KETAMIN ADJUVANT FOR SINGLE

SHOT THORACIC PARAVERTEBRAL

BLOCK ON MODIFIED RADICAL
Indrati Tyas Siwi TR*, Doso
Sutiyono**, Taufik(MRM)
Eko Nug
MASTECTOMY
*Anesthesiology and Intensive Care Resident, Medical Faculty of
Diponegoro University
**Anesthesiology and Intensive Care Department, Medical Faculty of
Background: Single shot thoracic paravertebral block (STPVB) is most commonly used Diponegoro
to provide anesthesia
and
University
1

analgesia. STPVB is more comfortable and easier to applied than the multiple shot TPVB . Ketamine has localanesthetic-like effects and has been extensively used through epidural and caudal routest 2. The effect of ketamine as

adjuvant in STPVB will be examined in this case.

Objectives : to evaluate the effectiveness of
ketamine adjuvant in STPVB for managing post
operative pain after MRM.
Methods: Six womans age 35-60 years old
were
scheduled
for
elective
MRM.
Premedication using midazolam 0,07 mg/kg.
They were randomized into 2 groups: (1) using
injection Bupivacaine 0,5 % + 0,1 mg
epinephrine, with total volume 21 cc (2)
bupivacain 0,5% + 0,1 mg epinephrine +
ketamine 0,5mg/kg with total volume 21cc.
Induction using propofol 2 mg/kg, rocuroneum
0,7 mg/kg. Maintenance with O2 and
sevoflurane. We evaluate post operative pain
using VAS scale and hemodynamic status of
patients. Ketorolac 30 mg intravenous
administration started when Visual Analogue
Scale > 4.

Table score VAS duration effect STPVB (hours)

Group 1

Group 2

VA
S

mean

mean

12

12

12

12

12

12

12

12

18

18

17

15

18

18

17

24

30

30

28

18

20

22

20

36

37

40

38

Diagram score VAS and duration

40
30
Hours 20
10
0

Group 1
Column1
VAS 1 VAS 2 VAS 3 VAS 4
score VAS

Result: Patient with STPVB (1) have been

managed post operative analgetic for 18, 20,
and 22 hours. In patient with ketamine adjuvant
(2) the analgetic effect have been prolonged for
36, 37, and 40 hours. Post operative
hemodynamic status was stable.

Conclusion: Ketamine as adjuvant on STPVB was improve acute

post operative pain management by increase the duration of
paravertebral block.
Discussion: Ketamine act on the central nervous system and
work as a noncompetitive antagonist of the N-methyl-D aspartate
receptor (NMDAR)2. The NMDAR is an excitatory glutamatergic
receptor in the spinal and supraspinal sites involved in the
afferent transmission of nociceptive signals 2,3. Ketamine will
spread in paravertebral space and enter to prevertebral plane,
epidural, intercostal space and absorb in systemic circulation on
STPVB4.

Keywords: Post operative pain management, single shot thoracic paravertebral

block,
ketamine
References
1. Coveney E, Weltz CR, Greengrass R, et al. Use of Paravertebral Block Anesthesia in The Surgical Management of Breast Cancer
Experience in 156 Cases, Ann Surg, 1998; 227:496-501 [cited on June 24 2015] www.ncbi.nlm.nih.gov/pmc/articles/PMC1191303/
2. Pai A, Heining M. Ketamine. Oxford Journal Continuing Education Anaesthesia Critical Care and Pain. 2007. 7 (2): 59-63
doi:10.1093/bjaceaccp/mkm00 [cited on June 25 2015] Available from http
://ceaccp.oxfordjournals.org/content/7/2/59.full.pdf+html
3. Tighe SQM, Greene MD, Rajadurai N. Paravertebral block. Oxford Journal Continuing Education Anaesthesia Critical Care and
Pain. 2010. 10 (5): 133-137. doi: 10.1093/bjaceaccp/mkq029 . [cited on June 25 2015] Available from http://
ceaccp.oxfordjournals.org/content/10/5/133.full.pdf+html?sid=24f05bd7-5a4a-40df-a08b-91cbad0ee6b1