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Elsaeidy AS, Ahmad AHM, Kohaf NA, Aboutaleb A, Kumar D, Elsaeidy KS, Mohamed OS, Kaye AD, Shehata IM. Efficacy and Safety of Ketamine-Dexmedetomidine Versus Ketamine-Propofol Combination for Periprocedural Sedation: A Systematic Review and Meta-analysis. Curr Pain Headache Rep 2024; 28:211-227. [PMID: 38214834 PMCID: PMC10940385 DOI: 10.1007/s11916-023-01208-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW The combination of ketamine with propofol and dexmedetomidine has gained popularity for sedation and general anesthesia in different populations. In our meta-nalysis, we helped the anesthesiologists to know the efficiency and the efficacy of both combinations in adult and pediatric patients. METHODS We searched PubMed, CENTRAL, Web of Science, and Scopus from inception to August 1, 2023. Our outcome parameters for efficacy were recovery time, pain score, and physician satisfaction while for safety were the related cardiorespiratory, neurological, and gastrointestinal adverse events. RECENT FINDINGS Twenty-two trials were included with a total of 1429 patients. We found a significantly longer recovery time in the ketadex group of 7.59 min (95% CI, 4.92, 10.26; I2 = 94%) and a significantly less pain score of - 0.72 (95% CI, - 1.10, - 0.34; I2 = 0%). Adults had a significantly better physician satisfaction score with the ketofol group, odds ratio of 0.29 (95% CI, 0.12, 0.71; I2 = 0%). Recovery agitations were higher in the ketofol group with an odds ratio of 0.48 (95% CI, 0.24, 0.98; I2 = 36%). Furthermore, we found a significant difference between the combinations with a higher incidence in the ketadex group with pooled odds ratio of 1.75 (95% CI, 1.06, 2.88; I2 = 15%). Ketadex was associated with lower pain scores, hypoxic events and airway obstruction, and emergence agitation. At the same time, ketofol had much more clinician satisfaction which might be attributed to the shorter recovery time and lower incidence of nausea and vomiting. Therefore, we suppose that ketadex is the better combination in periprocedural sedation for both adult and pediatric patients who are not at greater risk for postoperative nausea and vomiting.
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Affiliation(s)
| | | | - Neveen A Kohaf
- Clinical Pharmacy, Faculty of Pharmacy (Girls), Al-Azhar University, Cairo, Egypt
| | - Aya Aboutaleb
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Danisha Kumar
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Ola Saeed Mohamed
- Critical Care Medicine, Menofia University, Shibin El Kom, Menofia, Egypt
| | - Alan D Kaye
- Pharmacology, Toxicology, and Neurosciences, LSU School of Medicine, 1501 Kings Hwy, Shreveport, LA, 71103, USA
- Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA, USA
- Anesthesiology and Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
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Esmaillian M, Kouhestani S, Azizkhani R, Heydari F, Safavi MR. Dexmedetomidine versus propofol: An effective combination with ketamine for adult procedural sedation: A randomized clinical trial. Am J Emerg Med 2023; 73:95-101. [PMID: 37639920 DOI: 10.1016/j.ajem.2023.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/11/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Recently, drug combination protocols have been preferred over single drugs in procedural sedation and analgesia (PSA). This study aimed to compare the effectiveness and hemodynamic profile of ketamine-dexmedetomidine (ketodex) and ketofol as drug combinations with ketamine as a single medication for PSA in the emergency department (ED). METHODS This prospective, randomized, double-blind clinical trial was performed among adult patients (≥18 years) requiring PSA for a painful procedure in the ED. 135 patients were enrolled and assigned into three equal groups to receive either ketodex, ketofol, or ketamine. Additional ketamine was used as a rescue agent for inadequate sedation in three groups. Oxygen saturation, heart rate, and blood pressure were recorded from baseline until 120 min after induction of PSA. Adverse events, hemodynamic variables, induction, and recovery time were recorded and compared between groups. RESULTS The mean age of the patients was 38.16 ± 19.09 years and no differences were observed between the three groups in terms of demographic variables, pain scores, and procedures between the three groups. Respiratory events had similar incidences between the three groups. The O2 reduction was less in the Ketodex group in comparison with Ketofol and Ketamine groups (1.9%, 6.5%, and 3.8%, P = 0.015). No patient needed endotracheal intubation. Changes in mean arterial pressure from the baseline in Ketamine and Ketofol groups compared to Ketodex was higher (difference was 12.9 mmHg [95% CI, 9.5 to 20.3] and 8.6 mmHg [95% CI, 3.4 to 13.7]. Tachycardia in the Ketamine group had a significantly higher incidence. The recovery time was statistically shorter in the Ketofol group in comparison with other groups. The differences between Ketofol with Ketamine and Ketodex groups were 9.8 min (95% CI, [2.5 to 17.1]) and 8.3 min (95% CI, [1.5 to 15.1]). CONCLUSION Ketodex, as well as ketofol, were effective and safe combinations with good recovery profiles and hemodynamic stability for adult PSA in ED.
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Affiliation(s)
- Mehrdad Esmaillian
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Soheila Kouhestani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Azizkhani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Farhad Heydari
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad Raza Safavi
- Department of Anesthesiology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Kakarla A, Senapati LK, Das A, Acharya M, Sukanya S, Pradhan A. Intravenous Dexmedetomidine-Ketamine Versus Ketamine-Propofol for Procedural Sedation in Adults Undergoing Short Surgical Procedures: A Randomized Controlled Trial. Cureus 2023; 15:e40676. [PMID: 37485154 PMCID: PMC10357391 DOI: 10.7759/cureus.40676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Background and objective Moderate to deep sedation is a prerequisite during total intravenous anesthesia for short-duration surgeries, and it can be achieved by using individual drugs or in combination. Our study compared dexmedetomidine-ketamine (DK) versus ketamine-propofol (KP) in terms of sedation, procedural interference, hemodynamics, and incidence of side effects in patients undergoing short surgical procedures. Methods A total of 194 patients scheduled for short-duration elective surgeries were randomly allocated into two groups. Group DK received a loading dose of 1 µg/kg of dexmedetomidine and 1 mg/kg of ketamine followed by a maintenance infusion of dexmedetomidine at 0.3 µg/kg/h. Group KP received a loading dose of 1 mg/kg of ketamine and 1 mg/kg of propofol followed by a maintenance infusion of propofol at 25 µg/kg/h. For procedural interference, a rescue ketamine bolus was administered at 0.25 mg/kg. Patients were monitored for the requirement of rescue ketamine bolus, procedural interference, hemodynamics, sedation, recovery time, and adverse effects. Results The procedural interference was higher in group KP than in group DK and the difference was statistically significant (P=0.001). The time to the first rescue bolus was 8.72 ± 4.47 minutes in group KP and 10.82 ± 4.01 minutes in group DK, with a difference of 2.1 minutes (p=0.026). There was no statistically significant difference in the sedation scores between both groups except at time points of six minutes and 15 minutes. Conclusion For short-duration procedures, the DK combination is superior to the KP combination in terms of procedural interference and time to the first rescue bolus, while both groups were comparable with regard to safety and hemodynamics.
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Affiliation(s)
- Anusha Kakarla
- Anaesthesia, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
| | - Laxman K Senapati
- Anaesthesia, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
| | - Asima Das
- Obstetrics & Gynaecology, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
| | - Mousumi Acharya
- Obstetrics & Gynaecology, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
| | - Sailaja Sukanya
- Anaesthesia, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
| | - Amit Pradhan
- Anaesthesia, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, IND
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Comparison of the Effect of Adding Low-dose Ketamine to Dexmedetomidine and Propofol on the Quality of Sedation and Hemodynamic Response in Children During Upper Gastrointestinal Endoscopy: A Double-blind Randomized Clinical Trial. Anesth Pain Med 2023. [DOI: 10.5812/aapm-134581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background: As endoscopy is an invasive and painful procedure, it is necessary to use a suitable sedative with a minimum dose, especially in children. Objectives: This study aimed to compare the effect of adding low-dose ketamine to dexmedetomidine and propofol on the quality of sedation and hemodynamic response in children during upper gastrointestinal endoscopy. Methods: This double-blind, randomized clinical trial was conducted on 52 children who were candidates for endoscopy in 2 groups, each consisting of 26 patients. In the first group (Ketadex group), infusion of dexmedetomidine (0.7 - 1 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. In the second group (Ketofol group), infusion of propofol (50 - 100 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. Results: The mean blood pressure of children decreased slightly during and after the endoscopic procedure in the Ketadex group than in the Ketofol group (P < 0.05). The recovery time was significantly less in the Ketofol group (41.85 ± 7.03 minutes) than in the Ketadex group (55.12 ± 7.55 minutes; P < 0.001). Conclusions: The addition of the low-dose ketamine to propofol and dexmedetomidine did not result in any significant changes in the level of sedation, the incidence of adverse effects, and the endoscopist’s satisfaction; however, the recovery time was shorter in the propofol-ketamine combination than in the dexmedetomidine-ketamine combination.
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Magner K, Mikhailov T, Simpson P, Anderson L, Buchman B, Gedeit R, Margolis D, Meyer MT. Dexmedetomidine for sedation during hematopoietic stem cell harvest apheresis and leukapheresis in the PICU: Guideline development. Transfus Apher Sci 2023; 62:103525. [PMID: 36058778 DOI: 10.1016/j.transci.2022.103525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hematopoietic stem cell (HSC) harvest apheresis and leukapheresis are performed in the pediatric intensive care unit (PICU) for high-risk pediatric patients who require procedural sedation. Patients need central access either with their own central lines, ports or require apheresis catheter (CVL) placement. Previously, patients were either awake or emerging from sedation on PICU admission. Uncertainty regarding procedural sedation plans caused delays initiating sedation and apheresis. A guideline was developed to standardize Dexmedetomidine (DEX) for procedural sedation. We investigated if guideline implementation would improve efficiency during PICU admission as demonstrated by shorter time intervals for initiation of sedation, apheresis, PICU length of stay and less alternative sedating medication. METHODS Data was collected retrospectively from electronic health records of preguideline and post-guideline patients who were admitted to the PICU for sedated apheresis. We compared demographic and clinical characteristics, time intervals for sedation, apheresis, PICU length of stay, and sedation agents between the two groups using Fisher Exact tests and Mann-Whitney tests, as appropriate. RESULTS The groups did not differ in age or weight at the time of apheresis. All intervals of time compared were shorter post-guideline. Time intervals from admission to start of sedation, admission to start of apheresis, and admission to end of apheresis were statistically significantly different. The type and number of alternative sedating medications administered did not differ between the two groups. CONCLUSION This guideline implementation improved efficiency during PICU admission. This study might have been too small to demonstrate statistically significant differences in other time intervals studied.
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Affiliation(s)
- Kristin Magner
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA.
| | - Theresa Mikhailov
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences. Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lynnette Anderson
- Pediatric Hematology/Oncology, Children's Wisconsin, Milwaukee, WI, USA
| | - Bo Buchman
- Pediatric Hematology/Oncology, Children's Wisconsin, Milwaukee, WI, USA
| | - Rainer Gedeit
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - David Margolis
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Michael T Meyer
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
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Gao PF, Li SY, Li Y, Zhao L, Luo Q, Ji Y. The comparison of ketamine-dexmedetomidine (ketadex) and ketamine-propofol (ketofol) for procedural sedation in pediatric patients: A meta-analysis of randomized controlled trials. Heliyon 2022; 8:e11166. [PMID: 36303919 PMCID: PMC9593188 DOI: 10.1016/j.heliyon.2022.e11166] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/22/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The combination of different agents used for procedural sedation allows a greater range of desirable effects while minimizing side effects. The ketamine-dexmedetomidine combination (ketadex) and ketamine-propofol combination (ketofol) are successful examples. The purpose of this meta-analysis was to compare the safety and efficacy of ketadex with ketofol used for procedural sedation in pediatric patients. Methods We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from inception to June 2022. Studies were independently evaluated for inclusion criteria and exclusion criteria by two reviewers. Outcome measures for safety comparison were the incidence of hypotension, bradycardia, respiratory depression, nausea, vomiting, and agitation; Outcome measure for efficacy comparison was clinicians' satisfaction. In addition, we compared the recovery time of ketadex and ketofol. Results Nine studies were included in this meta-analysis. Compared with ketofol, ketadex sedation in pediatric patients had lower risk of respiratory depression (RR: 0.51, 95% CI: 0.34–0.76, P = 0.0009). However, ketadex displayed significant effect on recovery time (MD: 8.38 min, 95% CI: 7.55–9.22 min, P < 0.00001). Ketadex had similar incidence of hypotension (RR: 0.95, 95% CI: 0.33–2.67, P = 0.92) and bradycardia (RR: 1.80, 95% CI: 0.64–5.06, P = 0.26) compared to those with ketofol. Clinicians' satisfaction rate of ketadex and ketofol were both high (RR: 0.93, 95% CI: 0.69–1.25, P = 0.62). Also, no significant difference was observed between ketadex and ketofol on the incidence of nausea, vomiting, and agitation. Conclusions Both ketadex and ketofol can provide effective sedation and maintain stable hemodynamics. In consideration of good safety profile in respiratory problems, we suggest ketadex is a better option for procedural sedation in pediatric patients.
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Xie J, Feng S, Qu Z. Adoption of Dexmedetomidine in Different Doses at Different Timing in Perioperative Patients. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4008941. [PMID: 35872874 PMCID: PMC9307348 DOI: 10.1155/2022/4008941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/15/2022] [Accepted: 05/03/2022] [Indexed: 11/20/2022]
Abstract
Dexmedetomidine (Dex) is an alpha-2 agonist used for sedation during various procedures. Dex activates 2-adrenoceptors, and causes the decrease of sympathetic tone, with attenuation of the neuroendocrine and hemodynamic responses to anesthesia and surgery; it reduces anesthetic and opioid requirements; and causes sedation and analgesia. OBJECTIVE it was to compare the perioperative effects of different doses of Dex at different timing in patients using Dex during the perioperative period adopting a medical data classification algorithm based on optimized semi-supervised collaborative training (Tri-training). METHODS 495 patients requiring surgical treatment in Xingtai People's Hospital were randomly selected as the study subjects. The patients were divided into group A (used before induction), group B (used during induction), and group C (used after induction) according to different induction timing, with 165 cases in each group. Then, groups A, B, and C were divided into groups A1, B1, and C1 (0.4 μg/(kg·h) rate), groups A2, B2, and C2 (0.6 μg/(kg·h) rate), and groups A3, B3, and C3 (0.8 μg/(kg·h) rate) according to the dose used, with 55 cases in each group. Intraoperative anesthesia and postoperative adverse reactions were compared among the 9 groups. RESULTS the similarity between the Tri-training algorithm optimized by Naive Bayes (NB) classification algorithm and the actual classification (93.49%) was clearly higher than that by decision tree (DT) and K-nearest neighbor (kNN) classification algorithm (76.21%, 74.31%); heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) values decreased obviously after Dex used in groups B1, C1, B2, C2, B3, and C3 (P <0.05), but did not change significantly in groups A1, A2, and A3 (P >0.05); the proportion of patients with satisfactory Ramsay score in group A3 was distinctly superior than that in groups A1, A2, B1, B2, B3, C1, C2, and C3 (P <0.05); the incidence of adverse reactions in group A3 was significantly inferior than that in groups A1, A2, B1, B2, B3, C1, C2, and C3 (P <0.05). CONCLUSION the optimization effect of NB classification algorithm was the best, and the injection of Dex at the injection rate of 0.8 μg/(kg·h) before induction of anesthesia could apparently improve the fluctuation of HR, SBP, and DBP during perioperative period, and effectively reduce the occurrence of adverse reactions in patients, with better sedative effect on patients.
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Affiliation(s)
- Jing Xie
- Department of Anesthesiology, Xingtai People's Hospital, Xingtai, Hebei, China
| | - Shiqiang Feng
- Department of Anesthesiology, Xingtai People's Hospital, Xingtai, Hebei, China
| | - Zhenhua Qu
- Department of Anesthesiology, Xingtai People's Hospital, Xingtai, Hebei, China
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Li HP, Liu KP, Yao L. Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis. Am J Emerg Med 2021; 50:442-448. [PMID: 34492589 DOI: 10.1016/j.ajem.2021.08.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication. METHODS Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events. RESULTS 15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia. CONCLUSIONS DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.
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Affiliation(s)
- Hong-Pei Li
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Kun-Peng Liu
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China.
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