Comparison of TIVA with different combinations of ketamine–propofol mixtures in pediatric patients

Effects of propofol, ketamine-propofol mixture in pediatric dental patients undergoing intravenous sedation: a clinical study

This study aimed to evaluate the clinical effects, complications (peri- and postoperative), depth of sedation, recovery times, and changes in anxiety levels in paediatric dental patients receiving intravenous sedation with propofol and ketamine-propofol mixtures. This prospective clinical study included 69 healthy children (ASA 1) aged 3-7 years. The patients were assigned randomly to propofol group (n = 23), which received propofol; 1:3 ketofol group (n = 23), which received 1:3 ketofol; or 1:4 ketofol group (n = 23), which received 1:4 ketofol. The bispectral index (BIS) and Ramsay Sedation Scale (RSS) score were recorded at intervals of 5 min to measure the depth of sedation, and vital signs were evaluated. Peri- and postoperative complications and recovery times were recorded. Anxiety levels were also evaluated using the Facial Image Scale (FIS) and changes in saliva cortisol levels (SCLs) before and after the intravenous sedation procedure. The Kruskal‒Wallis test and Wilcoxon signed-rank test were used to determine pre- and posttreatment parameters. Dunn's test for post hoc analysis was used to determine the differences among groups. Children's pre- and posttreatment anxiety levels did not differ significantly according to FIS scores, and increases in SCLs were detected in 1:3 ketofol and 1:4 ketofol groups after dental treatment was completed. Compared with those in the other groups, the BIS values of the patients in 1:4 ketofol indicated a slightly lower depth of sedation. The recovery time of the patients in 1:3 ketofol was longer than that of patients in propofol and 1:4 ketofol. The incidence of postoperative complications (agitation, hypersalivation, nausea/vomiting, and diplopia) did not differ among the groups. Ketamine-propofol combinations provided effective sedation similar to that of propofol infusion without any serious complications during dental treatment performed under intravenous sedation. The ketofol infusion increased the anxiety level of paediatric dental patients to a greater extent than the propofol infusion.

The Total Intra Venous Anesthesia Effect Versus Volatile Anesthesia, on Stress and Pain Levels, in Patients Undergoing Breast Reconstruction in Ambulatory Surgery Center Total Intra Venous Anesthesia Protocol and Stress Response

AIM

To compare pain and stress response through cortisol and DHEA levels, implementing. Total intra venous anesthesia (TIVA) versus general anesthesia with volatile anesthetics (VOL).

DESIGN

This is a prospective randomized correlation study with consecutive measurements.

METHODS

In an ambulatory surgical center from October of 2019 to August of 2020, patients who underwent breast reconstruction with autologous fat grafting were randomized into 2 groups. Patients in the TIVA group (n = 23) received intravenous anesthesia and those in the VOL group (n = 23) received volatile anesthesia (desflurane). Demographic, anthropometric and clinical data were recorded. Arterial systolic (SP) and diastolic (DP) blood pressure, heart rate and oxygen saturation were recorded. Pain and stress levels were evaluated through salivary cortisol and DHEA levels at 4 different time points: T0) 1 hour before induction, T1) during the induction, T2) during anesthesia maintenance, and T3) in recovery phase. Statistical analysis was performed with SPSS 25.0 at significant level α = .05.

FINDINGS

There were no statistically significant differences between the 2 groups regarding demographic features. Interestingly that there was a statistically significant difference in the vital sign monitoring where patients in the TIVA group reported with higher levels of SP(T2) and DP (T2), whilst DHEA (T1) levels was correlated positively with patient's age and cortisol (T1) levels and negatively with DP (T3).

CONCLUSIONS

This study supports the use of TIVA as a safe and effective option for anesthesia in patients undergoing breast reconstruction with autologous fat grafting.

Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial

BACKGROUND

We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy.

METHODS

This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor).

RESULTS

Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition.

CONCLUSION

In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions.

CLINICAL TRIAL REGISTRATION

NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

Total Intravenous Anesthesia with Ketofol versus Combination of Ketofol and Lidocaine for Short-Term Anesthesia in Pediatric Patients; Double Blind, Randomized Clinical Trial of Effects on Recovery

Background: Ketofol admixture has been proposed to be useful for sedation and general anesthesia. The beneficial effect of the combination of ketofol with lidocaine may be a shortened time of anesthesia and recovery period. This study aimed to establish the effect of total intravenous anesthesia (TIVA) with ketofol and ketofol with lidocaine on recovery in children. Methods: Two hundred children from the ages of 1–12 years who underwent short surgical procedures were randomly allocated into two groups. Propofol mixtures (ketofol) were prepared for group l. A ratio of 1:4 of ketofol was used for induction and for the maintenance of anesthesia a ratio of was used 1:7. For the induction and maintenance of anesthesia ketofol with lidocaine (lidoketofol) was used in group II. The McFarlan infusion regimen was used with reduction. The extubating time, anesthesia duration and the length of stay in the post-anesthesia care unit (PACU) were recorded. Results: Extubation time showed to be considerably shorter in the lidoketofol group than in the ketofol group (120 s versus 240 s; p < 0.00001). The anesthesia duration was also significantly shorter in the lidoketofol group (35 min vs. 50 min; p < 0.00001). The lidoketofol group showed to have a lower length of stay in the post-anesthesia care unit (PACU) than the ketofol group (20 min vs. 35 min; p < 0.00001). The lidoketofol group showed lower fentanyl consumption per kg (2.1 µg per kg vs. 2.3 µg per kg; p < 0.056) and lower propofol consumption (6.6 mg per kg vs. 7.6 mg per kg; p < 0.032). Conclusion: The recovery in pediatric anesthesia can improve with usage of TIVA with ketofol plus lidocaine admixture with a reduced McFarlan dose regimen.

Effects on Recovery of Pediatric Patients Undergoing Total Intravenous Anesthesia with Propofol versus Ketofol for Short-Lasting Laparoscopic Procedures

BACKGROUND

Combining ketamine and propofol (ketofol) was suggested as a new concept for sedation and general anesthesia in pediatric populations for various conditions. The aim of the present study was to determine the effect of total intravenous anesthesia (TIVA) with propofol and ketofol on recovery after laparoscopic surgery in pediatric patients.

METHODS

Two hundred children with median age of 5 years who underwent laparoscopic surgery were randomized into two groups. Propofol 1% was used for induction and maintenance of anesthesia in group I, while ketamine-propofol combination (ketofol) was used in group II. Ketamine-propofol combination (ketofol) was prepared in the same applicator for group II. Ketofol ratios of 1:4 and 1:7 were used for induction and maintenance of anesthesia, respectively. A reduced McFarlan infusion dose was used in group I (1.2, 1.0, and 0.8 mL/kg/h for 15, 15, and 30 min, respectively), while a McFarlan infusion dose was used in group II (1.5, 1.3, and 1.1 mL/kg/h for 15, 15, and 30 min, respectively). Extubating time, duration of anesthesia, and length of stay in post-anesthesia care unit (PACU) were recorded.

RESULTS

Extubating time was significantly lower in the ketofol group than in the propofol group (240 s vs. 530 s; p < 0.00001). Significantly shorter duration of anesthesia (47 min vs. 60 min; p < 0.00001) as well as length of stay in the PACU (35 min vs. 100 min; p < 0.00001) were recorded in ketofol compared to the propofol group. Total fentanyl (100 µg (interquartile range, IQR 80, 125) vs. 50 µg (IQR 40, 60); p < 0.00001) and propofol (260 mg (IQR 200, 350) vs. 160 mg (IQR 120, 210); p < 0.00001) consumption per body weight were significantly lower in the ketofol group.

CONCLUSIONS

TIVA with ketamine-propofol combination (ketofol) using a reduced McFarlan dose regimen shortened extubating time, duration of anesthesia, as well as length of stay in the PACU in pediatric anesthesia after laparoscopic surgery.

Propofol use in newborns and children: is it safe? A systematic review

OBJECTIVES

To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios.

SOURCES

A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles.

SUMMARY OF THE FINDINGS

Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk.

CONCLUSIONS

Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.

Dexmedetomidine attenuates the propofol-induced long-term neurotoxicity in the developing brain of rats by enhancing the PI3K/Akt signaling pathway

BACKGROUND

Propofol induces short- and long-term neurotoxicity. Our previous study showed that dexmedetomidine (Dex) can attenuate the propofol-induced acute neurotoxicity in rodents by enhancing the PI3K/Akt signaling. However, whether treatment of young rats with Dex could protect them from long-term neurotoxicity induced by propofol is unclear.

MATERIALS AND METHODS

Seven-day-old male Sprague Dawley rats were randomized and injected intraperitoneally with saline (100 μL, NS), propofol (100 mg/kg), Dex (75 μg/kg), propofol (100 mg/kg) plus Dex (25, 50 or 75 μg/kg), 10% dimethyl sulfoxide (DMSO, 100 μL) or TDZD-8 (a GSK3β inhibitor, 1 mg/kg), or intracerebroventricularly with DMSO (5 μL) or LY294002 (a PI3K inhibitor, 25 μg/5 μL DMSO). Other rats in the experimental group were injected with the same doses of propofol, Dex and LY294002 or TDZD-8. All the rats were monitored until they were 9 weeks old. Their spatial learning and memory were tested by Morris water maze. The neuronal apoptosis, expression of PSD₉₅, expression and phosphorylation of Akt and GSK3β and synaptic ultrastructures were determined by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling, immunohistochemistry, Western blot and transmission electron microscopy assays, respectively.

RESULTS

Compared with the NS control group, young rats injected with intralipid, Dex, TDZD-8, LY294002 or DMSO alone did not show any significant change as they aged. Propofol significantly increased the escape latency time, hippocampal neuroapoptosis and synaptic ultrastructural changes but decreased the relative levels of PSD₉₅ expression, and Akt and GSK3β phosphorylation in the developing hippocampus of the rats. The neuronal toxic effects of propofol were significantly mitigated by the pretreatment with a higher dose of Dex. The neuroprotective effect of Dex was enhanced by the treatment with TDZD-8, but was completely abrogated by the treatment with LY294002.

CONCLUSION

Our results indicated that the pretreatment of young rats with Dex attenuated the propofol-induced long-term neurotoxicity in their developing hippocampus by enhancing the PI3K/Akt signaling.