Addition of Ketamine to Propofol-Alfentanil Anesthesia May Reduce Postoperative Pain in Laparoscopic Cholecystectomy Murat Karcioglu, MD,* Is¸il Davarci, MD,* Kasim Tuzcu, MD,* Yusuf B. Bozdogan, MD,* Selim Turhanoglu, MD,* Akin Aydogan, MD,w and Muhyittin Temiz, MDw Objective: The aim of this study was to assess whether intravenous anesthesia supplemented with ketamine reduces postoperative pain after elective laparoscopic cholecystectomy. Materials and Methods: Forty patients were enrolled and randomized 1:1 into one of 2 groups: the propofol group (received propofol and alfentanil supplemented with saline) and the ket- amine group (received propofol and alfentanil with ketamine). The study was double-blind. The number and amount of the intra- operative additional alfentanil doses were recorded. Pain assess- ments and cumulative analgesic consumption at postanesthesia care unit (PACU) admission, PACU discharge, postoperative 24th hour, and hospital discharge were recorded. Results: The visual analog scale scores at PACU admission, PACU discharge, postoperative 24th hour, and hospital discharge were signiﬁcantly lower in the ketamine group than the propofol group. The pain visual analog scale Z75 at the postoperative 24th hour for the propofol group was also signiﬁcantly lower (P< 0.035) than that of the ketamine group. The diﬀerence in analgesic con- sumption between groups was statistically signiﬁcant (P< 0.001). Conclusions: Our study showed that ketamine supplemented with propofol and alfentanil produced better analgesia intraoperatively and postoperatively and decreased analgesic consumption com- pared with the propofol group after laparoscopic cholecystectomy. Key Words: ketamine, propofol, postoperative pain, laparoscopic cholecystectomy (Surg Laparosc Endosc Percutan Tech 2013;23:197–202) V arious substances and modalities are used to manage postoperative pain. 1 The analgesic methods used should decrease the pain scores and, more importantly, should improve earlier mobilization and rehabilitation by de- creasing the complications due to analgesic agents that occur after patients are discharged. 2 Opioid-sparing drugs such as ketamine may be of value in adjuvant treatment for obtaining better analgesia with fewer side eﬀects. Ketamine also has oﬀ-label usage as an adjuvant in certain circum- stances such as treating neuropathic pain, acute post- operative pain, and refractory pain due to cancer. Researchers recently reported that opioids not only provide analgesia but may also cause hyperalgesia. Subsequently, perioperative opioid usage may lead to an increase in postoperative pain and needs for opioids. 3 Acute analgesic tolerance to opioid agents may be attenuated with N-methyl-D-aspartate antagonists, and they prevent the rebound hyperalgesia that occurs after opioid usage. Decreased opioid consumption and prolonged analgesia may be achieved with a ketamine and opioid combination. 4 Researchers have reported that these features of ket- amine provide its successful use in treating postoperative pain and have suggested that ketamine can decrease sensi- tization of the spinal cord during postoperative periods. 5 The propofol and ketamine combination may reduce the requirement for supplemental opioid analgesics. However, ketamine usage in the outpatient setting is limited because of the psychotomimetic eﬀects of the drug. 6 Ketamine and propofol ameliorate each other’s adverse eﬀects and pro- vide several advantages such as hemodynamic stability. 7 Researchers have suggested that postoperative pain can be prevented more eﬀectively and the recovery period after ambulatory surgery may be decreased by preemptive mul- timodal procedures consisting of centrally and peripherally acting analgesic agents. 2 The aim of this study was to assess the beneﬁts of adding ketamine to intravenous (IV) anesthesia in reducing postoperative pain in elective laparoscopic cholecystectomy. MATERIALS AND METHODS After obtaining approval from the Institutional Ethics Committee of Mustafa Kemal University, we enrolled 40 patients scheduled for elective laparoscopic chol- ecystectomy in this randomized, double-blind clinical trial. On the basis of the computer-generated random sequence, the study supervisor prepared the drug solutions. They were sealed in an envelope and transferred to the anesthesiologist blinded to the solutions. Informed consent was obtained from all patients. Inclusion criteria of the study were aged 18 years or older and American Society of Anesthesiologists (ASA) physical status I or II. The exclusion criteria were as follows: body mass index <18 kg/m 2 or >35 kg/m 2 , history of substance abuse, chronic analgesic use, chronic alcohol consumption, and contraindication of opioids, ketamine, or nonsteroidal anti-inﬂammatory drug usage. In the operating room, an IV catheter was placed after all patients were connected to noninvasive arterial pressure, pulse oximetry, electrocardiography, and bispectral index (BIS) monitoring. The BIS was recorded with a monitor (Inﬁnity Kappa monitor, Draeger), with an electrode (BIS TM SRS; Aspect Medical Systems, Newton, MA) on the patient’s forehead. Noninvasive arterial pressure, heart rate Received for publication March 19, 2012; accepted December 3, 2012. From the Departments of *Anesthesiology; and wGeneral Surgery, Faculty of Medicine, Mustafa Kemal University, Hatay, Turkey. The authors declare no conﬂicts of interest. Reprints: Murat Karcioglu, MD, Department of Anesthesiology, Faculty of Medicine, Mustafa Kemal University, Hatay, Turkey (e-mail: muratkarcioglu@mku.edu.tr). Copyright r 2013 by Lippincott Williams & Wilkins ORIGINAL ARTICLE Surg Laparosc Endosc Percutan Tech  Volume 23, Number 2, April 2013 www.surgical-laparoscopy.com | 197