postoperative requirement of
rescue analgesia on the first day was higher in the ketamine group
than in the group D and L (mean § SD [95% CI], 38.54 § 25.52 [27.77
to 49.32], 14.00 § 20.51 [5.53 to 22.47], and 6.25 § 15.20 [-0.17 to
12.67] mg, P < .001, respectively).
In the postanesthesia care unit (PACU), the incidence of nausea (P
< .001), retching (P = .001) and vomiting (P = .013) were higher in the
ketamine group.
In the ward, retching and nausea was more frequently observed in
group K when compared to groups D and L (retching: 14 vs 7 vs 2,
P = .001 and nausea: 13 vs 7 vs 1, P = .001). There was no difference
between the groups in terms of vomiting in the ward (Table 4).
There was no difference between the groups in terms of mobiliza-
tion time (P = .069). LOS was shorter in the lidocaine group compared
with the other groups (P = .002) (Table 1). Hemodynamic adverse
effects (hypotension, bradycardia), psychomimetic symptoms (hallu-
cinations, nightmares) and local anesthetic toxicity were not
observed. Intraoperative hemodynamics values of the groups at dif-
ferent time points were revealed in Figure 2.
Y.B. Ustun et al. Journal of PeriAnesthesia Nursing 37 (2022) 820−826

Table 1
Patient Demographics and Clinical Characteristics (N = 73)

Group K (n = 24) Group D (n = 25) Group L (n = 24) P value

Male / Female, n (%) 6 (25) / 18 (75) 8 (32) / 17 (68) 8 (33.3) / 16 (66.7) .795
Age (years) 36.00 § 12.96 (30.53-41.47) 37.64 § 11.45 (32.92-42.36) 34.67 § 9.68 (30.58-38.75) .662
BMI (kg/m2) 41.95 (45-37.93) 44.00 (48.45-39.25) 44.20 (48.15-39) .262
ASA II/III, n (%) 21 (87.5) / 3 (12.5) 20 (80) / 5 (20) 21 (87.5) / 3 (12.5) .697
Comorbidities, n (%)
Hypertension 3 (12.5) 3 (12) 2 (8.3) .831
Diabetes Mellitus 4 (16.7) 6 (24) 3 (12.5) .831
Goiter 1 (4.2) 1 (4) 0 (0) .831
Smoker 6 (25) 7 (28) 7 (29.2) .946
OSA 3 (12.5) 8 (32) 4 (16.7) .204
Stop-Bang score 3.83 § 1.47 (3.21-4.45) 3.44 § 1.58 (2.79-4.09) 3.58 § 1.38 (3.00-4.17) .645
Surgery time (min) 75.00 (60-92.75) 80.00 (75-110) 80.00 (66.25-90) .171
Mobilization time (hour) 4.00 (3-6) 4.00 (3.5-6) 3.75 (2-4) .069
LOS (day) 4.00 (3.25-4) 4.00 (3.5-4) 3.00 (3-4)* .002
BMI, body mass index; ASA, American Society of Anesthesiologists; OSA, Obstructive sleep apnea; LOS, length of stay.
Continuous variables are presented as median (Q1-Q3) and mean § standard deviation (95% confidence interval), while categorical variables are presented as counts (percentages).
P values shown in boldface represent statistical significance.
* P < .05 compared with group K and D.

Table 2
Visual Analogue Scale at Rest (N = 73)

VASrest Group K (n = 24) Group D (n = 25) Group L (n = 24) P value

PACU 7 (7-8.75) 6 (6-8) 5 (5-6.75)* .001

1st h 7.50 (6-8) 6 (5-7.5) 4 (4-6)* <.001
3rd h 6 (5-7) 5 (4-6) 3.5 (2-5)* <.001
6th h 4.5 (3-7) 4 (3-5) 2 (2-3)* <.001
12th h 3 (2-4.75) 3 (2-4) 1.5 (1-2)* <.001
24th h 2 (2-3) 2 (1-2) 1 (1 -1)* <.001
48th h 1 (1-2)y 1 (0-2) 1 (0-1) .044
15th d 0 (0-0) 0 (0-0) 0 (0-0) .360
PACU, postanesthesia care unit; VAS, Visual Analogue Scale.
Data are presented as median (Q1-Q3). P values shown in boldface represent statistical significance.
* P < .05 compared with group K and D.
y
P < .05 compared with group L.

Table 3
Visual Analogue Scale at Movement (N = 73)

VASmovement Group K (n = 24) Group D (n = 25) Group L (n = 24) P value

PACU 8 (8-9) 7 (7-9) 6 (5.25-7)* <.001

1st h 7 (7-9) 7 (6-8) 5 (4-6)* <.001
3rd h 6 (5-8) 6 (5-6.5) 4 (4-5)* <.001
6th h 5 (4-7.75) 4 (3.5-6) 3 (2-4)* <.001
12th h 4 (3-5)y 3 (2-4) 2 (2-3) .001
24th h 3 (2-3) 3 (2-3) 2 (1-2)* .008
48th h 2 (1-2.75)y 1 (1-2) 1 (0-1.75) .011
15th d 0 (0-0) 0 (0-0) 0 (0-0) 1.000
PACU, postanesthesia care unit; VAS, Visual Analogue Scale.
Data are presented as median (Q1-Q3). P values shown in boldface represent statistical significance.
* P < .05 compared with group K and D.
y
P < .05 compared with group L.

Discussion obese individuals.4 Multi Modal Analgesia (MMA) is associated with

In our study, the lidocaine group had lower pain scores and
shorter LOS. Postoperative rescue analgesia requirement was higher
in the ketamine group than in the other groups on the first day. Addi-
tionally, nausea, retching, and vomiting were significantly higher in
the ketamine group than in the other groups.
Sleep disorders such as obstructive sleep apnea and obesity hypo-
ventilation syndrome are more common in patients with obesity.
Adequate pain management is a challenge in patients who are prone
to respiratory depression due to their altered respiratory dynamics.
Although opioids are central to postoperative pain management, opi-
oid-free analgesia is recommended to avoid respiratory depression in
823
an opioid-sparing effect, better pain management, early postopera-
tive recovery, and lower costs.13 This study is the first to compare
intraoperative and postoperative infusions of three different adju-
vants in MMA.
There are many studies in literature that evaluate the analgesic
efficacy of ketamine at subanesthetic doses. However, there is no
consensus regarding the optimal dose due to heterogeneity in the
time (pre-intra-postop), the dose, and the method of administration
(bolus and/or infusion, IV, IM, PO.).14,15 The IV ketamine infusion
guidelines recommend an infusion rate not exceeding 1 mg/kg/h in
acute pain management.16 In our study, we used an infusion rate of
0.5 mg/kg/h, which was the dosage found to be effective compared to
Y.B. Ustun et al.
Table 4
Incidence of Nausea, Retching and Vomiting (N = 73)
PACU Group K (n = 24)
Nausea 16 (66.7)*
Retching 17 (70.8)*
Vomiting 4 (16.7)*
WARD
Nausea 13 (54.2)y
Retching 14 (58.3)y
Vomiting 1 (4.2)
PACU, post-anesthesia care unit.
Data are presented as count, n (%). P values shown in boldface represent statistical significance.
* P < .05 compared with group D and L.
y
P < .05 compared with group L.
Figure 2. Intraoperative hemodynamics values of the groups at different time-points. A. Heart rates, B. Mean arterial pressure. (N = 73)
a control group in patients undergoing bariatric surgery.17 Due to
hemodynamic side effects18 and altered pharmacokinetics and phar-
macodynamics in the obese patients,19 we did not administer a load-
ing dose in the dexmedetomidine group. Although studies have
widely reported use of 0.2 to 0.8 mcg/kg/h while maintaining hemo-
dynamic stability,20 our aim was to evaluate the effectiveness of a
stable infusion rate of 0.5 mcg/kg/h, as reported in a study by Zeeni
et al.11 Carabalona et al21 demonstrated that lidocaine remained
within the therapeutic window without exceeding the threshold
value of 5 mcg/kg22 when administered as a bolus of 1.5 mg/kg fol-
lowed by an infusion of 2 mg/kg/h. In studies involving bariatric sur-
gery where the use of was evaluated using a control group, the same
dose was reported to decrease opioid requirement.23,24 We therefore
used an infusion rate of 2 mg/kg in our study. Furthermore, lidocaine
infusion may preclude the ability to use other anesthesia techniques
such as regional anesthesia, peritoneal infiltration of local anesthetic,
local anesthesia injection by surgeon to the port sites and it is unclear
which of those techniques may yield the greatest benefit.
In the present study, pain scores at rest during the first 24 hours
and at movement during the first 6 hours were low in the lidocaine
group. Analgesic effects of lidocaine include inhibition of voltage-
gated sodium channels, blocking of N-methyl-D-aspartate receptors,
and anti-inflammatory properties. In addition to the opioid-sparing
effect, the fact that it increases the quality of recovery and decreases
the LOS has increased its usage. Song et al showed that low dose lido-
caine reduced post-operative pain and improved recovery with anti-
inflammatory effectiveness in laparoscopic cholecystectomy sur-
gery.5 In similar studies comparing lidocaine and placebo, the infu-
sion throughout the surgical procedure following the bolus dose led
to a decrease in postoperative morphine consumption.23,24 A meta-
analysis about laparoscopic surgeries reported that lidocaine reduced
the postoperative opioid consumption when administered at doses
of 2 mg/kg and above.25 However, in the study by Plass et al,26
although lidocaine reduced oxycodone consumption, this decrease
was not significantly reflected in the clinic, which is in contrast with
Journal of PeriAnesthesia Nursing 37 (2022) 820−826
Group D (n = 25) Group L (n = 24) P value
5 (20) 3 (12.5) <.001
9 (36) 4 (16.7) .001
0 (0) 0 (0) .013
7 (29.2) 1 (4.2) .001
7 (28) 2 (8.3) .001
3 (12) 1 (4.2) .454
our findings. In the aforementioned study in which a multimodal
analgesia regimen was used, lidocaine infusion was continued for a
short time in the PACU. Moreover, the pain scores recorded in the
PACU during the early postoperative period were lower than those
after 24 hours in both the groups, which might be due to the use of
strong opioids such as oxycodone during this period. The contribu-
tion of lidocaine to the quality of recovery might have been over
shadowed by this effect.26 In the study by Tovikkai et al,10 although
opioid consumption decreased in the group receiving lidocaine infu-
sion, this was not found to be statistically significant. However, the
study had limitations such as a retrospective design, absence of a
standard analgesia protocol and lidocaine dose, and different types of
surgeries were included in the study.10
Ketamine has a pronounced analgesic effect at low doses. Bolus
doses up to 1mg/kg and infusion doses up to 20 mcg/kg/min are
defined as low doses. There are variable results about the outcomes
at low doses in the literature.15 While low-dose ketamine alone
(0.15 mg/kg bolus + 0.12 mg/kg/h IV infusion) decreased postopera-
tive morphine consumption by 68%,27 it did not show a similar effect
in patients who received remifentanil concomitantly.28,29 No change
in morphine consumption was observed when intraoperative fenta-
nyl was added to ketamine infusion, which was continued for
24 hours postoperatively.30,31 The analgesic effect of ketamine is lim-
ited in studies in which opioids were used. In our study, we adminis-
tered tramadol bolus for induction, followed by remifentanil
infusion. The pain scores were higher in the ketamine group; as a
result, additional analgesia requirement on the first postoperative
day was markedly higher. This might be due to several reasons, such
as surgery that typically manifests as nociceptive pain. Opioid-
induced inhibition in nociceptive C fibers prevents the release of neu-
rotransmitters such as glutamate and substance P.32 Since there is no
neurotransmitter input to the dorsal horn, NMDA receptor blockade
following remifentanil administration did not seem to have the
desired effect in our study. NMDA receptor blockade in the dorsal
horn prevents wind-up. The low-dose ketamine mentioned by
824
Y.B. Ustun et al.
Schmid et al might have shown an anti hyperalgesic rather than anal-
gesic effect by preventing wind-up in continuous and repetitive C-
fiber stimulation, such as during surgery.33 Another reason for the
varied results regarding ketamine might be due to the differences in
bolus dose and time and duration of infusion. Moreover, the change
in the pharmacodynamics-pharmacokinetics of the drug in patients
with obesity might contribute to this result.
Another frequently used drug for MMA is dexmedetomidine. It is
a highly selective a2-adrenoreceptor agonist with hypnotic, sedative,
anxiolytic, sympatholytic, and analgesic properties without causing
respiratory depression. Because patients can be aroused under seda-
tion, dexmedetomidine is popular for sedoanalgesia. In the literature,
there are various protocols regarding the time and dose of dexmede-
tomidine and its bolus dose in bariatric surgery. Hence, the results
regarding the opioid consumption also showed an opioid-sparing
effect were heterogeneous.6,11,34,35 Such as, 1.4 mcg/kg bolus was
administered following by an infusion of 0.7 mcg/kg/h for 24 hours34
had a similar effect to 0.5 mcg/kg bolus was administered following
by an infusion 0.4 mcg/kg/h.6 The clinical results of dexmedetomi-
dine infusions following a bolus dose - with a possible pre-emptive
effect - appear to be better.20 However, in the present study, we did
not administer bolus doses to avoid adverse hemodynamic effects.
The control of nausea and vomiting with effective postoperative
analgesia is associated with early rehabilitation and better results.
The use of opioids in postoperative analgesia might increase respira-
tory complications and nausea and vomiting. In our study, the post-
operative use of opioids was higher in patients in the ketamine group
in the first 24 hours. Similarly, the higher rate of nausea, retching,
and vomiting in this group may be associated with higher use of anal-
gesics.
Although cost analysis was not one of the present study’s end-
points, early mobilization and reduction in LOS after surgical proce-
dures help reduce health care costs. Our patients were generally
mobilized after 4 hours, and there was no difference in the time to
mobilization between the groups. LOS was found to be shorter in the
lidocaine group, possibly due to the lower VAS values and lower use
of postoperative opioids in the lidocaine group. Moreover, the lower
incidence of nausea and vomiting in this group might have also con-
tributed to better quality of recovery and lower LOS.36,37 Similar to
reports in literature, in this study we have demonstrated that lido-
caine infusion shortens LOS by reducing postoperative pain and com-
plications, therefore allowing early recovery.38 This effect of lidocaine
is promising in liue of a potential reduction in health care costs and
more efficient use of recourses and therefore requires further investi-
gation.
This study has some limitations. First, postoperative sedation lev-
els of the patients could have been measured. Second, it would be
useful to determine the effective intraoperative blood concentrations
of the drugs because the pharmacodynamics-pharmacokinetic prop-
erties might be different in patients with obesity. However, we could
not measure the blood levels of the drugs due to the limited facilities
of our hospital. Finally, despite the fact that all of our research drugs
had previously been evaluated in obese patients, the study required a
control group.
Conclusion
In conclusion, this study showed that lidocaine used as an adju-
vant infusion reduces acute pain in the early postoperative period
and enables early discharge compared to ketamine and dexmedeto-
midine in patients undergoing laparoscopic sleeve gastrectomy.
However, these results need to be supported by studies using infu-
sions of dexmedetomidine following a bolus dose and different doses
of ketamine.
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