Neuroendocrine stress, analgesic outcomes, and patient satisfaction with levobupivacaine infiltration with or without ketamine in cesarean section: a prospective randomized controlled trial

Abstract

Background: The rates of cesarean section (SC) are increasing globally, making postoperative pain management a critical issue. Post-SC pain can impair recovery and activate neuroendocrine stress responses, including elevated cortisol, which may compromise healing and immunity. Multimodal analgesia combining levobupivacaine with lowdose ketamine can optimize pain relief, reduce stress responses, and improve patient satisfaction.
Methodology: This prospective, randomized, double-blind controlled trial was conducted from May to September 2025 at Raden Mattaher General Hospital, Jambi. Forty-two patients undergoing CS under spinal anesthesia (ASA I–II) were randomly assigned into three groups: levobupivacaine alone, levobupivacaine + ketamine 0.5 mg/kg, and levobupivacaine + ketamine 1 mg/kg. Subcutaneous infiltration was performed before skin closure. Randomization was computer-generated, and both participants and outcome assessors were blinded to group allocation. Serum cortisol levels were measured pre- and postoperatively. Pain intensity (VAS and PPT), need for rescue analgesics, and patient satisfaction were recorded within 24 h postoperatively.
Results: Significant intergroup differences were found in cortisol reduction, VAS scores, pain thresholds, and
satisfaction (P < 0.05). The levobupivacaine + ketamine 1 mg/kg group demonstrated the greatest cortisol reduction, lowest pain scores, no need for rescue fentanyl, and highest satisfaction ratings.
Conclusion: Subcutaneous infiltration with levobupivacaine combined with ketamine (1 mg/kg) provides superior analgesia, attenuates the stress response, and enhances patient satisfaction after cesarean delivery. This multimodal, opioid-sparing approach is a clinically valuable strategy for postoperative pain control.
Keywords: cesarean section; cortisol; ketamine; levobupivacaine; postoperative pain; randomized controlled trial; stress response
Citation: Hasyim A, Wirawan NS, Tan CW, Herlambang H. Neuroendocrine stress, analgesic outcomes, and patient satisfaction with levobupivacaine infiltration with or without ketamine in cesarean section: a prospective
randomized controlled trial. Anaesth. pain intensive care 2025;30(1):32-39. DOI: 10.35975/apic.v30i1.3099
Received: October 14, 2025; Revised: November 26, 2024; Accepted: December 05, 2025