10 – ORIGINAL ARTICLE

CLINICAL INVESTIGATION

Comparison of the effects of magnesium and ketamine on postoperative pain and

morphine consumption. A double-blind randomized controlled clinical study1

Müge ArıkanI, Bilge AslanII, Osman ArıkanIII, Eyüp HorasanlıIV, Abdulkadir ButV

DOI: http://dx.doi.org/10.1590/S0102-865020160010000010

I
Assistant Professor, Department of Anesthesiology, Karabuk Education and Research Hospital Affiliated, School of Medicine, Karabuk University,
Turkey. Acquisition of data, manuscript writing, carrying out the study.
II
PhD, Department of Anesthesiology, Zekai Tahir Burak Education and Research Hospital, Ankara, Turkey. Acquisition of data, carrying out the study.
III
PhD, Department of Surgery, Karabuk Education and Research Hospital Affiliated, School of Medicine, Karabuk University, Turkey. Manuscript
writing.
IV
Associate Professor, Department of Anesthesiology, School of Medicine, Yıldırım Beyazıt University, Ankara, Turkey. Design of the study, acquisition
of data.
V
Professor, Department of Anesthesiology, School of Medicine, Yıldırım Beyazıt University, Ankara, Turkey. Design of the study.

ABSTRACT
PURPOSE: To compare the effects of magnesium sulfate and ketamine on postoperative pain and total morphine consumption in a
placebo-controlled design.
METHODS: One hundred and twenty women scheduled for total abdominal hysterectomy were included in this prospective,
randomized, double-blind study. Postoperatively, when the Numeric Pain Rating Scale (NPRS) was four or more, IV-PCA morphine
was applied to all patients. The patients were randomized into three groups: Group K ketamine, Group M magnesium, and Group C
saline received as infusion. Total morphine consumption for 48h, pain scores, adverse effects, and patients’ satisfaction were evaluated.
RESULTS: Total morphine consumption was significantly lower in Group K (32.6±9.2 mg) than in Group M (58.9±6.5 mg) and in
Group C (65.7±8.2 mg). The satisfaction level of patients in Group K was higher than the other two groups (p<0.05). Pruritus and nausea
were observed more frequently in Group C.
CONCLUSİON: The addition of ketamine to IV-PCA morphine reduces the total consumption of morphine without psychotic effects;
however, magnesium did not influence morphine consumption.
Key words: Analgesia, Patient-Controlled. Morphine. Magnesium Sulfate. Ketamine.

Acta Cirúrgica Brasileira - Vol. 31 (1) 2016 - 67

Arıkan M et al.

Introduction The exclusion criteria were patients with severe hepatic,

renal, cardiovascular impairment, neurological or psychiatric
Intravenous patient-controlled analgesia (IV-PCA) disorders, with allergy to the study drugs, and with history of
with morphine is commonly used for postoperative pain control chronic pain, drug or alcohol abuse. Those with history of current
following major abdominal surgery. However, large amounts regular use of analgesics, anticonvulsants, antidepressants, or
of morphine may lead to significant adverse events, such as opioids within the last month were excluded from the study.
respiratory depression, nausea, vomiting, or hypotension . 1
Patients were randomly allocated into one of three equal
Multimodal analgesia using a non-opioid analgesic, in groups (n = 40) with a computerized random number generator:
addition to an opioid analgesic, has been suggested as a way to group K (ketamine bolus 0.2 mg/kg followed by infusion of 0.05
improve postoperative pain control and to reduce opioid use2-5. mg/kg/h, group M (magnesium bolus 50 mg/kg followed by 10
Since the mechanism of action differs from that of opioids, mg/kg/h infusion), and group C (normal saline). Study drugs were
ketamine may be a useful adjunct to improve the management of started in the postoperative period and continued for 48 h.
perioperative pain. The potential benefit of adding ketamine to During the preoperative visit, the patients were informed
IV-PCA with morphine has been reported by a number of studies about the purpose, and the use of the patient-controlled analgesia
across several types of surgery 5-12
. (PCA) device (Abbott Pain Management Providerc, Abbot
Magnesium sulfate has also been previously investigated Laboratories, North Chicago, IL, USA).
as a possible adjuvant for postoperative analgesia 13-23
. However; All patients were premedicated with midazolam (0.15
relatively few studies have been conducted on the effects of mg/kg, IV) 45 min before surgery. On arrival in the operating
postoperative intravenous magnesium administration (as an room, routine monitorization including electrocardiography
infusion) over a 24-hour period 17,21-23
. (ECG), pulse oximetry (SpO2), and noninvasive blood pressure
The current prospective, randomized study aimed to (NIBP) were implemented.
compare the effects of magnesium sulfate and ketamine on General anesthesia was induced with thiopental sodium (5
postoperative pain and total morphine consumption in a placebo- mg/kg) and fentanyl (1 µg/kg). Tracheal intubation was facilitated
controlled design. We also assessed the occurrence of adverse with 0.6 mg/kg of rocuronium. Maintenance of anesthesia was
effects and the level of patient satisfaction. accomplished by sevoflorane, 50% N2O in O2. Mechanically
controlled ventilation was adjusted to maintain end-tidal PCO2
Methods near 35 mmHg. Additional muscle relaxant and fentanyl were
administered during the operation according to clinical need and
The investigation was approved by the Ethics Committee the discretion of the attending anesthesiologist. However, in the
of Zekai Tahir Burak Training and Research Hospital, (ETIC last 20 min of the operation, fentanyl was not applied.
864/2013), according to the principles outlined in the Declaration All surgeries were performed by a single surgical team
of Helsinki. After obtaining approval from the hospital ethics with the same way. Ten minutes before the end of surgery, morphine
committee, written informed consent was obtained from all (0.05 mg/kg) and ondansetron (4 mg) were routinely administered.
patients. At the end of surgery, anesthesia was discontinued, and residual
This randomized (computerized), double-blind, placebo- neuromuscular blockade was antagonized with neostigmine (0.05
controlled, clinical study was conducted at the Zekai Tahir Burak mg/kg) and atropine (0.02 mg/kg). The trachea was extubated,
Training and Research Hospital, Ankara, Turkey, from May 2013 when the patient became fully awake. Patients were transferred to
to May 2014. the postanesthesia care unit (PACU).
One hundred and twenty patients belonging to American In the PACU, a physician, blinded to the groups, evaluated
Society of Anesthesiologist (ASA) physical status I and II, age the severity of pain by using a Numeric Pain Rating Scale (NPRS, 0
30-60 years, scheduled to undergo elective open total abdominal = no pain, 10 = worst pain). When a NPRS score of 4 was reached,
hysterectomy (TAH) for fibroid disease, or uterine myomectomy or the patient requested analgesic, a bolus dose of morphine 0.01
under general anesthesia were enrolled in the study. mg/kg was administered, and then the IV-PCA device containing

68 - Acta Cirúrgica Brasileira - Vol. 31 (1) 2016

 Comparison of the effects of magnesium and ketamine on postoperative pain and morphine consumption.
A double-blind randomized controlled clinical study

morphine 1 mg/mL was connected to the patients (bolus = 0.01 Demographic characteristics such as age, ASA, and
mg/kg, lock-out interval = 15 min, and continous background duration of surgery were also recorded for all patients.
infusion = 0.03 mg/kg/h)24. It was continued throughout the 48 h The physicians collecting the postoperative data, as well
study period. as the patients, were unaware of the infused solutions.
Patients were randomly allocated into three equal groups The primary endpoint was total morphine consumption
(n = 40) with a computerized random number generator in a
48 h after surgery. The secondary outcome measures were the pain
double-blinded manner:
scores, the presence of adverse effects, and the patient satisfaction
1. Ketamine group (Group K), patients received a bolus
levels.
dose of ketamine (0.2 mg/kg), and followed by continuous infusion
of ketamine (0.05 mg/kg/h),
Statistical analysis
2. Magnesium group (Group M), patients received a
bolus dose of magnesium (50 mg/kg), and followed by continuous
The morphine consumption by PCA at the end of 48
infusion of magnesium (10 mg/kg/h),
hours was the primary outcome variable on which sample size
3. Control group (Group C), patients received a bolus
dose, and continuous infusion of normal saline. estimation was based at the beginning of the study. A sample size
The bolus doses of the study drugs were administered, of 25 per group was required to detect a difference in morphine
and their infusions were started simultaneously with the initiation consumption between treatments at a two-sided 5% significance
of the IV-PCA morphine. All studied solutions were continued level with a power of 90%25.
until 48 h postoperatively via an infuser. Thus, patients had two Data were expressed as mean ± standard deviation (SD),
separate mechanical infusion devices during the study period. or number (%) of patients. For the statistical analysis, SPSS
The severity of pain (with NPRS) was recorded at 2, 4, version 13.0 (SPSS Inc. Illinois) was used. A one-way ANOVA
6,12, 24, and 48 h after surgery. Patients received tenoxicam 20 was used to compare the continuous variables among the groups.
mg (IV) as rescue analgesia, if pain was not adequately controlled If a significant difference was noted, to know which group differs
(pain score >3 on the NPRS)24. The total number of rescue from which others, post hoc Tukey was used. Categorical variables
analgesic doses were noted in the 48 h period.
were analyzed using the chi-square test or Fisher exact test, as
The degree of sedation was assessed using modified
appropriate. P value of less than 0.05 was considered statistically
Ramsay sedation scale at 2-6-12-24 and 48 h after PCA device
significant. The Bonferroni Correction was applied for all possible
had been started.
multiple comparisons controlling Type I error.
Adverse events such as nausea, vomiting, pruritus,
hypotension, bradycardia, hypoventilation, constipation,
Results
headache, dizziness, nightmare, sedation (Ramsay sedation score
>3), and hallucination were also recorded. The complications were
In the present study, a total of 120 patients met the inclusion
treated according to each individual case.
The satisfaction level of the patients was divided into one criteria, and consented for the study. Patients were randomized to
of four levels: very satisfied (4), generally satisfied (3), moderately one of three groups (Figure 1). There were no dropouts or loss to
satisfied (2), and unsatisfied (1). follow-up. There were no significant differences among the three
Total morphine consumption, the number of rescue groups with respect to demographic data or the duration of the
analgesic given, and the level of the patient satisfaction were operation (Table 1).
recorded at 48 h after surgery.

Acta Cirúrgica Brasileira - Vol. 31 (1) 2016 - 69

Arıkan M et al.

FIGURE 1 - The flow chart of the study.

TABLE 1 - Demographic characteristics of patients and TABLE 2 - Morphine consumption (48h after surgery),
duration of surgery. and Numeric Pain Rating Scores.
Group C Group M Group K Group
Group C Group K
(n=40) (n=40) (n=40) M P
(n=40) (n=40)
(n=40)
Age (years) 58.45±5.71 56.81±5.12 59.35±4.96
Morphine
Weight (kg) 70.85±12.51 69.05±11.12 68.52±10.02 consumption 65.7±8.2 58.9±6.5 32.6±9.2* 0.015*
(mg)
Duration
of surgery 1.53±0.23 1.57±0.20 1.56±0.12 NPRS 2h 6.6±1.9 6.4±1.6 6.2±0.6 0.39
(hours)
6h 4.4±0.9 4.1±1.7 4.0±1.1 0.47
Data are the mean ± SD. There were no significant differences among the groups.

12 h 3.9±1.1 3.6±0.7 3.5±1.7 0.25

The mean morphine consumption doses after 48 h was 24 h 3.1±1.0 2.8±0.3 2.7±0.5 0.31
lowest in the ketamine group (p<0.05). There was no statistically
48 h 2.8±0.5 2.6±0.9 2.5±1.1 0.42
significant difference between the control group and magnesium
Data are the mean ± SD. A one-way analysis of variance was used to compare the
group (p>0.05). The NPRS at all time points were similar among continuous variables among the groups with a post hoc Bonferroni multiple com-
the three groups (Table 2). parisons test. *p<0.05; vs Group C and Group M.

70 - Acta Cirúrgica Brasileira - Vol. 31 (1) 2016

 Comparison of the effects of magnesium and ketamine on postoperative pain and morphine consumption.
A double-blind randomized controlled clinical study

The postoperative 48h; rescue analgesic was given to Intravenous patient-controlled analgesia (IV-PCA) with
16/40 patients (40%) in Group C, 12/40 patients (30%) in Group morphine is commonly used for postoperative pain control after
M, and 5/40 patients (12.5%) in Group K. Additional analgesic major abdominal surgery. White et al.26 concluded that the use of
requirements were less in Group K (p<0.05). The level of the morphine infusion combined with PCA boluses may result in a
patient satisfaction was higher in Group K compared to Group M better control of pain and lower morphine consumption. Therefore,
and Group C (Group K, Group M, and Group C: 3.4±0.2, 2.3±0.8, in our study, we used this method. In addition, rescue analgesia
and 2.4±0.5, respectively) (p<0.05). with tenoxicam (20 mg, IV) was given27.
The incidence of adverse events such as hypotension, Different drugs have been used as an adjuvant in order
bradycardia, vomiting, nightmare, hallucination, and dizziness to reduce morphine consumption. The N-methyl D-aspartate
were comparable among the groups. However, pruritus (p=0.012), (NMDA) receptor is found in many parts of the body, including the
and nausea (p=0.015) were observed more frequently in Group C nerve endings, and it plays a well-defined role in pain modulation.
than in the other two groups (Table 3). NMDA receptor antagonists, such as, magnesium sulfate, and
ketamine, have been previously investigated as a possible adjuvant
for postoperative analgesia13.
TABLE 3 - Adverse events.
Several studies have demonstrated the analgesic
Group C Group M Group K
effectiveness of perioperatively administered ketamine during
(n=40) (n=40) (n=40)
the acute postoperative period2-4. A systematic review has shown
Hypotension 3 (7.5%) 1 (2.5%) 0 the analgesic benefit of ketamine, especially in surgery that is
accompanied by high levels of postoperative pain2, and when
Bradycardia 2 (5%) 1(2.5%) 0 combined with morphine to lower morphine consumption8.
Nesher et al.11 reported that IV-PCA with a subanesthetic
Nausea 10 (25%)* 6 (15%) 5 (12.5%) dose of ketamine and morphine following transthoracic lung and
heart surgery resulted in lower pain scores, morphine consumption,
Vomiting 3 (7.5%) 1 (2.5%) 1(2.5%) and incidence of nausea-vomiting without increasing side effects.
Zakine et al.12 compared ketamine infusion during the
Pruritus 5 (12.5%)* 1 (2.5%) 0 intraoperative period alone with that for the perioperative period
(intraoperative plus postoperative, 48h). The authors demonstrated
Dizziness 0 0 1(2.5%) that low dose ketamine improved postoperative analgesia, reduced
morphine consumption and incidence of nausea. Remerand and
Hallucination 0 0 1(2.5%) colleagues10 demonstrated that an IV bolus at the beginning
of surgery followed by a 24h infusion decreased morphine
Nightmare 0 0 0 consumption in patients undergoing total hip arthroplasty.
Akhavanakbari et al.28 showed that adding ketamine to morphine
Data are expressed as the number and proportion (%) of patients in each group.
*p<0.05; vs Group K and Group M. in IV-PCA reduced pain score and morphine consumption.
In this study, ketamine has been used only for the
postoperative period without pre- or perioperative administration.
Discussion In line with the previous studies, we found that the morphine
consumption was less in ketamine group, and the use of the low
This study showed that the addition of ketamine to IV- dose (0.05 mg/kg/h) of ketamine was not associated with any
PCA with morphine was associated with less morphine consumed, psychotic effects. These results were also confirmed in a previous
less number of patient needed rescue analgesic, and more patient study3.
satisfaction. The occurrence of pruritus and nausea were more Perioperative intravenous magnesium sulfate at very
frequent in morphine alone group. In our study, we observed that high doses has been reported to reduce postoperative morphine
magnesium sulfate had no impact on morphine consumption. We consumption but not postoperative pain scores15. Murphy et al.29
did not find any differences among groups in terms of pain scores, found that the perioperative infusion of magnesium sulfate was
and other side effects. associated with a decrease in postoperative opioid consumption;

Acta Cirúrgica Brasileira - Vol. 31 (1) 2016 - 71

Arıkan M et al.

nevertheless, the decrease in opioid consumption was not group. Ketamine is still one of the most advantageous adjuvant
associated with a decrease in opioid related side effects (eg, drugs for treating postoperative pain.
postoperative nausea and vomiting). In addition, they also found
that perioperative magnesium sulfate infusion was associated with References
a decrease in visual analog scale pain scores up to 4-6 hours after
1. Rothbard RL, Schreiner BF, Yu PN. Hemodynamic and respiratory
surgery.
effects of dezocine, ciramadol, and morphine. Clin Pharmacol Ther.
Ryu et al.30 gave magnesium sulfate (50mg/kg bolus 1985 Jul;38(1):84-8. PMID: 3839174.
followed by 15mg/kg/h) or placebo intraoperatively to patients 2. Ding X, Jin S, Niu X, Wang T, Zhao X, Ren H, Tong Y, Li Q.
Morphine with adjuvant ketamine versus higher dose of morphine
undergoing total abdominal hysterectomy under general alone for acute pain: a meta-analysis. Int J Clin Exp Med. 2014
anesthesia. They found that postoperative PCA morphine use and Sep;7(9):2504-10. PMID: 25356103.
pain scores were lower in the magnesium group at 24 and 48 h, 3. Hadi BA, Daas R, Zelkó R. A randomized, controlled trial of a
clinical pharmacist intervention in microdiscectomy surgery - Low
and PONV incidence was also lower than with placebo. Tramer dose intravenous ketamine as an adjunct to standard therapy. Saudi
et al.15 reported that patients undergoing lower abdominal surgery Pharm J. 2013 Apr;21(2):169-75. doi: 10.1016/j.jsps.2012.08.002.
4. Lahtinen P, Kokki H, Hendolin H, Hakala T, Hynynen M.
with magnesium supplementation consumed 30% less morphine
Propacetamol as adjunctive treatment for postoperative pain after
in the postoperative period compared with control patients. Ozcan cardiac surgery. Anesth Analg. 2002 Oct;95(4):813-9. PMID:
et al.21 found that postoperative use of magnesium sulfate reduced 12351250.
5. Carstensen M, Møller AM. Adding ketamine to morphine for
opioid consumption for pain after thoracotomy operations. intravenous patient-controlled analgesia for acute postoperative
However; in our study, we did not find any positive effect of pain: a qualitative review of randomized trials. Br J Anaesth. 2010
magnesium sulfate on morphine consumption. Lysakowski et Apr;104(4):401-6. doi: 10.1093/bja/aeq041.
6. Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for
al.31, in a systemic review of randomized trials, reached different acute post-operative pain: a quantitative and qualitative systematic
conclusions as to whether magnesium sulfate is a useful adjuvant review (Cochrane review). Acta Anaesthesiol Scand. 2005
Now;49(10):1405-28. PMID: 16223384.
to postoperative analgesia. Their trials do not provide convincing
7. Dahmani S, Michelet D, Abback PS, Wood C, Brasher C, Nivoche
evidence that perioperative magnesium sulfate has favorable Y, Mantz J. Ketamine for perioperative pain management in
effects on postoperative pain intensity and analgesic requirement. children: a metaanalysis of published studies. Pediatr Anaesth. 2011
Jun;21(6):636-52. doi: 10.1111/j.1460-9592.2011.03566.x.
Unlugenc et al.23 compared the effects of magnesium
8. Himmelseher S, Durieux ME. Ketamine for perioperative pain
sulfate with ketamine on postoperative analgesia and morphine management. Anesthesiology. 2005 Jun;102(1):211–20. PMID:
consumption. They found that both drugs significantly reduced 15618805.
9. Parikh B, Maliwad J, Shah VR. Preventive analgesia: Effect
morphine consumption during the first 24 hours. In this study, the of small dose of ketamine on morphine requirement after renal
total morphine consumption was significantly lower in ketamine surgery. J Anaesthesiol Clin Pharmacol. 2011 Oct;27(4):485-8. doi:
group, but we did not find any favorable effects of magnesium 10.4103/0970-9185.86592.
10. Remerand F, Le Tender C, Baud A, Couvret C, Pourrat X, Favard
sulfate on morphine consumption. Postoperative pain scores were L, Laffon M, Fusciardi J. The early and delayed analgesic effects
similar in all groups. The incidence of nausea and pruritus were of ketamine after total hip arthroplasty: a prospective, randomized,
controlled, doubleblind study. Anesth Analg. 2009 Dec;109(6):1963-
more common in morphine alone group.
71. doi: 10.1213/ANE.0b013e3181bdc8a0.
This study had some limitations. The present study was 11. Nesher N, Serovian I, Marouani N, Chazan S, Weinbroum AA.
that pain scores were not recorded after the postoperative first 48 Ketamine spares morphine consumption after transthoracic lung
and heart surgery without adverse hemodynamic effects. Pharmacol
hours. Moreover, we evaluated the pain intensity only at rest. The Res. 2008 Jul;58(1):38-44. doi: 10.1016/j.phrs.2008.06.003.
analgesic effects of the study drugs on postoperative mobilization, 12. Zakine J, Samarcq D, Lorne E, Moubarak M, Montravers P, Beloucif
and hospital discharge time were not evaluated. These effects S, Dupont H. Postoperative ketamine administration decreases
morphine consumption in major abdominal surgery: a prospective,
should be addressed in future studies. randomized, double-blind, controlled study. Anesth Analg. 2008
Jun;106(6):1856-61. doi: 10.1213/ane.0b013e3181732776.
Conclusions 13. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review
of intravenous ketamine for postoperative analgesia. Can J Anaesth.
2011 Oct;58(10):911–23. doi: 10.1007/s12630-011-9560-0.
Patients in morphine alone group experienced more 14. Liu HT, HollmannMW, Liu WH, Hoenemann CW, Durieux
nausea and pruritus than in the other groups. The total consumption ME. Modulation of NMDA receptor function by ketamine and
magnesium: part I. Anesth Analg. 2001 May;92(5):1173–81. PMID:
of morphine, and additional analgesic requirements were less, 11323343.
while the satisfaction level of patients were higher in the ketamine 15. Tramer MR, Schneider J, Marti RA, Rifat K. Role of magnesium

72 - Acta Cirúrgica Brasileira - Vol. 31 (1) 2016

 Comparison of the effects of magnesium and ketamine on postoperative pain and morphine consumption.
A double-blind randomized controlled clinical study

sulfate in postoperative analgesia. Anesthesiology. 1996 analgesia: a systematic review and meta-analysis. Middle East J
Feb;84(2):340–7. PMID: 8602664. Anaesthesiol. 2013 Feb;22(1):11-20. PMID: 23833845.
16. Zarauza R, Saez-Fernandez AN, Iribarren MJ, Carrascosa F, Adame 30. Ryu JH, Kang MH, Park KS, Do SH. Effects of magnesium sulphate
M, Fidalgo I, Monedero P. A comparative study with oral nifedipine, on intraoperative anaesthetic requirements and postoperative
intravenous nimodipine, and magnesium sulfate in postoperative analgesia in gynaecology patients receiving total intravenous
analgesia. Anesth Analg. 2000 Oct;91(4):938–43. PMID: 11004053. anaesthesia. Br J Anaesth. 2008 Mar;100(3):397-403. doi: 10.1093/
17. Benhaj Amor M, Barakette M, Dhahri S, Ouezini R, Lamine K, bja/aem407.
Jebali A, Ferjani M. Effect of intra and postoperative magnesium 31. Lysakowski C, Dumont L, Czarnetzki C, Tramer MR. Magnesium
sulphate infusion on postoperative pain. Tunisie Médicale. 2008 as an adjuvant to postoperative analgesia: a systematic review of
Jun;86(6):550–5. PMID: 19216446. randomized trials. Anesth Analg. 2007 Jun;104(6):1532-9. PMID:
18. Kara H, Sahin N, Ulusan V, Aydogdu T. Magnesium infusion reduces 17513654.
perioperative pain. Eur J Anaesthesiol. 2002 Jan;19(1):52–6. PMID:
11913804.
19. Seyhan TO, Tugrul M, Sungur MO, Kayacan S, Telci L, Pembeci K, Acknowledgement
Akpir K. Effects of three different dose regimens of magnesium on
propofol requirements, haemodynamic variables and postoperative
pain relief in gynaecological surgery. Br J Anaesth. 2006 English-language editing of this manuscript was provided
Feb;96(2):247–52. PMID: 16311277.
by Journal Prep.
20. Jaoua H, Zghidi SM, Wissem L, Laassili S, Ammar N, Ali J,
Darmoul S, Askri A, Khelifi S, Ben Maamer A, Cherif A, Ben Fadhel
K. Effectiveness of intravenous magnesium on postoperative pain
after abdominal surgery versus placebo: double blind randomized
Correspondence:
controlled trial. Tunis Med. 2010 May;88(5):317-23. PMID:
Müge Arikan
20517827.
Alpaslan Street, 1
21. Ozcan PE, Tugrul S, Senturk NM, Uludag E, Cakar N, Telci L, Esen
Sırınevler - Karabuk Turkey
F. Role of magnesium sulfate in postoperative pain management for
Phone: +90 5053969097
patients undergoing thoracotomy. J Cardiothorac Vasc Anesth. 2007
Fax: +90 3704125628
Dec;21(6):827-31. PMID: 18068060.
[email protected]
22. Unlugenc H, Gunduz M, Ozalevli M, Akman H. A comparative
study on the analgesic effect of tramadol, tramadol plus magnesium,
Received: Sept 22, 2015
and tramadol plus ketamine for postoperative pain management
Review: Nov 18, 2015
after major abdominal surgery. Acta Anaesthesiol Scand. 2002
Accepted: Dec 23, 2015
Sep;46(8):1025-30. PMID: 12190807.
Conflict of interest: none
23. Unlugenc H, Ozalevli M, Guler T, Isik G. Postoperative pain
Financial source: none
management with intravenous patient-controlled morphine:
comparison of the effect of adding magnesium or ketamine. Eur J
Anaesthesiol. 2003 May;20(5):416-21. PMID: 12790216. Research performed at Zekai Tahir Burak Education and Research
1

24. Sivrikoz N, Koltka K, Oguz HB, Buget M, Atalar A, Senturk M. Hospital, Ankara, Turkey.
Analgesia for arthroscopic shoulder surgery: a comparison of
interscalene and subacromial levobupivacaine with iv morphine
patient controlled analgesia. Int J Anesthesiol Res. 2013 Dec;1(2):68-
73. doi: 10.14205/2310-9394.2013.01.02.2.
25. Lerman J. Study design in clinical research: sample size estimation
and power analysis. Can J Anaesth. 1996 Feb;43(2):184-91. PMID:
8825545.
26. White I, Ghinea R, Avital S, Chazan S, Dolkart O, Weinbroum AA.
Morphine at “sub-analgesic” background infusion rate plus low-
dose PCA bolus control pain better and is as safe as twice a bolus-
only PCA regimen: a randomized, double blind study. Pharmacol
Res. 2012 Aug;66(2):185-91. doi: 10.1016/j.phrs.2012.03.016.
27. Chang WK, Wu HL, Yang CS, Chang KY, Liu CL, Chan KH, Sung
CS. Effect on pain relief and inflammatory response following
addition of tenoxicam to intravenous patient-controlled morphine
analgesia: a double-blind, randomized, controlled study in patients
undergoing spine fusion surgery. Pain Med. 2013 May;14(5):736-
48. doi: 10.1111/pme.12067.
28. Akhavanakbari G, Mohamadian A, Entezariasl M. Evaluation the
effects of adding ketamine to morphine in intravenous patient-
controlled analgesia after orthopedic surgery. Perspect Clin Res.
2014 Apr;5(2):85-7. doi: 10.4103/2229-3485.128028.
29. Murphy JD, Paskaradevan J, Eisler LL, Ouanes JP, Tomas VA,
Freck EA, Wu CL. Analgesic efficacy of continuous intravenous
magnesium infusion as an adjuvant to morphine for postoperative

Acta Cirúrgica Brasileira - Vol. 31 (1) 2016 - 73