Analysis of Propofol and Low-Dose Ketamine Admixtures for Adult Outpatient Dentoalveolar Surgery: A Prospective, Randomized, Positive-Controlled Clinical Trial

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.

Ketamine-propofol (ketofol) in procedural sedation: a narrative review

Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.

Risk-adapted strategy or universal multimodal approach for PONV prophylaxis?

The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than pain. Numerous findings of research indicate that PONV significantly affects patients' well-being and is among the important determinants of patient satisfaction with perioperative care. Numerous investigations have confirmed the efficacy of combining pharmacological interventions indicating that PONV is a clinical complication that is in principle avoidable. Nonetheless, PONV continues to be bothersome for too many patients. Thus, perhaps the biggest challenge across the field is to achieve a uniformly high standard of PONV management using the currently available resources. Although a risk-adapted approach has been advocated in the past, the current trend incorporated in clinical guidelines support a more liberal approach of multimodal antiemetic prevention. The current article emphasizes pros and cons of the various approaches to PONV prophylaxis and depicts most promising strategies to achieve a "PONV-free hospital."

Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults: 2020–2025

Writing guidelines on procedural sedation and analgesia is a formidable and challenging task. There are many disciplines and societies at international level now involved in writing guidelines and we need to be aware of what they see as important in their guidelines. We always need to identify new trends in sedation; for that we need to be involved at international level. Our aim with these guidelines is to provide a guidance for safe sedation practice for all healthcare providers who are involved in sedation practice. In this issue we have added adverse events and record-keeping, accreditation and the importance of simulation training to our recommendations under clinical governance. We would like our sedation practitioners to keep records and report adverse events to our societies, e.g. SOSPOSA, so that we all can benefit from the information we get. It is also crucial that sedation practitioners keep their logbooks and update them regularly – “if it is not written down, it never happened”. All aspects of accreditation remain an important issue and we need to address this urgently. This forms an important part of safe sedation practice, also done at international level, and we need to follow this. The facilities where we work, especially outside the operating theatre, must meet the requirements for safe practice. It is our responsibility to see that this is the case. In the appendices there is a practice appraisal protocol that should be filled in by sedation practitioners doing sedation outside the operating theatre. We do not cover sedation techniques in the guidelines. We believe sedation practitioners must learn the techniques with supervised clinical training. Capnography for sedation outside the operating theatre will become a focus point in future. We are only supposed to be doing ASA I and II patients outside the operating theatre so there may be a feeling we do not need capnography. There is pressure to include capnography under monitoring as a minimum monitoring standard, like pulse oximetry and blood pressure monitoring. Our appendices have been revised with more information on what patients need to know about sedation e.g. an example of a cover letter to the patient. This will include information to the patient, as well as information from the patient. Sedation is today one of the fastest growing areas in anaesthesia care. Our research studies show a low incidence of side-effects, and a high incidence of patient satisfaction. To all our readers we wish you a safe sedation journey.

Effects of the addition of low-dose ketamine to propofol anesthesia in the dental procedure for intellectually disabled patients

Background

This study aimed to examine whether the combination of low-dose ketamine and propofol in deep sedation is clinically useful in controlling the behavior in intellectually disabled patients who are typically extremely noncooperative during dental procedures.

Methods

A total of 107 extremely noncooperative intellectually disabled adult patients were analyzed. In all patients, deep sedation was performed using either propofol alone (group P) or using a combination of propofol and 0.2 mg/kg or 0.4 mg/kg ketamine (groups PK0.2 and PK0.4, respectively). The procedures were performed in the order of insertion of nasal cannula into the nostril, attachment of mouth gag, and mouth cleaning and scaling. The frequency of patient movement during the procedures, mean arterial pressure, heart rate, peripheral oxygen saturation, recovery time, discharge time, and postoperative nausea and vomiting were examined.

Results

The three groups were significantly different only in the frequency of patient movement upon stimulation during single intravenous injection of propofol and scaling.

Conclusion

For propofol deep sedation, in contrast to intravenous injection of propofol alone, prior intravenous injection of low-dose ketamine (0.4 mg/kg) is clinically useful because it neither affects recovery, nor causes side effects and can suppress patient movement and vascular pain during procedures.

Anesthetic Agents Commonly Used by Oral and Maxillofacial Surgeons

Oral and maxillofacial surgeons have a variety of anesthetic agents that can be used to provide anesthesia safely and efficiently in the office-based environment. However, it is critical to have a thorough understanding of the particulars for each agent. Commonly used anesthetic agents, administered either individually or in combination, include diazepam, midazolam, propofol, ketamine, opioid agonists such as fentanyl or remifentanil, dexmedetomidine, and inhalational agents, including nitrous oxide and sevoflurane. These agents help provide extreme flexibility for those creating an individualized anesthetic plan that also balances the patient's history and the anticipated surgical plan to maximize success.

Remifentanil in Combination With Propofol Is Suitable for Use in the Dental Outpatient Setting

Although several adjuncts to the general anesthetic propofol have been proposed, there is insufficient research identifying the ideal agent, and in what dosage, to combine with propofol in dental outpatient anesthesia. Here we examined the combination of remifentanil or nitrous oxide and propofol in patients with severe dental avoidance undergoing dental treatment in the outpatient setting. Eighty patients were randomized to 4 groups and administered propofol/saline solution (PS; n = 20), propofol/remifentanil 0.25 μg/kg/min (PRe-0.25; n = 20), propofol/remifentanil 0.125 μg/kg/min (PRe-0.125; n = 20), or propofol/66% nitrous oxide (PN; n = 20). During anesthesia, the bispectral index value was kept between 40 and 60. Body movements and hemodynamic changes during anesthesia, emergence, and recovery as well as anesthetic cost were compared between the combinations. Body movements were observed in all patients administered PS but in no patients administered PRe-0.25, PRe-0.125, or PN. Postoperative nausea was observed in 5 patients (25%) administered PRe-0.25 and in 1 patient (5%) administered PN. Although both PRe-0.125 and PN were useful clinically, PRe-0.125 was the least expensive combination.

Efficacy and safety of low-dose ketamine as an adjunct analgesic and amnesic during caesarean section under general anaesthesia

Background and Aims:

The practice of avoiding sedatives or anxiolytics during caesarean section under general anaesthesia (GA) until delivery of the baby could result in exaggerated haemodynamic responses and an increased risk of awareness. We aimed to assess the efficacy and safety of low-dose ketamine, used as an adjunct analgesic and amnesic, in attenuating these responses during caesarean section under GA.

Methods:

This prospective, randomised study was conducted in 40 patients. Group K (n = 20) received 0.25 mg/kg ketamine, whereas Group C received 5 ml normal saline intravenously (IV) just before induction of anaesthesia. After intubation, patients were ventilated with O₂ and N₂O (40:60%) with 0.7% end-tidal isoflurane. Fentanyl and midazolam were given following delivery of the baby. Mann–Whitney and Fisher's exact tests were used for statistical analysis.

Results:

Preinduction haemodynamic parameters and those recorded at 1 min after induction were comparable in both groups. However, heart rate and systolic blood pressure recorded after intubation (at 3, 5, 7, 9, 12, 15, 20, 30 and 45 min after induction) showed significantly high values in Group C (P < 0.05). Mean arterial pressure also showed a similar pattern. Umbilical vein pO₂, pCO₂ and pH were comparable in both groups. Though Apgar score at 1 min showed a higher scoring in Group K, at 5 min both groups had comparable scores. In Group C, intraoperative lacrimation (50% vs. 0%) and hallucinations/recall of intraoperative events (10% vs. 0%) were high.

Conclusion:

IV ketamine 0.25 mg/kg can be safely used as an adjunct analgesic and amnesic to attenuate haemodynamic responses during caesarean section under GA without affecting the foetal outcome.