Effect of ketamine as an adjuvant in ultrasound-guided supraclavicular brachial plexus block: A double-blind randomized clinical trial study


Departments of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Supraclavicular brachial plexus block is one of the most effective anesthetic procedures in operations for the upper extremity. Ketamine has been reported to enhance the analgesic effects of local anesthetics. We have conducted this study to assess whether coadministration of ketamine can prolong the local analgesic effect of lidocaine in the supraclavicular brachial plexus block for patients undergoing elective upper extremity surgery.
Materials and Methods:
 Sixty adult patients undergoing elective surgery of the elbow, forearm, wrist or hand were randomly allocated in two groups of 30 patients each. Group 1 (ketamine group) received 5 mg/kg lidocaine 1.5% plus 2 mg/kg ketamine, Group 2 (control group) received 5 mg/kg lidocaine 1.5% and saline. The outcome measures included severity of pain by using visual analog scale (VAS, 0 = no pain 10 cm = the most severe pain), time of first request for analgesia, and total dose of postoperative opioid administration. The data was analyzed using the χ2 test, student's t-test, Kaplan-Meier survival analysis, and Multivariate analysis tests.
 Patients in the control group had a higher VAS than patients who received ketamine, at all time points during the first 24 hours after surgery (all P < 0.05). The time of first request for analgesia in the ketamine group was significantly more than in the control group (8.93 ± 1.0 vs. 7.30 ± 1.9, respectively, P < 0.001).
Conclusion: The addition of ketamine to lidocaine in the ultrasound-guided brachial plexus block could decrease the postoperative pain and need for analgesic. Therefore, it could be considered as an option in the brachial plexus block to enhance the analgesic action of lidocaine


De Tran QH, Clemente A, Doan J, Finlayson RJ. Brachial plexus blocks: A review of approaches and techniques. Can J Anaesth 2007;54:662-74.  Back to cited text no. 1
Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M. Brachial plexus anesthesia: A review of the relevant anatomy, complications, and anatomical variations. Clin Anat 2014;27:210-21.  Back to cited text no. 2
Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994;78:507-13.  Back to cited text no. 3
Nishikawa K, Kanaya N, Nakayama M, Igarashi M, Tsunoda K, Namiki A. Fentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism. Anesth Analg 2000;91:384-7.  Back to cited text no. 4
Movafegh A, Nouralishahi B, Sadeghi M, Nabavian O. An ultra-low dose of naloxone added to lidocaine or lidocaine-fentanyl mixture prolongs axillary brachial plexus blockade. Anesth Analg 2009;109:1679-83.  Back to cited text no. 5
Swami SS, Keniya VM, Ladi SD, Rao R. Comparison of dexmedetomidine and clonidine (α2 agonist drugs) as an adjuvant to local anaesthesia in supraclavicular brachial plexus block: A randomised double-blind prospective study. Indian J Anaesth 2012;56:243-9.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
Trivedi V, Patel N. A comparative clinical study of injection clonidine versus midazolam in supraclavicular brachial plexus block for sedation and postoperative analgesia: A study of 60 cases. J Indian Med Assoc 2010;108:563-7.  Back to cited text no. 7
Chawda PM, Sharma G. A clinical study comparing epinephrine 200 µg or clonidine 90 µg as adjuvants to local anaesthetic agent in brachial plexus block via supraclavicular approach. J Anaesthesiol Clin Pharmacol 2010;26:523-7.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006;102:263-7.  Back to cited text no. 9
Haas DA, Harper DG. Ketamine: A review of its pharmacologic properties and use in ambulatory anesthesia. Anesth Prog 1992;39:61-8.  Back to cited text no. 10
Reves JG, Glass PS, Lubarsky DA, McEvoy MD, Martinez Ruiz R. Intravenous Anesthetics. In: Miller R, editor. Miller's Anesthesia. 7 th ed. Orlando: Churchill Livingstone; 2009. p.225.  Back to cited text no. 11
Sethi M, Sethi N, Jain P, Sood J. Role of epidural ketamine for postoperative analgesia after upper abdominal surgery. Indian J Anaesth 2011;55:141-5.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kissin I. Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanism: A study in postoperative patients. Neurosci Lett 1996;215:5-8.  Back to cited text no. 13
Lee IO, Kim WK, Kong MH, Lee MK, Kim NS, Choi YS, et al. No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade. Acta Anaesthesiol Scand 2002;46:821-6.  Back to cited text no. 14
Rahimzadeh P, Faiz SH, Ziyaeifard M, Niknam K. Effectivness of adding ketamine to ropivacaine infusion via femoral nerve catheter after knee anterior cruciate ligament repair. J Res Med Sci 2013;18:632-6.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
Nishiyama T. Comparison of the motor and sensory block by ropivacaine and bupivacaine in combination with lidocaine in interscalene block. Med Arh 2012;66:315-7.  Back to cited text no. 16
Biradar PA, Kaimar P, Gopalakrishna K. Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: A prospective, randomised, double-blind study. Indian J Anaesth 2013;57:180-4.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother 2006;60:341-8.  Back to cited text no. 18
Argiriadou H, Papagiannopoulou P, Foroulis CN, Anastasiadis K, Thomaidou E, Papakonstantinou C, et al. Intraoperative infusion of S(+)-ketamine enhances post-thoracotomy pain control compared with perioperative parecoxib when used in conjunction with thoracic paravertebral ropivacaine infusion. J Cardiothorac Vasc Anesth 2011;25:455-61.  Back to cited text no. 19
Dowdy EG, Kaya K, Gocho Y. Some pharmacologic similarities of ketamine, lidocaine, and procaine. Anesth Analg 1973;52:839-42.  Back to cited text no. 20
Weber WV, Jawalekar KS, Jawalekar SR. The effect of ketamine on nerve conduction in isolated sciatic nerves of the toad. Neurosci Lett 1975;1:115-20.  Back to cited text no. 21
Dale O, Somogyi AA, Li Y, Sullivan T, Shavit Y. Does intraoperative ketamine attenuate inflammatory reactivity following surgery? A systematic review and meta-analysis. Anesth Analg 2012;115:934-43.  Back to cited text no. 22
Loix S, De Kock M, Henin P. The anti-inflammatory effects of ketamine: State of the art. Acta Anaesthesiol Belg 2011; 62:47-58.  Back to cited text no. 23
Niesters M, Martini C, Dahan A. Ketamine for chronic pain: Risks and benefits. Br J Clin Pharmacol 2014;77:357-67.  Back to cited text no. 24
Zohar E, Luban I, Zunser I, Shapiro A, Jedeikin R, Fredman B. Patient-controlled bupivacaine wound instillation following cesarean section: The lack of efficacy of adjuvant ketamine. J Clin Anesth 2002;14:505-11.  Back to cited text no. 25
Rosseland LA, Stubhaug A, Sandberg L, Breivik H. Intra-articular (IA) catheter administration of postoperative analgesics. A new trial design allows evaluation of baseline pain, demonstrates large variation in need of analgesics, and finds no analgesic effect of IA ketamine compared with IA saline. Pain 2003;104:25-34.  Back to cited text no. 26
Clerc S, Vuilleumier H, Frascarolo P, Spahn DR, Gardaz JP. Is the effect of inguinal field block with 0.5% bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S(+) ketamine? Clin J Pain 2005;21:101-5.  Back to cited text no. 27