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C om par ison o f mor
ph ine and m orphine
w ith ketam ine for
postoperat ive analgesia
Kei t h B . J a ve r y DO, T od d W . U sse r y M D,
H e r b e r t G . S t e g e r ph D , G e o r g e W . C o l c l o u g h M D
Pu r p o s e :
The purpose o f th i s s tudy was to compa re morph ine
wi th ke tamine to morph ine a lone in a doub le -b l ind inves t iga-
t ion o f pos t surg ica l pa in con tro l.
Metho ds: For ty - two ASA 1 and 2 pa t ien t s undergo ing e lec t i ve
microd iscec tom y we re admin is tered e i ther I rag . m1-1 o f mor-
p h i n e
n =
20) or I mg . m1-1 o f bo th morph ine and ke tamine
(n = 22) v ia i v pa t ien t con tro l led ana lges ia (1VPCA). Pa in
re l i e f and s ide e f f ec t s were assessed a t 24 h r a f t e r surgery .
Resu l t s :
The mean (SD) v i sua l ana logue sca le (VAS) pa in ra t -
ing o f 2 .3 ( l .67 ) for pa t ien t s rece iv ing mo rph ine w i th ke tamine
was low er (P < 0 .001) than the VAS scores o f pa t ien t s rece iv -
ing on ly morph ine 4 .5 (1 .54) . P a t ien t s rece iv ing morph ine a nd
ke tamine a l so had le ss d i f f i cu l t y w i th s ide e f f ec t s , repor t ing
less nausea (P < 0 .05) , prur i tus (P < 0 .001) , and ur inary
re ten t ion (P < 0 .05) . A l though dysphor ia i s repor ted to be a
comm on s ide e f f ec t o f ke tamine , compla in t s o f dysphor ia we re
rare in bo th groups , w i th on ly one sub jec t (5%) in the mor-
ph ine wi th ke tamine group and three (15%) sub jec t s rece iv ing
morph ine a lone repor t ing th i s s ide e f f ec t .
C o n c l u s i o n :
IVPCA ke tamine in combina t ion wi th morph ine
prov ides su per ior pos t surg ica l pa in re l i e f a t lower dosage a nd
wi th f ew er s ide e f f ec t s than morp h ine a lone .
Objec t i f Cette ~tude en doub le aveug le visai t ?~ com par er la
kd tamine assoc i~e ~ la morph ine avec la morph ine seu le u t i -
l isde dans l e bu t de t ra i t e r la dou leur pos topdra to i re .
M # t h o d e : Q u a r a n t e -d e u x p a t ie n t s A S A 1 e t 2 pr o g r a m m d s
pou r un e microdisco~'dectomie ont ref u 1 rag. m1-1 de m or-
ph ine (n = 10) ou 1 m g .ml - j ?~ la fo i s de morph ine e t de kd ta -
K e y w o r d s
ANALGESIA: po stop era t ive ;
ANALGESICS: ke tam ine , m orp hin e;
SURGERY orthopaedic
From the Department o f Anesthesiology, U niversity o f
Kentucky C ollege of Medicine.
Address correspondence to :
Dr. Keith B. Javery,
Department o f Anesthesiology, Universi ty of Kentucky
Medical Center, 800 Rose Street, N-202, Lexington, KY
40536-0084 U.S.A.
Accep ted fo r pub l ica t ion 8 th Sep tember , 1995.
mine i v (n = 22) par un d i spos i t i f d 'ana lgds ie au tocon tr~ l~e
(PCAIV) . L e sou lagem ent e t l e s e f f e t s seconda ires on t ~ t~ ~va-
luds 24 h apr~s la chirurgie.
Rdsu l ta t s : La moyenne (ET) de la va leur dd termin~e sur une
dche l le v i sue l le ana log ique (EVA) de 2 ,3 (1 ,67) pour l e s
pa t ien t s qu i ava ien t re fu m orph ine-k~tamine d ta i t p lus basse
(P < 0 ,001) que ce l l e des pa t ien t s sous m orph ine 4 ,5 (1 ,54).
Les pa t ien t s sous morph ine-kd tamine on t eu auss i moins d ' e f -
f e t s seconda ires don t moins de nausde (P < 0 ,05) , de prur i t (P
< 0,001), e t de r~tention urinaire (P < 0,05). B ien que la dys-
phor ie su i t un e f f e t seconda ire f rdquen t de la k~ tamine , e l l e a
~t~ rarement rappor t~e dans l e s deux groupes , a vec un seu l
su je t (5%) du groupe morph ine-k~tamine e t t ro i s du groupe
morph ine seu le (15%) .
C o n c l u s i o n :
En PCAIV, la k~ tamine assoc ide ~ la morph ine
procure une sou lagement pos topdra to i re de la dou leur f i des
doses p lus fa ib les e t avec moins d 'e f f e t s seco nda ires que la
morph ine seu le .
I n t r a v e n o u s m o r p h i n e i s c o m m o n l y u s e d a s a n a n a l -
g e s i c i n t h e p o s t o p e r a t i v e p e r i o d f o r m a j o r s u r g e r y a n d
i s th e s t a n d a r d b y w h i c h a l l o t h e r a n a l g e s i c s a r e g a u g e d .
K e t a m i n e h a s b e e n u s e d a s a n i n t r a v e n o u s a n a e s t h e t i c .
T h e r e p o r t e d E D s 0 f o r t h e a b o l i t i o n o f r e s p o n s e t o
p a i n f u l s t i m u l a t i o n i s 1 .3 r a g . k g - l . I K e t a m i n e h a s a l s o
b e e n u s e d i n s u b - a n a e s t h e t i c d o s e s a s a n a n a l g e s i c f o r
b o t h a c u t e a n d c h r o n i c p a i n r e l ie f . 2 -s T h e a n a l g e s i c
e f f e c t s o f k e t a m i n e o c c u r a t p l a s m a c o n c e n t r a t i o n s
b e t w e e n 1 0 0 a n d 1 5 0 n g . m 1 - 1 . T h e s e c o n c e n t r a t i o n s
h a v e b e e n a c h i e v e d b y i n f u s i o n s a s l o w a s 3 t o 4
l ag- kg - I . r a i n - I a f t e r an i n i t ia l l oad i n g dose . 6 S ucces s f u l
a n a l g e s i a w i t h o u t a n i n i t i a l l o a d i n g b o l u s h a s b e e n
r e p o r t e d w i t h i n f u s i o n s o f 1 4 b t g. k g - l . m i n 1 .
K e t a m i n e h a s m a n y d e s i r a b l e q u a l i t i e s a s a n a n a l -
g e s i c. I t d o e s n o t s u p p r e s s c a r d i o v a s c u l a r f u n c t i o n i n t h e
p r e s e n c e o f a n i n t a c t n e r v o u s s y s t e m ; 7 i t does no t
d e p r e s s t h e l a r y n g e a l p r o t e c t i v e r e f l e x e s ; 8 it d e p r e s s e s
v e n t i l a t i o n l e s s t h a n o p i o i d o r n o n o p i o i d a n a e s t h e t i c
a g e n t s ; 9 a n d i t m a y s t i m u l a t e r e s p i r a t i o n ~ D e c r e a s e d
a i r w a y r e s i s t a n c e h a s b e e n r e p o r t e d i n p a t i e n t s w i t h
r eac t i ve a i r way d i sease a f t e r ke t ami ne admi n i s t r a t i on . l ~
CAN J ANAESTH 1996 I 43: 3 / pp212-5
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Javery
e t a l :
MORPHINE AND KETAMINE 213
Adverse s ide e f fec t s a s soc ia ted wi th sub-anaes the t i c
doses o f k e tam ine inc lude to le rance , ~2 accum ula t ion o f
m e tabo l i t e s , 13 pos tope ra t ive m a la i s e , 14 and ca rd iov ascu-
la r exc i ta t ion . One o f the m os t d i s conce r t ing s ide e f fec t s
o f k e t a m i n e i s i t s a d v e r s e p s y c h o m i m e t i c e f f e c t s ,
inc lud ing d izz ines s , f r igh ten ing dream s , depe rsona l i za -
t ion , and ha l luc ina t ions . These reac t ions appea r to be
m o re com m o n in adu l t s than in ch i ld ren 15 and in w om en
than in men . 16
T h e c o m b i n a t i o n o f m o r p h i n e a n d k e t a m i n e
i v
has
been s tud ied w i th va r ied re su l t s. S om e au thors have rec -
o m m e n d e d t h is c o m b i n a t i o n b e c a u s e o f i m p r o v e d r e s p i -
ra to ry ra te s and l e s s s l eep ines s fo r the s am e degree o f
ana lges ia , j4 Othe rs have repor ted inc reased ana lges ia
whe n ke tam ine i s added to m eper id ine , ~7 bu t h ave no ted
a n i n c r e a s e i n t h e p s y c h o m i m e t i c e f f e c t s w i t h k e t a m i n e
use 18
T h e c o m b i n a t i o n o f lo w d o s e k e t a m i n e a n d m o r p h i n e
has been used a t our ins t i tu tion to p rov id e be t t e r ana lge -
s i a w h e n m o r p h i n e ( I V P C A ) h a s p r o v e d t o b e i n a d e -
qua te . The com bina t ion s eem s to be a s a fe and re l i ab le
m e t h o d o f p r o v i d i n g p o s t o p e r a t i v e a n a l g e s i a t h a t i s
s u p e r i o r t o m o r p h i n e a l o n e . T h e p r e s e n t s t u d y w a s
under tak en to de te rm ine i f the add i t ion o f sub-anaes the t -
i c d o s e s o f k e t a m i n e t o m o r p h i n e d e l i v e r e d b y I V P C A
w o u l d p r o v i d e b e t t e r a n a l g e s i a t h a n m o r p h i n e a l o n e ,
a n d m i n i m i z e u n t o w a r d s i d e e f f ec t s . A P C A a p p r o a c h t o
drug adm in i s t ra t ion was used to obv ia te the a rb i t ra ry
d o s i n g g u i d e l i n es n e c e s s a r y w i t h i n f u s io n s . U s e o f P C A
avoids under - o r ove rdos ing ana lges ic , a l lowing the
pa t i en t to t i t ra te the dose o f op io id to ach ieve e f fec t ive
ana lges ia. 19
e t h o d s
B a s e d o n p i l o t s tu d y e x p e r i e n c e w i t h t h e s t u d y ' s d e p e n -
den t m easures , a to ta l s am ple s i ze o f 40 was ca lcu la ted
a s n e c e s s a r y t o d e m o n s t r a t e e x p e r i m e n t a l e f f e c t s a t a n
a c c e p t a b l e c o n f i d e n c e l e v e l. F o l l o w i n g a p p r o v a l o f t h e
U n i v e r s i t y o f K e n t u c k y M e d i c a l I n s t i t u t i o n a l R e v i e w
B o a r d , 4 2 A S A 1 a n d 2 p a t i e n ts b e t w e e n t h e a g e s o f 2 1
a n d 5 5 y r w h o w e r e t o u n d e r g o e l e c t i v e l u m b a r
m i c r o d i s c e c t o m y g a v e i n f o r m e d c o n s e n t b e f o r e e le c t i n g
to pa r t i c ipa te in the s tudy . P a t i en t s were random ized in
a d o u b l e - b l i n d f a s h i o n t o r e c e i v e I V P C A c o n s i s t i n g
e i t h e r o f m o r p h i n e 1 m g . m1 -1 o r m o r p h i n e w i t h k e t a -
m i n e 1 m g . m 1 -1 o f e a c h . B A R D a m b u l a t o r y I V P C A
p u m p s w e r e p r o g r a m m e d t o d e l i v e r 1 m l o f s o l u t i o n
wi th a lock out o f s ix m inu tes . No basa l in fus ion was
used .
P a t ie n t s w e r e p r e - m e d i c a t e d i n t h e h o l d i n g a r e a w i t h
m i d a z o l a m , u p t o 0 .0 5 m g - k g-1
i v
N o p r e o p e r a t i v e o p i -
o i d s o r n o n s t e r o i d a l m e d i c a t i o n s w e r e u s e d . G e n e r a l
a n a e s t h e si a w a s i n d u c e d w i t h t h i o p e n t o n e 5 m g . k g -1
and t rachea l in tuba t ion was fac i l i t a t ed wi th succ iny l -
cho l ine 1 .5 m g. kg 1 . P a t i en t s were a l lowe d to rece ive
fen tan y l up to 2 k tg . kg 1 wi th in 2 0 m in a f t e r in tuba t ion .
A n a e s t h e s i a w a s m a i n t a i n e d w i t h i s o f l u r a n e a n d 1 0 0 %
o x y g e n w i t h v e c u r o n i u m b r o m i d e f o r m u s c l e r e l a x a ti o n
d u r i n g t h e r e m a i n d e r o f t h e c a s e . P a t i e n t s w e r e t h e n
t a k e n t o t h e p o s t o p e r a ti v e r e c o v e r y r o o m w h e r e , u p o n
o b t a i n i n g a d e q u a t e c o g n i t i v e f u n c t i o n , t h e y w e r e
i n s t ru c t e d o n t h e u s e o f th e I V P C A u n i t a n d c o n n e c t e d
t o t h e I V P C A p u m p . P a t i e n t s w e r e r e t u r n e d t o t h e i r
w a r d s w i t h t h e p u m p s f u l l y o p e r at i o n a l. N o s u p p l e m e n -
ta l ana lges ia o r s eda t ion was adm in i s te red to the
pa t i en t s dur ing the i r pos t surg ica l hosp i t a l s t ay .
D a t a w e r e c o l l e c t e d 2 4 h r a f t e r s u r g e r y . T h e v o l u m e
o f d r u g w a s d o w n l o a d e d f r o m t h e 1 V P C A p u m p t o a
l a p t o p c o m p u t e r . V i s u a l a n a l o g s c o r e s w e r e c o l l e c t e d 2 4
h r a f t e r s u r g e r y f r o m p a t i e n t s u s i n g a s t a n d a r d 1 0 c m
V A S p a i n r u l e r t h a t t h e p a t i e n t c o u l d m a n i p u l a t e t o a
d e s i r e d p a in r a t in g . A V A S s c o r e o f 0 w a s d e f i n e d a s n o
pa in , whi le 10 was de f ined a s wors t pa in im aginab le .
S ide e f fec t s o f nausea , u r ina ry re ten t ion , s eda t ion , and
p r u r it u s w e r e e v a l u a t e d u s i n g a n u m e r i c a l s c a le f r o m 1
to 5 , 1 was d e f ined a s no s ide e f fec t and 5 the w ors t
s e v e r i t y o f s i d e e f f e c t i m a g i n a b le . I f t h e p a t i e n t c o u l d b e
a r o u s e d o n l y b y v i g o r o u s s t i m u l at i o n , a r a ti n g o f 5 w a s
t a b u l at e d f o r s e d a ti o n . I f t h e p a t i e n t r e q u i r e d a n y f o r m
of u r ina ry ca the te r i za t ion , th i s was recorded a s a 5 on
the 1 to 5 u r ina ry re ten t ion s ca le . In add i t ion , the in ten-
s i ty o f a n y d y s p h o r i c e x p e r i e n c e s u c h a s b a d f e e l i n g s ,
ha l luc ina t ions , n igh tm ares , o r d izz ines s , was recorded
on a 1 to 5 dysphor ia s ca le . P a t i en t s were ins t ruc ted to
s c a le t h e s e e x p e r i e n c e s o v e r t h e p r e v i o u s 2 4 h r p e r i o d .
In add i t ion , the pa t i en t ' s v i t a l s igns (b lood pres sure ,
p u l s e r a t e , a n d r e s p i r a t o r y r a t e ) w e r e r e c o r d e d e v e r y
four hours .
S ta t i s t i ca l ana lyses o f da ta were pe r form ed us ing
S P S S . 2~ D i f f e r e n c e s b e t w e e n g r o u p s w e r e a n a l y z e d w i t h
the t t e s t . Re la t ionsh ips be tween va r iab le s were inves t i -
g a t e d u s i n g P e a r s o n p r o d u c t m o m e n t c o r r e l a t i o n s . A
p r o b a b i l i t y l e v e l o f 0 . 0 5 w a s s e t f o r r e j e c t i o n o f n u l l
h y p o t h e s e s o f n o d i f f e r e n c e b e t w e e n t h e g r o u p s .
Resu l t s
Of the 42 sub jec t s enro l l ed in the s tudy , 22 were
a s s i g n e d t o t h e m o r p h i n e - p l u s - k e t a m i n e g r o u p a n d 2 0 t o
t h e m o r p h i n e o n l y g r o u p . T h e g r o u p s w e r e c o m p a r a b l e
and d id no t d i f fe r in d i s t r ibu t ion o f s ex , age , o r we igh t
(Tab le I ) .
P a t i e n t s w h o r e c e i v e d m o r p h i n e p l u s k e t a m i n e r a t e d
their p ain as l ow er (me an __+ SD; 2.3 _+ 1.67) than those
rece iv ing on ly m orp hine (4 . 5 _ 1 . 54) (P < 0 . 001) . The
m o r p h i n e g r o u p r e c e i v e d a l m o s t t w i c e a s m u c h o p i o i d
(51 . 1 _+ 20 . 8) a s the m orph ine -p lus -ke tam ine g rou p
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214
(25.82 _+ 16.40) (P < 0 .001) at a grea ter hou r ly rate (2 .6
_+ 1 .1) than did those who had ketamine added (1 .2 _+
0.7) (P < 0 .001) .
Pa t i en t s r ece i v i ng ke t ami ne r epo r t ed f ewer s i de
ef f ec t s t han t hose r ece i v i ng morph i ne a l one (Tab l e I I ) .
They r epo r t ed l ess nausea , p ru r i t u s , and u r i nary r e t en -
t i on t han t he morph i ne g roup . The g roups d i d no t d i f f e r
i n t he amoun t o f seda t i on o r dysphor i a . No r esp i r a t o ry
depress i on was seen , and t here were no r epo r t s o f v i t a l
s i gn dev i a t i ons >30% f rom base l i ne . Th ree sub j ec t s i n
t he morph i ne g roup (15%) r epo r t ed som e d i f f i cu l t y wi t h
dysphor i a , compared wi t h on l y one i n t he morph i ne-
p l us -ke t am i ne g roup (5%) .
The on l y pos i t i ve co r r e l a t i on o f s i de e f f ec t wi t h dose
was u r i nary r e t en t i on (Tab l e 11 I) . Pa t i en t s r ece i v i ng
mo rph i ne wi t h ke t am i ne r epo r t ed a r e l a t ionsh i p be t ween
p a i n V A S s c o r e s a n d a m o u n t o f m e d i c a t i o n r e c e i v e d
( r = 0 .42 , P < 0 .05 ) and a ne ga t i ve r e l a ti onsh i p be t ween
seda t i on and dysphor i a ( r = -0 .74 , P < 0 .001).
i s cu s s i on
Our s t udy demons t r a t es t ha t t he combi na t i on o f ke t a -
mi ne i n l ow doses wi t h morph i ne , de l i vered v i a IVPCA,
prov i ded super i o r pa i n r e l i e f a t l ower dosage o f mor -
p h i n e a n d w i t h f e w e r s i d e e f f e c ts t h a n w h e n u s i n g m o r -
ph i ne a l one . Our r esu l t s suppor t t he conc l us i on t ha t
morph i ne p l us ke t ami ne i s bo t h a sa fe and an e f f ec t i ve
mi x t u re .
Pa t i en t s who r ece i ved morph i ne p l us ke t a rn i ne r a t ed
t he i r pa i n as l ower t han t hose r ece i v i ng on l y morph i ne .
Th i s d i f f e r ence was subs t an t i a l , cons i der i ng t ha t t he
m o r p h i n e g r o u p s e l f- a d m i n i st e r e d a lm o s t t w i c e a s m u c h
med i ca t i on . Thus , i t appear s t ha t t he ke t ami ne g roup
rece i ved super i o r ana l ges i a . The morph i ne-p l us -ke t a -
mi ne g roup admi n i s t e r ed l ess t han ha l f t he average
h o u r l y a m o u n t o f m e d i c a t i o n a n d h a d f e w e r p r o b l e m s
wi t h s i de e f f ec t s . These f i nd i ngs mi gh t be exp l a i ned by
t he l ower dose o f morph i ne admi n i s t e r ed , r esu l t i ng i n
fewer s i de e f f ec t s . Overa l l t he morph i ne g roup se l f -
admi n i s t e r ed l ess op i o i d , perhaps due t o u r i nary r e t en -
t i on . Th i s w as t he on l y s i de e f f ec t i n wh i ch t here was
found t o be a r e l a t i onsh i p be t ween dose and s i de e f f ec t ,
a l t hough i t was n o t observed i n t he morph i ne wi t h ke t a -
m i n e g r o u p . T h e a d d i t i o n o f k e t a m i n e h a s a m o r p h i n e
spar i ng e f f ec t , and , due t o a r e l a t i ve l y l ower dose o f
se l f - admi n i s t e r ed d rug , t h i s g roup av o i ded u r i nary r e t en -
t ion.
W hi l e t he add i t i on o f ke t ami ne t o m orph i ne does p ro -
duce more po t en t ana l ges i a , w i t h a l ower i nc i dence o f
s i de e f f ec t s , t here m ay be a sub t l e a l t e r a ti on i n t he wa y
t he ke t ami ne o r i t s combi na t i on wi t h morph i ne a f f ec t s
t he r e l a ti onsh i p be t ween pa i n r epo r t i ng an d dos i ng . One
exp l ana t i on mi gh t be r e l a t ed t o t he e f f ec t o f ke t am i ne on
CANADIAN JOURNAL OF ANAESTHESIA
TABLE I Sample characteristics for morphine and morphine-plus-
ketamine groups
M o r p h i n e
V a r i a bl e M o r p h i n e K e t a m i n e
Sex 88 male 79 male
Age 39.5 • 7.2 37.3 • 9.9
Weight (kg) 83.9 • 10.7 78.2 • 13.1
TABLE 11 Side effects reported by patients receiving morphine or
morphine plus ketamine
M o r p h i n e
S i d e e f f e c t M o r p h i n e K e t a m i n e P
Dysphoria 1.85 • 0.366 1.95 • 0.213 NS
Nausea 2.20 • 1.196 1.39 • 0.755 <0.05
Pruritus 1.80 • 0.516 1.18 • 0. 39 5 <0 .0 01
Sedation 2.05 • 0.999 1.50 • 1.058 NS
Urinary retention 1.70 • 0.801 1.14 • 0.640 <0.05
TABLE 1II Correlations (r) between dose and side effects for mor-
phine and morphine-plus-ketamine groups
S i d e e f f e c t
M o r p h i n e M o r p h i n e K e t a m i n e
T o t a l d o s e m l . h r 1 T o t a l d o s e m l . h r I
Dysphoria 0.24 -0.4 2 0.28 0.29
Nausea -0.0 3 -0.14 0.08 0.07
Pruritus 0.01 0.25 0.06 0.06
Sedation 0.02 0.12 0.36 0.34
Urinary retention 0.5 1' 0.57t 0.21 0.17
P < 0 . 0 5 .
tP < 0.01.
t he t ha l amo-neocor t i ca l p ro j ec t i on sys t em.21 Ketamine
depresses neu rons i n t he co r t ex and t ha l amus , wh i l e
s i mu l t ane ous l y i ncreas i ng ac t i v i t y i n t he l i mb i c sys t em,
a phe nom enon t e rmed func t i ona l d i so rgan i za t ion . '22
Exci t a t i on o f l i mb i c func t i on i ng combi ned wi t h dep res -
s i on o f t ha l ami c co r t i ca l func t i on i ng cou l d a f f ec t t he
pa t i en t ' s emot i ona l r esponse o r eva l ua t i on o f pa i n sen -
sa t i on . Thus , pa t i en t s r ece i v i ng ke t ami ne m ay be expe r i -
enc i ng l ess su f f e r i ng o r emot i ona l r esponse t o a s i m i l a r
l eve l o f noc i cep t i on o r somat i c pa i n sensa t i on . Fu t u re
s t u di e s m i g h t e m p l o y m o r e s e n s it iv e m e a s u r e s o f b e h a v -
i ou r , pa i n , and su f f e r i ng t o e l uc i da t e t he r e l a t i onsh i p
be t we en pa i n r epo r t and me d i ca t i on dos i ng .
An i mal s t ud i es have demons t r a t ed po t en t i a t i on
b e t w e e n s u b - e f f e c t i v e d o s e s o f k e t a m i n e a n d m o r -
phine, 23,24 but th i s has not be en dem onst r ated in hu ma ns.
E d w a r d s
e t a l
18 com bi ned an i n fus i on o f morp h i ne a nd
ket am i ne fo r pos t opera t i ve ana l ges i a i n e l der l y pa t ien t s .
T h e a d d i ti o n o f k e t a m i n e d i d n o t i m p r o v e t h e a n a l g e s i a
o r pos t opera t i ve l ung func t i on . Increas i ng t he dose o f
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Javery
et al.:
MORPHINE AND KETAM1NE 215
ketamine resulted only in an increased incidence of
postoperative dreaming. However, our findings support
prev ious studies 14,17 that the combina tion is useful, and
has an increased analgesic effect.
One of the most troubling side effects of ketamine is
the high incidence of adverse psychomimetic effects,
with a reported range from 4 to 80 . 25,26In our inves-
tigation, psychomimetic effects were clinically and sta-
tistically insignificant among our patients who received
ketamine with their morphine. Only one patient receiv-
ing the ketamine-plus-morphine mixture reported dys-
phoria compared with three in the morphine- only group.
We have found that the combination of ketamine at
low, sub-dissociative doses and morphine delivered via
IVPCA is a safe and effective means of providing post-
operative analgesia that deserves consideration as part
of the postoperative pain control armamentarium.
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