Addition of Low-Dose Ketamine to Propofol-Fentanyl Sedation for Gynecologic Diagnostic Laparoscopy: Randomized Controlled Trial

Implementation of a protocol using ketamine-propofol ('ketofol') in a 1 to 4 ratio for procedural sedation in adults at a university hospital emergency department - report on safety and effectiveness

Objectives: To test the feasibility of an evidence-based protocol for procedural sedation in adults at our emergency department, using a mixture of ketamine and propofol ('ketofol') in a 1 to 4 ratio. We hypothesize that the protocol is safe and effective and can facilitate procedural sedation.Methods: During 14 months, adults in need of procedural sedation at our university hospital emergency department were included in a prospective convenience sample study. Patients with important comorbidity were discussed with the anaesthesiology department for feasibility of sedation in the emergency department setting. Outcome measures were procedural success, respiratory and hemodynamic events, vomiting, agitation or hallucinations, recall and physician's satisfaction.Results: Sixty-one patients between 18 and 89 years were included. All but one procedure were successful. Six respiratory events were registered in 6 patients (9.8%). These consisted of airway obstruction alleviated by airway repositioning and without influence on vital signs except for one brief episode of desaturation. Neither hemodynamic events nor vomiting were reported. Five patients (8.2%) experienced pleasant hallucinations and one patient (1.6%) became agitated upon awakening but recovered rapidly without medication. Three patients (4.9%) had recall and physician satisfaction rate was 93.4%.Conclusion: A feasibility trial of an implemented protocol for ketofol procedural sedation in adults showed only minor respiratory events, a low incidence of agitation or hallucinations, minimal recall and a high success and physician satisfaction rate. Despite a non-consecutive and limited sample used, ketofol in a 1 to 4 ratio appears safe and effective for use in the emergency department.

Comparison of Infusion of Propofol and Ketamine-Propofol Mixture (Ketofol) as Anesthetic Maintenance Agents on Blood Pressure of Patients Undergoing Orthopedic Leg Surgeries

Background

Some studies have reported the effects of anesthesia induction using a single propofol dose and low ketamine doses in short-term outpatient operations.

Objectives

In this study, we aimed to evaluate the intra and post-operative hemodynamic effects of ketamine-propofol mixture (Ketofol) infusion in comparison with propofol infusion.

Methods

This study was performed on 54 class I and II of the American Society of Anesthesia patients aged 15 to 45 years who were candidates for leg fracture surgery. The patients were randomly assigned to propofol and ketofol groups. In the propofol and ketofol groups, propofol infusion (100 µg/kg/min) and propofol-ketamine infusion (50 µg/kg/min propofol + 25 µg/kg/min ketamine) were used for the maintenance of anesthesia, respectively. Heart rate and systolic, diastolic and mean blood pressure before, immediately after the induction of anesthesia and at 10-minute intervals were measured and recorded. Pain, nausea, and vomiting were recorded immediately after surgery and each 2 hours until 6 hours.

Results

Systolic, diastolic and mean blood pressure were significantly higher in the ketofol group than in the propofol group at 10 - 60 min intervals (P < 0.05). There was no significant difference, however, between the two groups in terms of the severity of nausea and pain and vomiting frequency.

Conclusions

Infusion of hypnotic doses of ketofol leads to increase in diastolic and systolic blood pressure and improves blood pressure stability in addition to inducing more as compared with propofol infusion, but it leads to higher risk of nausea and vomiting.

Efficacy of Low-dose Ketamine as Sole Analgesic Agent in Maintaining Analgesia and Intraoperative Hemodynamics During Laparoscopic Gynecological Surgeries

BACKGROUND

Ketamine, in low doses, is known to possess intense analgesic properties. The available literature shows wide variation regarding the time and dose of administration of ketamine during surgery.

AIM

The aim of this study was to evaluate the effect of intraoperative administration of ketamine when used as sole analgesic in low doses, on hemodynamics and postoperative analgesia in patients undergoing laparoscopic gynecological surgery and compared on the basis of duration of surgery.

SETTINGS AND DESIGN

This prospective, observational study was conducted from July to December 2015, over a period of 6 months in a tertiary care medical college and hospital.

MATERIALS AND METHODS

Seventy patients between 23 and 55 years planned for laparoscopic gynecological surgery were recruited. Ketamine was given in a dose of 0.5 mg/kg preoperatively and then repeated every ½ hourly in a dose of 0.25 mg/kg throughout the surgery. Hemodynamic parameters, time to the first rescue analgesia and complications were recorded for the first 8 h. Statistical evaluation was done and result expressed as percentage. Paired t-test was employed for the comparison of numerical variables within the group.

RESULTS

Seventy percent of the patients did not require any postoperative rescue analgesia during the first 8 h after surgery. None of the patients complained of pain immediately after extubation, and 16% of the patients had minor postoperative complications. The intraoperative hemodynamic profile was significantly altered. Duration of surgery and dose of ketamine required did not affect the duration of analgesia.

CONCLUSION

Ketamine in low dose proved to be an efficacious analgesic even in the long duration laparoscopic gynecological surgeries. It stabilizes intraoperative hemodynamics thereby reducing the requirement of other anesthetic and antihypertensive agents.

Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography

Background

We evaluated whether the addition of a small dose of ketamine or fentanyl would lead to a reduction in the total dose of propofol consumed without compromising the safety and recovery of patients having endoscopic ultrasonography (EUS).

Methods

A total of 210 adult patients undergoing elective EUS under sedation were included in the study. Patients were randomized into three groups. Patients were premedicated intravenously with normal saline in group 1, 50 µg fentanyl in group 2, and 0.5 mg/kg ketamine in group 3. All patients received intravenous propofol for sedation. Propofol consumption in mg/kg/h was noted. The incidence of hypotension, bradycardia, desaturation, and coughing was noted. The time to achieve a Post Anesthesia Discharge Score (PADS) of 10 was also noted.

Results

There were 68 patients in group 1, 70 in group 2, and 72 in group 3. The amount of propofol consumed was significantly higher in group 1 (9.25 [7.3–13.2]) than in group 2 (8.8 [6.8–12.2]) and group 3 (7.6 [5.7–9.8]). Patient hemodynamics and oxygenation were well maintained and comparable in all groups. The time to achieve a PADS of 10 was significantly higher in group 3 compared to the other two groups.

Conclusions

The use of 50 µg fentanyl or 0.5 mg/kg ketamine in a single dose during EUS reduces the dose of propofol required for sedation. However, unlike the addition of fentanyl, the addition of ketamine increased the time to recovery. Thus, 50 µg fentanyl is a good additive to propofol infusion for sedation during EUS to reduce the requirement for propofol without affecting the time to recovery.

The use of propofol for procedural sedation in emergency departments

BACKGROUND

There is increasing evidence that propofol is efficacious and safe for procedural sedation (PS) in the emergency department (ED) setting. However, propofol has a narrow therapeutic window and lacks of a reversal agent. The aim of this review was to cohere the evidence base regarding the efficacy and safety profile of propofol when used in the ED setting for PS.

OBJECTIVES

To identify and evaluate all randomized controlled trials (RCTs) comparing propofol with alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE (1950 to September week 2 2013) and EMBASE (1980 to week 2 2013). We searched the Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (September 2013). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction. We re-ran the search in February 2015. We will deal with the one study awaiting classification when we update the review.

SELECTION CRITERIA

RCTs comparing propofol to alternative drugs (benzodiazepines, barbiturates, etomidate and ketamine) used in the ED setting for PS in participants of all ages.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using The Cochrane Collaboration tool for assessing risk of bias.

MAIN RESULTS

Ten studies (813 participants) met the inclusion criteria. Two studies only included participants 18 years and younger; six studies only included participants 18 years and older; one study included participants between 16 and 65 years of age and one study included only adults but did not specify the age range. Eight of the included studies had a high risk of bias. The included studies were clinically heterogeneous. We undertook no meta-analysis.The primary outcome measures of this review were: adverse effects (as defined by the study authors) and participant satisfaction (as defined by the study authors). In one study comparing propofol/fentanyl with ketamine/midazolam, delayed adverse reactions (nightmares and behavioural change) were noted in 10% of the ketamine/midazolam group and none in the propofol/fentanyl group. Seven individual studies reported no evidence of a difference in adverse effects between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions. Three individual studies reported no evidence of a difference in pain at the injection site between intravenous propofol and alternative interventions. Four individual studies reported no evidence of a difference in participant satisfaction between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions (ketamine, etomidate, midazolam). All the studies employed propofol without the use of an adjunctive analgesic and all, except one, were small (fewer than 100 participants) studies. The quality of evidence for the adverse effects and participant satisfaction outcomes was very low.Nine included studies (eight comparisons) reported all the secondary outcome measures of the review except mortality. It was not possible to pool the results of the included studies for any of the secondary outcome measures because the comparator interventions were different and the measures were reported in different ways. Seven individual studies reported no evidence of difference in incidence of hypoxia between intravenous propofol, with and without adjunctive analgesic agents, and alternative interventions.

AUTHORS' CONCLUSIONS

No firm conclusions can be drawn concerning the comparative effects of administering intravenous propofol, with or without an adjunctive analgesic agent, with alternative interventions in participants undergoing PS in the ED setting on adverse effects (including pain at the injection site) and participant satisfaction. The review was limited because no two included studies employed the same comparator interventions, and because the number of participants in eight of the included studies were small (fewer than 100 participants).

Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for colonoscopy: a randomized, double-blind, controlled trial

STUDY OBJECTIVE

To evaluate the effects of low-dose ketamine on midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy.

DESIGN

Prospective, randomized, double-blinded, placebo-controlled trial.

SETTING

Gastroenterology unit at a practice and clinical research center.

SUBJECTS

Ninety-seven healthy American Society of Anesthesiology physical status 1 volunteers.

INTERVENTIONS

Subjects were randomized to receive midazolam (0.02 mg/kg), fentanyl (1 μg/kg), and ketamine (0.3 mg/kg) and midazolam (0.02 mg/kg), fentanyl (1 μg/kg), and placebo (0.9% sodium chloride) in group K and group C, respectively. In both groups, incremental doses of propofol were used to maintain a Ramsay sedation score of 3 to 4.

MEASUREMENTS

Values of heart rate, blood pressure, oxygen saturation, and respiratory rate were measured. Procedure times, recovery times, drug doses used, complications associated with the sedation, and physician and patient satisfaction were also recorded.

MAIN RESULTS

In group K, mean amount of propofol used and mean induction time (P < .001), the need for the use of jaw thrust maneuver and mask ventilation, and the incidence of disruptive movements were significantly lower (P < .05) and gastroenterologist satisfaction at the beginning of the procedure was significantly superior (P < .05). Mean systolic blood pressures at 4, 6, 8, and 10 minutes (P < .01); diastolic blood pressures at 4, 6, and 8 minutes (P < .05); respiratory rates at 4, 6, 8, 10, 15, 20, and 25 minutes (P < .01); and oxygen saturation at 6, 8, 10, 15, and 20 minutes (P < .05) were significantly lower in group C. Patient satisfaction scores, recovery times, and discharge times were similar. No patient in either group experienced unpleasant dreams or hallucination in the postanesthesia care unit and on the first postoperative day.

CONCLUSIONS

Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy resulted in more rapid and better quality of sedation, less propofol consumption, more stable hemodynamic status, and less adverse effects with similar recovery times in adult patients.

Effects of the addition of low-dose ketamine to propofol-fentanyl anaesthesia during diagnostic gynaecological laparoscopy

OBJECTIVES

Diagnostic gynaecological laparoscopy (DGL) is a brief procedure, generally performed on an outpatient basis. Propofol-fentanyl is often used for anaesthesia in minor outpatient procedures because of its rapid onset, short duration of action and smooth patient awakening. However, propofol has various cardiovascular effects such as reduced arterial pressure, cardiac output and cardiac index. Ketamine is an intravenous anaesthetic and short-acting analgesic that could alleviate the haemodynamic effects of propofol due to its sympathomimetic activity. The aim of this placebo-controlled trial was to evaluate the effects of the addition of low-dose ketamine to propofol-fentanyl anaesthesia in DGL.

STUDY DESIGN

In this double-blind randomized trial, 60 healthy women undergoing gynaecological laparoscopy to investigate infertility were studied. Following injection of midazolam and fentanyl in all patients, the study group (n=30) received ketamine 0.5 mg/kg and propofol 1-2.5 mg/kg, and the placebo group (n=30) received saline 0.9% and propofol 1-2.5 mg/kg. Propofol was subsequently infused for the maintenance of anaesthesia.

RESULTS

Patients in the study group had a significantly lower incidence of pain than patients in the placebo group during propofol injection (13% vs 87%, respectively; p<0.0001). After induction of anaesthesia, 16 (53%) patients in the placebo group and three (10%) patients in the study group had a decreased heart rate (p<0.001). The decrease in mean arterial pressure was greater in the placebo group compared with the study group (37% vs 7%, respectively; p<0.001). During the procedure, the total mean±standard deviation dose of propofol was 420±65 mg in the placebo group and 330±35 mg in the study group (p<0.001). Pain scores for the first 3h after the operation were significantly lower in the study group (p<0.001).

CONCLUSION

Use of low-dose ketamine with propofol-fentanyl anaesthesia in patients undergoing DGL was associated with less pain during propofol injection, lower incidence of haemodynamic changes, lower total dose of propofol and improved postoperative analgesia.

Effect of adding ketamine to pethidine on postoperative pain in patients undergoing major abdominal operations: a double blind randomized controlled trial

To determine the effect of adding ketamine to pethidine in reducing post-operative pain in patients undergoing major abdominal operations, in a double blind randomized controlled trial, 100 patients aged 15-60 years who were candidate for elective major abdominal surgery allocated into two groups of pethidine + ketamine group (5 mg pethidine and 0.25 mg kg(-1) ketamine) or pethidine and placebo group (10 mg pethidine and NS) according to the regimen prescribed in postanesthesia care unit. Severity of pain (using visual analogue scale), prescribed dose of pethidine and side effects were recorded until 24 h after operation. Regarding post-operative pain, pethidine + ketamine group showed significant lower scores in all the times except 0 min, 2, 6 and 16 h. Nausea was significantly less frequent amongst pethidine + placebo group at times of 0, 15, 30 and 45 min (p < 0.05). Comparison of two groups did not show significant differences in prescribed pethedine dose in 0, 9, 12, 16, 20 and 24 h (p > 0.05). Yet, the mean dose of administered pethidine as rescue analgesic was significant lower in pethidine + ketamine group compared to pethidine + placebo group (112 +/- 31.5 mg vs. 133.5 +/- 24.5 mg, p < 0.001). In conclusion, our results showed that co-administration of ketamine and pethidine in postanesthesia care unit will improve postoperative pain and reduce narcotic consumption. It may, however, increase rate of postoperative nausea in the first hour after operation.

Prevention of pain with the injection of microemulsion propofol: a comparison of a combination of lidocaine and ketamine with lidocaine or ketamine alone

Background

Aquafol, a microemulsion propofol, causes more severe and frequent pain on injection than propofol. The purpose of this study was to compare a combination of lidocaine and ketamine on aquafol-induced pain with lidocaine or ketamine alone during the induction of anesthesia.

Methods

In this prospective, randomized, double-blinded study, 130 healthy patients who were undergoing elective surgery under general anesthesia were enrolled. The patients received IV lidocaine 40 mg plus ketamine 25 mg (Group LK, n = 43), lidocaine 40 mg (Group L, n = 42), or ketamine 25 mg (Group K, n = 45) with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol. The pain score was assessed by a 4-point verbal rating scale (VRS) at 10 seconds after injection of microemulsion propofol 30 mg and during the injection of the remaining total dose.

Results

The incidence and severity of pain was significantly lower in Group LK than Group L or Group K at 10 seconds after the injection of microemulsion propofol 30 mg (P < 0.05). And the incidence and severity of pain was significantly lower in Group LK and Group K than Group L during the injection of the remaining total dose (P < 0.05).

Conclusions

Pretreatment with IV lidocaine 40 mg plus ketamine 25 mg with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol is more effective than lidocaine 40 mg or ketamine 25 mg alone in preventing pain from the injection of microemulsion propofol.