Ketamine and Magnesium: a Successful Combination for Bariatric Surgery
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LETTER TO THE EDITOR
Ketamine and Magnesium: a Successful Combination for Bariatric Surgery Michele Carron 1
&
Giovanna Ieppariello 1 & Federico Linassi 1 & Paolo Navalesi 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Letter to the Editor Multimodal analgesia is a pharmacologic approach, which combines analgesics, adjuvants, and local anesthetics to achieve perioperative nociception management [1]. The rationale behind multimodal analgesia is that the use of more agents at smaller doses maximizes the desired effects while simultaneously minimizing side effects [1], with the aim of increasing pain relief, and reducing opioid requirements and opioid-related adverse effects [2, 3]. Multimodal analgesia is strength of successful perioperative care in patients with obesity [3, 4] and has been recommended for enhanced recovery after bariatric surgery [5]. Among the wide variety of available analgesics and adjuvants, ketamine and magnesium should be considered [3]. The principal anti-nociceptive effects of ketamine are mediated by N-methyl-D-aspartate (NMDA) receptors, located on peripheral afferent nociceptive neurons that synapse in the dorsal horn of the spinal cord [1]. Blocking nociceptive inputs at this level impedes the entry of these signals into the spinal cord [1]. Ketamine also acts on NMDA receptors in the brain, which contributes to its anti-nociceptive effects [1]. Similarly, the anti-nociceptive effects of magnesium are primarily mediated by NMDA receptor antagonism and inhibitory effects at glutamatergic synapses [1]. To better understand the impacts of these NMDA receptor antagonists on postoperative pain control in patients undergoing bariatric surgery, we performed a meta-analysis of data from randomized, controlled trials, comparing ketamine[6–10] or magnesium-treated [11, 12] patients with controls (Fig. 1). The search strategy, methodology followed during
* Michele Carron [email protected] 1
Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121 Padova, Italy
the meta-analysis, and the statistics have been described in Fig. 1. The meta-analysis results confirmed an overall benefit of NMDA receptor antagonists in reducing postoperative pain scores in treated obese patients, compared with non-treated obese patients (Fig. 1). The study by Jabbour et al., in the April 2020 issue of Obesity Surgery, is a welcome contribution to the topic [13]. This study demonstrated the synergistic effects of ketamine and magnesium, resulting in improved postoperative pain control after bariatric surgery [13]. Moreover, this study raises the issue of potential favorable mood effects that may occur in patients undergoing bariatric surgery, due to the synergistic action observed in multimodal analgesia. Mood disorders are common among patients seeking and undergoing bariatric surgery [14, 15]. A random-effects meta-analysis of data from 59 publications (65,363 patients) showed that the estimated prevalence of any
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