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Effect of low dose ketamine pretreatment on laparoscopic pneumoperitoneum

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https://www.eduzhai.net Clinical Medicine and Diagnostics 2016, 6(4): 96-102 DOI: 10.5923/j.cmd.20160604.02 Effect of Low – Dose Ketamine Pretreatment in Laparoscopic Pneumoperitoneum Soad S. A. EL Gaby1,*, Sabah E. Abd-Elraheem2 1Anesthesiology and ICU Department, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt 2Clinical Pathology Department, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt Abstract Background: Laparoscopic surgery has become an integral part of modern-day surgical practice. Despite the general safety of the procedure, sudden changes in intra-abdominal pressure (IAP) that trigger ischemia/reperfusion effect lead to post surgical oxidative stress even causing cellular damage and resultant organ dysfunction. The anesthesiologist should use an anesthetic agent that would result in "homeostatic regulation" of the acute inflammatory reaction and the stress – induced immune disturbances. The aim of this work: was to evaluate the anti-inflammatory and anti-oxidant effect of low–dose ketamine (0.5 mg/kg) intraperitoneal pretreatment in laparoscopic pneumoperitoneum. Patients and Methods: the study was carried out on 44 Adult patients between 20 and 40 years old, scheduled for laparoscopic cholecystectomy surgery. History, clinical examination and basic laboratory investigations were carried out on the preoperative day. Patients were randomly allocated into one of two groups, ketamine intraperitoneum (KIP) group (n = 22 patients): 0.5 mg/kg ketamine diluted in 50 ml normal saline was injected IP and saline intraperitoneum (SIP) group (n = 22 patients): 50 ml of normal saline was injected IP. The following parameters were recorded: Time to extubation, discharge time, time of the first request of analgesia, visual analogue scale (VAS), the total dose of pethidine postoperatively, the occurrence of any side effects or complications. Biochemical Assay: Human tumor necrosis factor–alpha and Serum superoxide dismutase assay were performed by ELISA. The sampling time of TNF-alpha and SOD: preoperative and 4 hours postoperative. Results: The patients in KIP had lower VAS at all time assessment point. The times for first analgesic request postoperatively were 240±3.5 and 60.0±5.6 in KIP group and SIP group respectively. Patients in KIP required less dose of pethidine in the first 24h of postoperative period (51±43.5) compared to SIP group (109.4±31.7) (P<0.001). The postoperative serum TNF-alpha concentration was significantly lower in KIP group (9.45±1.02 pg/ml) compared to SIP group (12.53±0.98 pg/ml) (p-value 0.019). However the postoperative serum SOD concentration was significantly high in KIP group (26.39 + 15.79 U/ml) compared to SIP group (17.57 + 7.23 U/ml) (with p-value 0.022). Conclusions: this study suggests the low dose ketamine (0.5mg/kg) pre-treatment IP can reduce the inflammatory response and oxidative stress associated with laparoscopic pneumoperitoneum. Also, it reduces postoperative pain and analgesic requirement. Keywords LOW – DOSE KETAMIN 1. Introduction Laparoscopic surgery has become an integral part of modern-day surgical practice [1]. Despite the general safety of the procedure, sudden changes in intra-abdominal pressure (IAP) that trigger ischemia/reperfusion effect lead to postsurgical oxidative stress even causing cellular damage and resultant organ dysfunction [2]. There are several defense mechanisms against ischemia-reperfusion injury (IRI) in the body. Endogenous enzymes such as superoxide dismutase (SOD), catalase and glutathione peroxides play a * Corresponding author: Soadsayed1.@hotmail.com (Soad S. A. EL Gaby) Published online at https://www.eduzhai.net Copyright © 2016 Scientific & Academic Publishing. All Rights Reserved part in the defense mechanisms of the body in normal conditions [3]. Ketamine is a dissociative anesthetic analgesic, antioxidant and anti-inflammatory, so it's a drug promoting the inflammatory homeostasis. Locally, ketamine interferes early on the determinants of primary immunity. It prevents the exacerbation and extension of local inflammation without blunting the local process & delaying inflammatory resolution. Ketamine also prevents the general anti pro-inflammatory mechanisms to excessively overcome the pro-inflammatory influence [4]. Therefore, the anesthesiologist should use an anesthetic agent that would result in homeostatic regulation of the acute inflammatory reaction and the stress – induced immune disturbances. The aim of this work: was to evaluate the anti-inflammatory and anti-oxidant effect of low–dose Clinical Medicine and Diagnostics 2016, 6(4): 96-102 97 ketamine (0.5 mg/kg) intraperitoneal pretreatment in laparoscopic pneumoperitoneum. 2. Patients and Methods This study was carried out in Al-Azhar University Hospital. After approval from the hospital ethics committee and obtaining signed informed consent from patients, the study was carried out on 44 Adult patients between 20 and 40 years old, scheduled for laparoscopic cholecystectomy surgery. History, clinical examination and basic laboratory investigations (CBC, liver function test, and renal function test) were carried out on the preoperative day. Patients with a history of systemic hypertension, cardiac diseases, hepatic diseases, renal diseases, diabetes mellitus, alcoholism and drug addiction were excluded from the study. All patients were NPO at least 6 hours before the operation and premedicated with midazolam 0.05 mg/kg and ondansetron 4 mg IV, 15min before the operation. After 2-3 min preoxygenation, anesthesia was induced with fentanyl 1-2 mg/kg, Lidocaine30-50mg, and propofol 2mg/kg, and rocuronium bromide 0.6-1 mg/kg IV was used to facilitate tracheal intubation with oral cuffed endotracheal tube. Anesthesia was maintained with 50% O2 in air and isoflurane concentration (1-2%) was adjusted to maintain adequate anesthesia & hemodynamic stability. Lung ventilation was controlled to maintain ETCO2 tension at 35±5 mmHg. The Incremental doses of rocuronium 0.6 mg/kg were given every 30 min, and fentanyl 0.5 µg/kg IV if the intraoperative pain was suspected. Crystalloid solution 6-10 ml/kg/h IV was given. Continuous monitoring of heart rate was performed with ECG, and noninvasive monitoring of systolic, diastolic, mean arterial pressure, and oxygen saturation. Veress needle was introduced towards the pubis through a small one cm elliptical subumbilical incision with the patients in the Trendelenburg position. Pneumoperitoneum (PP) was achieved by CO2 insufflations at the rate of one L/min for the first min, then at the rate of 3-4 L/min with a maximum IAP 15 mmHg. The introduction of a safety reusable metal trocar through the previous incision was done. The camera scope was then introduced. The pelvis and abdomen were inspected. Patients were randomly allocated into one of the two groups. In ketamine intraperitoneum (KIP) group: (n = 22 patients): 0.5 mg/kg ketamine diluted in 50 ml normal saline was injected IP. In saline intraperitoneum (SIP) group(n = 22 patients): 50 ml of normal saline was injected IP and patients kept in the Trendelenburg position for 5-10 min then patients of both groups were put in antitrendelenburg position with rising of the right shoulder. After the end of surgical procedures, discontinuation of isoflurane, FiO2 was increased to 100% and atropine 0.01-0.02 mg/kg, prostigmine 0.04-0.08mg/kg was used to antagonize the residual of rocuronium bromide. After tracheal extubation the patients were transferred to PACU and the following parameters were recorded: 1- Time to extubation in min:time from the end of surgery to tracheal extubation. 2- Discharge time in min: time from the discontinuation of anesthetic gas till the patients met the discharge criteria (modified Aldrete’s score). 3- Time of the first request of analgesia (If the VAS was 3 or more). 4- The pain was assessed with visual analogue scale (VAS), that explained to all patients preoperatively (0 = no pain to 10 the worst pain) VAS were recorded at TO (Immediately postoperative), every 2 hours for the first 6th hours then every 6th hours for the first 24 hours postoperatively. If the VAS was 3 or more, it was treated by Pethidine 0.5 mg/kg IM. 5- Total doses of pethidine postoperatively (mg/24h). 6- Any side effects or complications such as Hypoxia (spo2<94%), Apnea, PONV were recorded for all patients and was managed accordingly. Biochemical Assay: All patients were subjected to the following: Laboratory investigations: Six ml of fasting venous blood samples was taken from each patient in the study and divided into two portions as follows: The first portion: collected into EDTA containing tube for estimation of CBC. Were determined on Sysmex KX-21N. The second portion was put in a plain tube, left to clot then centrifuged at 1600 rpm for 20 minutes and serum was separated and used for estimation of: Liver function test, kidney function test, and fasting blood glucose were done on Hitachi 911 auto-analyzer (Roche-Hitachi, Japan). The human tumor necrosis factor-alpha assay was performed using ELISA KITS supplied from assay pro. Company with, Catalog No. ET2010-1 USA. intra-assay, inter-assay coefficients of variation were 5.5% and 7.0% respectively. The Assay Max Human TN-alpha ELISA kit was designed for detection of TNF-alpha in human plasma, serum or cell culture supernatants. This assay employs a quantitative sandwich enzyme immunoassay technique that measures TNF-alpha in less than 5 hours. A murine monoclonal antibody specific for human TNF-alpha has been pre-coated onto a microplate. TNF-alpha in standards and samples was sandwiched by the immobilized antibody and a biotinylated polyclonal antibody specific for human TNF-alpha, which was recognized by a streptavidin-peroxidase conjugate. All unbound material was then washed away and a peroxidase enzyme substrate was added. The color development was stopped and the intensity of the color was measured, and the microtiter plate was the read at 450nm wavelength. The level of IL-18 was calculated from standard curve corresponding to the measured optical density. The results were expressed as pg/ml, NV 5-25 pg/ml. The serum superoxide dismutase assay was performed 98 Soad S. A. EL Gaby et al.: Effect of Low – Dose Ketamine Pretreatment in Laparoscopic Pneumoperitoneum using ELISA KITS supplied from glory science Co., Ltd. Del Rio, TX 78840, USA. Briefly. The kit uses a double-antibody sandwich enzyme-linked immune sorbent assay (ELISA) to assay the level of human superoxide dismutase (SOD) in samples. Superoxide dismutase (SOD) was added into Well which was pre-coated with Human superoxide dismutase (SOD) monoclonal antibody, after incubation; superoxide dismutase (SOD) antibodies labeled with biotin, and combined with streptavidin-HRP was added to form the immune complex; then incubation and washing were carried out to remove the uncombined enzyme. Then chromogen solution A, B, were added, the color of the liquid changed into the blue, and at the effect of acid, the color finally became yellow. The chroma of color and the concentrations of the Human Substance superoxide dismutase (SOD) of the sample were positively correlated. Assay range of the kit is 5 mU/L à 180mU/L and the lowest assay sensitivity of the kit is < 5mU/L. Sampling times of TNF-alpha and SOD were preoperative and 4 hours postoperative. Statistical analysis We calculate sample size according to Raosoft and all statistical calculations were done using SPSS (statistical package for the social science version 20.00) statistical program. at 0.05, 0.01 and 0.001 level of probability [23], Qualitative data were presented as number and percentages and compared using Chi-square test while quantitative data with parametric distribution was done using t-test was presented using mean ±standard deviation, median (IQR). Comparison between two paired groups was done using Paired t-test. The confidence interval was set to 95% and the margin of error accepted was set to 5%. The p-value was considered nonsignificant (NS) at the level of > 0.05, significant (S) at the level of > 0.05 and highly significant (HS) at the level of < 0.01. 3. Results There were no significant differences in either the demographic data, duration of surgery and anesthesia between the two groups (table 1). The patients in KIP had lower VAS at all time assessment points, (table 2) (figure 1). The time for first analgesic request postoperatively were 240±3.5 and 60.0±5.6 in KIP group and SIP group, respectively (P < 0.001). Furthermore, patients in KIP required less dose of pethidine in the first 24h, of postoperative period (51.±43.5) compared to SIP group (109.4+ 31.7) (P <0.001) (Table 3). In term of the time to extubation was 6.3±1.25 min and 9.6±2.3 min in KIP group and SIP group, respectively with p-value (0.001). However, discharge time was lower in KIP group (14.28±3.5min) compared to SIP group (35.5±4.8 min) with p-value (0.001). (table 4). As regards postoperative complications reported in this study, a number of patients who had postoperative vomiting in KIP group was one patient (4.55%), while 7 patients (31.82%), were in SIP group (p-value 0.019). There was no statistically significant difference between the two groups as regards the other observed complications as apnea and hypoxia (table 5). The postoperative serum TNF-alpha concentration was significantly lower in KIP group (9.45±1.02pg/ml) compared to SIP group (12.53±0.98pg/ml) with p-value 0.019 (table 6). However the postoperative serum SOD concentration was significantly high in KIP group (26.39 + 15.79 U/ml) compared to SIP group (17.57 + 7.23 U/ml) with p-value 0.022, (table 6). The intergroup comparison (preoperative and postoperative) showed in table 7 and 8. Table (1). Demographic and operative data among the two studied groups Parameters Gender (no.{%}) ASA (no{%}) Groups Females Males I II Saline IP group n = 22 19 (86.36%) 3 (13.64%) 17 (77.27%) 5 (22.73%) Ketamine IP group n = 22 18 (81.82%) 4 (18.18%) 16 (72.73%) 6 (27.27%) Chi-square test P-value 0.170 0.680 0.121 0.727 Parameters Age (years) BMI (kg/m2) Time of anesthesia (min) Time of surgery (min) Groups Mean±SD Mean±SD Mean±SD Mean±SD Saline IP group n = 22 42.3±3.6 28.16±4.85 87.9±7.8 59.0±11.8 Ketamine IP group n = 22 41.5±4.4 27.9±4.97 89.6±9.9 59.9±13.9 t test P-value 0.660 0.176 0.633 0.232 0.513 0.861 0.530 0.818 Clinical Medicine and Diagnostics 2016, 6(4): 96-102 99 Table (2). VAS (median (IQR)) in both groups 0 h 2 h 4 h 6 h 12 h 24 h SalineIP group Median (IQR) 3.65 (0.98) 1.70 (1.23) 2.50 (0.65) 4.48 (1.13) 3.10 (0.6) 4.75 (1.47) KitamineIP group Median (IQR) 1.05 (0.58) 1.50 (0.83) 2.32 (1.20) 2.55 (0.85) 2.85 (0.88) 4.20 (1.15) *: Data represented as median (IQR) scale 5 4.5 4 3.5 3 2.5 2 saline 1.5 ketamine 1 0.5 0 0 h 2 h 4 h 6 h 12 h 24 h Time Figure (1). VAS (Median) in both groups Table (3). Time to first analgesic request and total dose of pethidine (mg/24h) Parameters Groups Time to first request analgesia (min) Total dose of pethidine (mg/24h) Ketamine IP n = 22 240 ± 3.5 51.1 ± 43.5 Saline IP n = 22 60.0 ± 5.6 109.4 ± 31.7 Independent t-test t p-value 127.847 <0.001 * 5.08 <0.001 * :Data represented as Mean±SD. *:HS = highly significant at independent t-test p<0.001. Table (4). Time to extubation and discharge time among the two studied groups Parameters Groups Time to extubation (min) Discharge time (min) Saline IP group Mean ± SD 6.3 ± 1.25 35.5 ± 4.8 Ketamine IP group Mean ± SD 9.6 ± 2.3 14.28 ± 3.5 Independent t-test T P-value 5.913 <0.001 * 16.754 <0.001 * :Data represented as Mean±SD. *:HS = highly significant at independent t-test p<0.001. Table (5). Reported postoperative complications among the two studied groups Parameters Groups Nausea Vomiting Apnea Hypoxia Saline IP No. % 6 27.27% 7 31.82% 1 4.55% 3 13.64% Ketamine IP No. % 2 9.09% 1 4.55% 0 0.00% 1 4.55% Chi-square test X2 P-value 2.444 0.117 5.500 0.019 * 1.023 0.311 1.100 0.294 *: S = significant at Chi-square test p<0.05. 100 Soad S. A. EL Gaby et al.: Effect of Low – Dose Ketamine Pretreatment in Laparoscopic Pneumoperitoneum Table (6). Comparison of TNF-alpha (pg/ml) and SOD (u/ml) levels preoperative and postoperative in the saline group and ketamine group by paired t-test and between the two groups by independent t-test Groupss Parameters Saline IP Range Mean ± SD Ketamine IP Range Mean±SD t-test P value TNF –alpha(pg/ml) Preoperative 4 h post-operative 10 – 12.5 10.9 – 17 10.79 ± 0.69 12.53 ± 0.98 9 – 12.5 5 – 14 11.17 ± 0.92 9.45 ± 1.02 -1.539 4.357 0.131 0.019 NS S Superoxide dismutase (SOD) (u/ml) Preoperative 4 h post-operative 9.8 – 52.1 8 – 43 22.22 ± 8.69 17.57 ± 7.23 9 – 72.2 13 – 83.5 21.37 ± 15.01 26.39 ± 15.79 0.230 -2.381 0.819 NS 0.022 NS S :Data represented as Mean±SD. *:S = highly significant at independent t-test p<0.05. Table (7). Mean of difference in TNF-alpha, SOD, and their statistical significance in the saline group Pair TNF-alpha pre - TNF-alpha post-operative after 4 h Saline IP Group NO= 22 Paired differences Mean of difference STE 1.74 0.037 Paired t-test t 4.909 Sig (2-tailed) 0.000 SOD pre-SOD postoperative after 4 h -4.65 0.451 7.171 0.000 Table (8). Mean of difference in TNF-alpha, SOD, and their statistical significance in Ketamine group Pair TNF-alpha pre - TNF-alpha post-operative after 4 h Ketamine IP Group NO= 22 Paired differences Mean of difference STE -1.72 0.137 Paired t-test t 4.615 Sig (2-tailed) 0.000 SOD pre-SOD postoperative after 4 h 5.02 0.648 7.344 0.000 4. Discussion Laparoscopic surgical procedures usually require the creation of a capnoperitoneum obtained by peritoneal insufflations pressurized dry CO2, Indeed, the diffusion of gas in the abdominal cavity could be responsible for peritoneal desiccation injury [5]. The pneumoperitoneum (pp) associated with short-term compartment situation has immediate transient, lasting, local and global consequence [6]. The gas insufflations and direct surgical touching by instruments initiate an acute phase stress protein release, that predisposes the peritoneum and organ structures to inflammation, results in pain perceived by the patient [7]. The commonly used anesthetic, ketamine, the low dose has sedative, analgesic and anti-inflammatory effects [8]. Structures of benzene may play a protective role in scavenging free radicals and inhibiting the activity of inflammatory cytokines [9]. The NMDA receptors have a role in central sensitization. The blunting of central sensitization has played an important role in prevention and treatment of both postoperative pain and chronic pain [10]. Although central NMDA receptors still receive a great deal of attention, evidence suggests that NMDA receptors located in peripheral tissue (IP) and viscera play an important role in nociception and provide noval mechanism of peripheral sensitization [11]. Activation of the peripheral NMDA receptors caused the Ca-dependent release of proinflammatory, substance p and produces nociceptive behavior, and peripheral injection of NMDA receptor antagonists attenuates pain associated with neuropathic pain or inflammatory condition [12]. The present study showed that KIP 0.5 mg/kg was associated with significant decrease in VAS and analgesic dose requirement postoperatively; this could be explained by peripheral blockade of peripheral NMDA receptors (IP). Clinical Medicine and Diagnostics 2016, 6(4): 96-102 101 There are a few experimental studies that evaluated IP administration of NMDA receptor antagonists. Beniro et al. (2003) demonstrated that IP administration of NMDA receptor antagonists decreased the nociception observed during the late phase of the formalin test in niece [13]. A study performed by Guardsobrinho et al., concluded that the intra-articularly delivered ketamine as an analgesic agent during total knee replacement surgery provides effective postoperative analgesia [14]. Another study demonstrated that the topical use of ketamine cream or gel up to 20% has been successfully used in the treatment of pain [15]. Furthermore in 2014 meta-analysis by Cho et al., reported that in tonsillectomy in children, preoperative administration of ketamine, either systemic or locally, resulted in significantly decreased pain and analgesic need over 24 hours [16]. Similar results to our study reported in a study done in 2015 by Gome and AbdElhamid, they stated that the peripheral (peritoneal) NMDAreceptor blockade by S (+) ketamine was involved in the reduction of postoperative pain and analgesic requirement following bariatric surgery [17]. We observed that SIP group extubate earlier than the KIP group, due to the analgesic effect of Ketamine. However, rapid recovery from anesthesia for SIP group did not mean early discharge from PACU. Pain and postoperative vomiting recorded in SIP group delay discharging from PACU. We decided to study the serum of TNF- Alpha level, as it is one of the earliest and most potent mediators of host responses to acute inflammation & injury. We found that with KIP group there's a highly significant decrease of TNF & concentration postoperative compared to preoperative value and SIP. This might be attributed to ketamine ability to inhibit the production o inflammatory cytokines and thus reducing stress responses during pneumoperitoneum. The results of the present study are in agreement with previously reported results that reported low dose ketamine pretreatment can reduce oxidative stress and the inflammatory cytokine response associated with pneumoperitoneum in rat [1]. Also, our results in accordance with data from meta-analysis showing that ketamine significantly inhibits the early postoperative inflammatory response [18]. In addition to these, ketamine infusion decreased the level of TNF-Alpha, IL-13- and IL6 induced by lipopolysaccharide in lung tissue [19]. Anti-inflammatory effect of ketamine is thought to be mediated through inhibition of nuclear factor (NF) – KB, which regulates the transcription of genes that encode the production of pro-inflammatory cytokines. Indeed, anti-inflammatory effects of ketamine have been well demonstrated mainly in terms of reducing the activity of proinflammatory mediators [20]. We found that ketamine treatment provided antioxidant effects, as evidenced by increased the SOD level postoperatively. SOD is a ubiquitous antioxidant enzyme and shows that oxidative tissue injury was more pronounced in SIP group. Xingeixu et al 2014 Supported our results by low dose ketamine pretreatment can reduce oxidative stress and the inflammatory response associated with pneumoperitoneum in rate. Moreover, ketamine treatment reduced the activity of the antioxidant enzymes superoxide dismutase [21]. Antioxidant characteristics of ketamine were revealed through various mechanisms, it blocks N-methyl-d-aspartate receptors, prevents Ca++ from entering cells and increases blood flow in ischemic tissue.17 In addition, reducing adhesion molecules such as p-selectin and ICAM-1 in leukocyte, thrombocyte and endothelial cells [22]. There are limitations to our study, single dose of ketamine was studied, and further studies are warranted to determine the most appropriate dose of ketamine IP. 5. Conclusions This study suggests the low dose ketamine (0.5mg/kg) pre-treatment IP can reduce the inflammatory response and oxidative stress associated with laparoscopic pneumoperitoneum. Also, it reduces postoperative pain and analgesic requirement. REFERENCES [1] Xingweixu, Xin G, Peng Z, Tan F, et al. (2014): Low – dose ketamine pretreatment reduces oxidative damage and inflammatory response following CO2 pneumoperitoneum in rat. ClinInvest Med; 37 (3), 124-130. [2] Arioz, Tolga D, Polat et al. (2009): What should be the ideal time for IR preconditioning in a laparoscopic rat model. J laparoendoscopicand advanced surgical techniques; 19 (2) 141-7. 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EL Gaby et al.: Effect of Low – Dose Ketamine Pretreatment in Laparoscopic Pneumoperitoneum [8] Duj, Huang YG, YU XR and Zhao (2011): Effect of preoperative ketamine on the endocrine – metabolic and inflammatory response to laparoscopic surgery. Clin med J; 124 (22) 3721-5. [9] Hayashi H, Dikkes P and Soriano SG (2002): Repeated administration of ketamine may lead to neuronal degeneration in the developing rat brain. Pediatr. Anesth; 19 (9); 770-4. [10] Radvansky BM, Sahk, Parikh A et al. (2015): Acute postoperative pain management. Bio Med research international article ID 749837. tonsilectomy in children. Meta-analysis. PLOS one; 9 (6): 101259. [17] Gom HM and Abd Elhamid B (2015): Intraperitoneal ketamine reduces postoperative analgesic requirement in morbidly obese patients: A controlled study. Enliven Journal anesthiology and critical car Medicine; (3) 5. [18] Dako Somogyi AA, Liy, Sullivan T and Shavit Y (2012): Dose intraoperative ketamine attenuate inflammatory reactivity following surgery: a systematic review and met-analysis. Anesth. Analgesia; 115 (4) 934-943. [11] Peternko AB, Yamakura T, Bab H and Shimoji K (2003): The role of N-Methyl – D- Aspartate (NMDA) receptors in pain: A Review. Anesth. Analgesia; 97: 11058-16. [12] Me Roberts JA, Coutinho SV, Marvizon JCG, Gkady EF, Tongetto M et al. (2001): The role of peripheral N-Methyl – D – Aspartate receptors in visceral nociception in rate. gastroenterology; 120, 1736-1748. [13] Beniro L, Oliva P, Massimo F, Aurilio C, Maioon S et al. (2003): Antinociceptive effect in mice of intraperitoneal N-Methyl – D – Aspartate receptor antagonists. Eur J Pain; 7 (2) 131-7. [14] Sobrinho HG, Garci JBS, Vasconcelos JW, Sousa JCA and Ferro LSG (2012): Analgesic efficacy of the intrarticular administration of S (+) ketamine in patients undergoing total knee arthroplasty. 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[22] Omer K, Nermin G, Ali A, Mehmet A, Unal D, Solak Sezen K, and Hakan K (2016): Tourniquet-induced ischaemia-reperfusion injury: the comparison of antioxidative effects of small-dose propofol and ketam. Brazilian Journal of Anesthesiol doi:10.1016/j.bjane.2015.09.005. [23] Snedecor, G. M. & Cochran, W. G. (1982): Statistical methods-7th edition, lowa state Univ., Press, Ames., loww3a, USA., pp. 325-330

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