BACKGROUND OF RESEARCH: In the developing world, Ketamine is a vital and highly valued drug that allows performance of interventions and operations that may otherwise prove impossible, especially when resources are limited. Ketamine is one of the most available anaesthetic agents in low- to middle-income countries (LMICs)[1]. With the recent developments of anesthetic and newer surgical techniques and a need to reduce costs, surgeries such as laparoscopic cholecystectomy are now performed with minimal hospital stay or done as outpatient services. Delayed hospital discharge is mainly due to the intensity of postoperative pain and the occurrence of nausea or vomiting. Inadequate management of postoperative pain in laproscopic cholecystectomy can lead to negative consequences such as late mobilization with consequent delay in discharge development of chronic pain and increased treatment costs. Ketamine, an NMDA (N-methyl-D-Aspartate) receptor antagonist is a potent analgesic and a dissociative anaesthetic agent used in anaesthetic procedures in a routine. It’s newly found neuro-protective, anti-inflammatory and anti-tumor effects, and the finding of the usefulness of low dose ketamine regimens have helped to widen the clinical application profile of ketamine. In Developing World, Ketamine is currently used extensively due to its versatility, availability and low side-effect profile. There has been discussion about its potential for misuse and whether greater controls worldwide are required. Fewer notable newer mechanisms of action ketamine, i. NMDA receptor interaction with ketamine plays a role in the opioid induced anti-hyperalgesic effects of ketamine[2] ii. Its anti-pro-inflammatory effects may be responsible for its antihyperalgesic effects[2]. iii. Its immediate analgesic effects are mediated predominantly by a combination of opioid system sensitization and anti-nociception[3] iv. Sub-anesthetic doses of ketamine via NMDA receptor blockade potentiate opioid analgesia[4] Dipti et al. on using low dose ketamine as a sole anaesthetic agent in laproscopic gynecological surgeries found out that low dose ketamine has efficacious analgesic effect in long duration laproscopic gynecological surgeries and also stabilises the intraoperative hemodyanamics[5]. Harsimran et al. Studied on preemptive analgesia with ketamine for laproscopic cholecystectomy found that ketamine has a definitive role in reducing postoperative pain and analgesic requirement and also the lower dosage is devoid of the adverse effects and hemodyanamic changes in optimal dose[6]. Ozhan et al. on comparing sub anaesthetic doses of ketamine in scheduled cases of laproscopic cholecystectomy found out that there is decrease in need of total analgesic consumption in postoperative period and Cognitive functions at 24th postoperative hour were identical to those at baseline[7]. STEPS OF STUDY PROCEDURE I. Preoperative evaluation II. PREMEDICATIONS -Inj. Glycopyrolate 10mcg/kg Inj. Fentanyl 2mcg/kg ( 5mins before induction) III. PREOXYGENATION x 3 mins IV. INDUCTION -Inj Propofol 2mg/kg V. INTUBATIOIN FOLLOWING Inj Atracurium 0.5mg/kg VI. 1. INFUSION OF TEST DRUG with syringe pump with 50 ml syringe containing preloaded prefixed dose of test drug 2. Inf Paracetamol 15mg/kg VII. MAINTAINENCE - N2O:02 = 7:3 ISOFLURANE @ 0.5 - 1 MAC Inj Atracurium 0.2mg/kg VIII. INTRAOPERATIVE DRUGS- Inf. RL/NS Inj Ondanseteran 4mg (30mins before end of surgery) IX. Stop maintainence doses and test drug at end of skin closure X. Extubatation with Inj. Neostigmine 0.5mg/kg + Inj Glycopyrolate 0.2mg/kg XI. Shift to PACU after reversal and follow-up XII. Shift to Post-operative unit in surgical ward after 4 hours and follow-up XIII. Follow up till 24hours with documentation of study parameters and interventions the case proforma EXPECTED OUTCOME : By using different doses of ketamine the optimal dose to use in a day today practice in Laproscopic Cholecystectomy patients with the decrease in adverse effects of ketamine itself and also achieving a of better haemodynamic and postoperative outcome with a decrease in need of intervention in postoperative period will be evaluated. Using a placebo centered group will show the effectiveness of performing the study with infusion ketamine intraoperatively. REFERENCES: 1. Dong TT, Mellin-Olsen J, Gelb AW. Ketamine: a growing global health-care need. Br J Anaesth. 2015;115(4):491-493. 2. Persson J. Wherefore ketamine? Curr Opin Anaesthesiol. 2010;23:455–60. 3. Sleigh J, Harvey M, Voss L, Denny B. Ketamine-more mechanisms of action than just NMDA blockade. Trends Anaesth Crit Care. [In press] 4. Hirota K, Lambert DG. Ketamine: New uses for an old drug? Br J Anaesth. 2011;107:123–6. 5. Saxena D, Dixit A, Kumar N, Arya B, Sanwatsarkar S, Bhandari S. Efficacy of low-dose ketamine as sole analgesic agent in maintaining analgesia and intraoperative hemodynamics during laparoscopic gynecological surgeries. Anesth Essays Res 2017;11:385-9 6. Singh, Harsimran & Kundra, Sandeep & M Singh, Rupinder & Grewal, Anju & K Kaul, Tej & Sood, Dinesh. (2013). Preemptive analgesia with Ketamine for Laparoscopic cholecystectomy. Journal of anaesthesiology, clinical pharmacology. 29. 478-84. 10.4103/0970-9185.119141. 7. Ozhan Y, Bakan N, Karaoren GY, Tomruk SG, Topaç Z. Effects of subanesthetic ketamine on pain and cognitive functions in TIVA. J Clin Anal Med. 015;6(4):452-7. |