Propofol-ketamine mixture for anesthesia in pediatric patients undergoing cardiac catheterization

Total intravenous anesthesia with Ketofol in rabbits: a comparison of the effects of constant rate infusion of midazolam, fentanyl or dexmedetomidine

BACKGROUND

When inhalant anesthetic equipment is not available or during upper airway surgery, intravenous infusion of one or more drugs are commonly used to induce and/or maintain general anesthesia. Total intravenous anesthesia (TIVA) does not require endotracheal intubation, which may be more difficult to achieve in rabbits. A range of different injectable drug combinations have been used as continuous infusion rate in animals. Recently, a combination of ketamine and propofol (ketofol) has been used for TIVA in both human patients and animals. The purpose of this prospective, blinded, randomized, crossover study was to evaluate anesthetic and cardiopulmonary effects of ketofol total intravenous anesthesia (TIVA) in combination with constant rate infusion (CRI) of midazolam, fentanyl or dexmedetomidine in eight New Zealand White rabbits. Following IV induction with ketofol and endotracheal intubation, anesthesia was maintained with ketofol infusion in combination with CRIs of midazolam (loading dose [LD]: 0.3 mg/kg; CRI: 0.3 mg/kg/hr; KPM), fentanyl (LD: 6 µg/kg; CRI: 6 µg/kg/hr; KPF) or dexmedetomidine (LD: 3 µg/kg; CRI: 3 µg/kg/hr; KPD). Rabbits in the control treatment (KPS) were administered the same volume of saline for LD and CRI. Ketofol infusion rate (initially 0.6 mg kg- 1 minute- 1 [0.3 mg kg- 1 minute- 1 of each drug]) was adjusted to suppress the pedal withdrawal reflex. Ketofol dose and physiologic variables were recorded every 5 min.

RESULTS

Ketofol induction doses were 14.9 ± 1.8 (KPM), 15.0 ± 1.9 (KPF), 15.5 ± 2.4 (KPD) and 14.7 ± 3.4 (KPS) mg kg- 1 and did not differ among treatments (p > 0.05). Ketofol infusion rate decreased significantly in rabbits in treatments KPM and KPD as compared with saline. Ketofol maintenance dose in rabbits in treatments KPM (1.0 ± 0.1 mg/kg/min) and KPD (1.0 ± 0.1 mg/kg/min) was significantly lower as compared to KPS (1.3 ± 0.1 mg/kg/min) treatment (p < 0.05). Ketofol maintenance dose did not differ significantly between treatments KPF (1.1 ± 0.3 mg/kg/min) and KPS (1.3 ± 0.1 mg/kg/min). Cardiovascular variables remained at clinically acceptable values but ketofol infusion in combination with fentanyl CRI was associated with severe respiratory depression.

CONCLUSIONS

At the studied doses, CRIs of midazolam and dexmedetomidine, but not fentanyl, produced ketofol-sparing effect in rabbits. Mechanical ventilation should be considered during ketofol anesthesia, particularly when fentanyl CRI is used.

The association between different anesthetic techniques and outcomes in patients undergoing transfemoral aortic valve replacement

Background

There is an increasing number of patients undergoing transfemoral aortic valve replacement (TAVR) with sedation. There is limited data assessing the efficacy and safety of the different types of sedative drugs. The objective was to compare two sedation techniques with regard to the need for vasoactive support, respiratory support, rate of conversion to general anesthesia (GA), common perioperative morbidities, intensive care unit (ICU) stay, and in-hospital mortality.

Methods

A retrospective chart review study conducted among patients who underwent TAVR at a specialized cardiac center between January 2016 and December 2019. Data collection included patient diagnosis, preoperative comorbidities, intraoperative outcomes, and postoperative outcomes.

Results

A total of 289 patients received local anesthesia; 210 received propofol infusion and 79 received a mixed propofol-ketamine infusion (Ketofol). The average age was 75.5 ± 8.9 years and 58.1% of the patients were females. Comparing propofol and ketofol groups, 31.2% and 34.2% of the patients required drug support, 7.6% and 6.3% required conversion to GA, 46.7% and 59.5% required respiratory support, respectively. These intraoperative outcomes were not significantly different between groups, P = 0.540, P = 0.707, and P = 0.105, respectively. In-hospital 30-day mortality in propofol and ketofol groups were 1.9% and 3.8%, respectively, P = 0.396. In both groups, the median post-procedure coronary care unit stay was 26 hours while post-procedure hospital stay was 3 days.

Conclusions

There were no significant differences in perioperative or postoperative outcomes in TAVR patients receiving either propofol or ketofol. Propofol infusion, either alone or with ketamine, is reliable and safe, with minimal side effects.

Ketamine-propofol for total intravenous anaesthesia in rabbits: a comparison of premedication with acepromazine-medetomidine, acepromazine-midazolam or acepromazine-morphine

OBJECTIVE

To describe ketamine-propofol total intravenous anaesthesia (TIVA) following premedication with acepromazine and either medetomidine, midazolam or morphine in rabbits.

STUDY DESIGN

Randomized, crossover experimental study.

ANIMALS

A total of six healthy female New Zealand White rabbits (2.2 ± 0.3 kg).

METHODS

Rabbits were anaesthetized on four occasions, each separated by 7 days: an intramuscular injection of saline alone (treatment Saline) or acepromazine (0.5 mg kg^-1) in combination with medetomidine (0.1 mg kg^-1), midazolam (1 mg kg^-1) or morphine (1 mg kg^-1), treatments AME, AMI or AMO, respectively, in random order. Anaesthesia was induced and maintained with a mixture containing ketamine (5 mg mL^-1) and propofol (5 mg mL^-1) (ketofol). Each trachea was intubated and the rabbit administered oxygen during spontaneous ventilation. Ketofol infusion rate was initially 0.4 mg kg^-1 minute^-1 (0.2 mg kg^-1 minute^-1 of each drug) and was adjusted to maintain adequate anaesthetic depth based on clinical assessment. Ketofol dose and physiological variables were recorded every 5 minutes. Quality of sedation, intubation and recovery times were recorded.

RESULTS

Ketofol induction doses decreased significantly in treatments AME (7.9 ± 2.3) and AMI (8.9 ± 4.0) compared with treatment Saline (16.8 ± 3.2 mg kg^-1) (p < 0.05). The total ketofol dose to maintain anaesthesia was significantly lower in treatments AME, AMI and AMO (0.6 ± 0.1, 0.6 ± 0.2 and 0.6 ± 0.1 mg kg^-1 minute^-1, respectively) than in treatment Saline (1.2 ± 0.2 mg kg^-1 minute^-1) (p < 0.05). Cardiovascular variables remained at clinically acceptable values, but all treatments caused some degree of hypoventilation.

CONCLUSIONS AND CLINICAL RELEVANCE

Premedication with AME, AMI and AMO, at the doses studied, significantly decreased the maintenance dose of ketofol infusion in rabbits. Ketofol was determined to be a clinically acceptable combination for TIVA in premedicated rabbits.

The effect of the duration of the procedure on the risk of complications during pediatric cardiac catheterization

Background

This study aims to evaluate the frequency of and associated risk factors for adverse events caused by cardiac catheterization procedures in pediatric patients.

Methods

Between January 2009 and January 2012, a total of 599 pediatric patients (320 males, 279 females; mean age 5.4±4.7 years; range, 1 day to 21 years) who underwent cardiac catheterization in our cardiac catheterization laboratory were retrospectively analyzed. Demographic and clinical data of the patients including the duration of the procedure, management of anesthesia, the American Society of Anesthesiologists class, and Catheterization Risk Score for Pediatrics, and procedure-related serious adverse events were recorded.

Results

The incidence of procedure-related serious adverse events was 9.18%. Potential risk factors associated with serious adverse events were identified as interventional heart catheterization, high scores obtained from the Catheterization Risk Score for Pediatrics, the use of endotracheal tube in airway control, and prolonged procedural duration.

Conclusion

Our study results suggest that prolonged duration of catheterization is a potential risk factor for procedure-related adverse events and the duration of the procedure needs to be included as a variable in the Catheterization Risk Score for Pediatrics scoring system for predicting procedure-related adverse events.

Dexmedetomidine or midazolam in combination with propofol for sedation in endoscopic retrograde cholangiopancreatography: a randomized double blind prospective study

Introduction

Interventional endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), often require sedation during the procedure. The most commonly used drugs for this purpose are midazolam and propofol, which are used as sedative and hypnotic agents with minimal analgesic potential.

Aim

To compare the analgesic sedative effects of midazolam-propofol and dexmedetomidine-propofol combinations and their influence on hemodynamic and respiratory variables in patients undergoing ERCP.

Material and methods

Forty adult patients aged 20-78 and undergoing ERCP were randomized to two groups. Patients were premedicated with midazolam (0.05 mg/kg 10 min before the procedure) in group M and with dexmedetomidine (1 μg/kg for 10 min) in group D. Propofol was used for maintenance. The sedation level was monitored using the bispectral index (BIS) to maintain a score between 70 and 80. Hemodynamic and respiratory variables, recovery time and adverse events were recorded.

Results

The hemodynamic and respiratory variables were similar in both groups. Total propofol consumption was significantly lower in the dexmedetomidine group (208.5 ±80.0 vs. 154.5 ±66.7 mg; p = 0.011). The recovery period was shorter in group D (time to achieve the Aldrete score 9 was 9.4 ±2.1 vs. 6.6 ±1.1 min; p < 0.001). Changes in hemodynamic and respiratory variables and adverse events were not different between the two groups.

Conclusions

We found a shorter recovery time and comparable sedative and adverse effects with the dexmedetomidine-propofol combination compared with the midazolam-propofol combination. Dexmedetomidine in combination with propofol may be a safe and useful alternative for sedation for ERCP patients.

Renal effects of general anesthesia from old to recent studies

Various types of anesthesia are being utilized to maintain physiologically secured surgical conditions. Nearly all categories of general anesthesia are characterized by various perioperative and postoperative complications. These shortcomings are important aspects that need to be considered by the anesthesiologist and surgeon before administration of these compounds. The renal effects of anesthesia play an important role in understanding possible systemic changes due to the fact that the kidney has a direct or indirect impact on nearly all the systems of the body. Various studies have been conducted to find out changes in renal parameters and its systemic effects upon administration of the anesthesia and its postoperative repercussions. Besides that, the impaired renal function might have an impact on the excretion of anesthetic metabolites, which can lead to long-term dysfunction. Patients with a previous history of disease ought to be brought under consideration because these chemicals can ameliorate pre-existent symptoms. This review is intended to discuss the early and latest studies based on the effects of general anesthesia on the renal system.

Propofol versus Ketofol for Sedation of Pediatric Patients Undergoing Transcatheter Pulmonary Valve Implantation: A Double-blind Randomized Study

OBJECTIVE

The study was done to compare propofol and ketofol for sedation of pediatric patients scheduled for elective pulmonary valve implantation in a catheterization laboratory.

DESIGN

This was a double-blind randomized study.

SETTING

This study was conducted in Prince Sultan Cardiac Centre, Saudi Arabia.

PATIENTS AND METHODS

The study included 60 pediatric patients with pulmonary regurge undergoing pulmonary valve implantation.

INTERVENTION

The study included sixty patients, classified into two groups (n = 30). Group A: Propofol was administered as a bolus dose (1-2 mg/kg) and then a continuous infusion of 50-100 μg/kg/min titrated as needed. Group B: Ketofol was administered 1-2 mg/kg and then infusion of 20-60 μg/kg/min. The medication was prepared by the nursing staff and given to anesthetist blindly.

MEASUREMENTS

The monitors included heart rate, mean arterial blood pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, fentanyl dose, antiemetic medications, and Aldrete score.

MAIN RESULTS

The comparison of heart rate, mean arterial pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, and Aldrete score were insignificant (P > 0.05). The total fentanyl increased in Group A more than Group B (P = 0.045). The required antiemetic drugs increased in Group A patients more than Group B (P = 0.020). The durations of full recovery and in the postanesthesia care unit were longer in Group A than Group B (P = 0.013, P < 0.001, respectively).

CONCLUSION

The use of propofol and ketofol is safe and effective for sedation of pediatric patients undergoing pulmonary valve implantation in a catheterization laboratory. However, ketofol has many advantages more than the propofol. Ketofol has a rapid onset of sedation, a rapid recovery time, decreased incidence of nausea and vomiting and leads to rapid discharge of patients from the postanesthesia care unit.

Dexmedetomidine versus ketofol sedation for outpatient diagnostic transesophageal echocardiography: A randomized controlled study

Background

Moderate sedation is required for out-patient transesophageal echocardiography (TEE). Our objective was to compare the effect of Ketofol and dexmedetomidine for outpatient procedural sedation in diagnostic TEE with a hypothesis that Ketofol would be as effective as dexmedetomidine. Patients and.

Methods

Fifty adult patients of age group 18-60 years with atrial septal defect, rheumatic valvular heart disease undergoing diagnostic TEE in the outpatient echocardiography laboratory were randomized into two groups, group D and group KF. GROUP D: Dexmedetomidine infusion -200 μg in 20 ml normal saline. GROUP KF: Ketofol infusion: (ketamine: propofol, 1mg: 3 mg in 20 ml syringe). Loading dose of drug at 1ml/kg/hour IV till Ramsay sedation score (RSS) ≥ 3 achieved followed by maintenance infusion at 0.05 ml/kg/hour till end of procedure.

Results

The primary outcome - time to achieve Ramsay sedation score ≥ 3 was significantly lesser with Ketofol as compared to Dexmedetomidine 260[69] seconds vs 460 [137], (p value<0.05).

Conclusion

In out-patient setting, ketofol is favourable over dexmedetomidine for sedation regimen for diagnostic TEE as lesser time is taken to achieve optimal sedation with lesser hemodynamic perturbations, post procedure complications and better cardiologist satisfaction.

Dexmedetomidine-propofol vs ketamine-propofol anaesthesia in paediatric and young adult patients undergoing device closure procedures in cardiac catheterisation laboratory: An open label randomised trial

Background and Aims:

Several drug combinations have been tried in patients with acyanotic congenital heart disease (ACHD) undergoing transcatheter device closure in the cardiac catheterisation laboratory (CCL). Adequate sedation, analgesia, akinesia, cardiorespiratory stability, and prompt recovery are key requirements. Ketamine with propofol is used for this purpose. Dexmedetomidine carries a shorter recovery time. This study compared dexmedetomidine–propofol (DP) with ketamine–propofol (KP) in patients in the CCL.

Methods:

This was an open label randomised trial at a CCL over a 2-year period from August 2012 to August 2014. Fifty-six paediatric and 44 young adults with ACHD underwent device closure and were randomised to receive DP or KP. The primary outcome studied was time to regain full consciousness, airway and motor recovery.

Results:

Baseline characteristics were similar in the study groups. In the DP arm as compared to the KP arm, the time to recovery of consciousness (mean ± SD) was significantly faster in both paediatric patients [30 ± 15 vs. 58 ± 13 min (P < 0.001)] and in young adult patients [22 ± 10 vs. 35 ± 12 min (P < 0.001)]. There was significantly faster motor recovery also (mean ± SD) [paediatric: 25 ± 05 vs. 40 ± 14 (P < 0.001); young adult: 10 ± 05 vs. 22 ± 10 min (P < 0.001)].

Conclusion:

Procedural anaesthesia with DP in paediatric and young adult patients with ACHD undergoing device closure in the CCL resulted in faster recovery of consciousness and motor recovery compared to KP.

Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium

OBJECTIVES

Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers.

DESIGN

Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015.

SETTING

Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals.

PATIENTS

Children from birth to less than or equal to 21 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic.

CONCLUSIONS

Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Comparison of Dexmedetomidine Versus Ketamine-Propofol Combination for Sedation in Cataract Surgery

OBJECTIVE

The aim of this study is to compare the sedative properties and haemodynamic and respiratory effects of dexmedetomidine and a ketamine-propofol combination (ketofol), which are expected to have minimal effects on spontaneous breathing.

METHODS

Sixty patients were enrolled in this prospective randomised study. Patients were divided into 2 groups according to the administration of dexmedetomidine (Group D) and ketofol (Group K). Target sedation level was determined as a Ramsay Sedation Score of 3. In Group D, 0.5 mcg kg(-1) dexmedetomidine was administered via intravenous route in 10 minutes versus 0.125 mL kg(-1) of a solution containing 200 mg propofol and 100 mg ketamine in Group K. Haemodynamic and respiratory effects, postoperative awakening time, analgesic properties and satisfaction levels of the patients and surgeon were assessed.

RESULTS

There was a statistically significant decrease in mean arterial pressures following drug administration compared to initial measurements in both groups. However, there was a statistically significant decrease in heart rate only in Group D. There was no significant difference between the two groups regarding respiratory rate and protection of spontaneous respiration. Although the time for Aldrete score to be 9 was 16.1 minutes for Group K, it was 24.9 minutes for Group D, and this difference was statistically significant (p<0.01). There was no significant difference between the two groups regarding adverse effects, pain scores and satisfaction levels of the patients and surgeon.

CONCLUSION

Compared to dexmedetomidine, at similar sedation levels, sedation provided by ketofol enables satisfactory analgesia. Moreover, ketofol has a more rapid onset of action and a shorter recovery period from anaesthesia without causing significant haemodynamic or respiratory adverse effects.

Anesthesia and the pediatric cardiac catheterization suite: a review

Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.

Sedation for paediatric transcatheter atrial septal defect closure: comparison of two sedation protocols

AIM

This study aimed to compare the effects of dexmedetomidine-propofol and ketamine-propofol sedation on haemodynamic stability, immobility, and recovery time in children who underwent transcatheter closure of atrial septal defects.

METHODS

In all, 46 children scheduled for transcatheter closure of atrial septal defects (n = 46) were included. The dexmedetomidine-propofol group (n = 23) received dexmedetomidine (1 μg/kg) and propofol (1 mg/kg) for induction, followed by dexmedetomidine (0.5 μg/kg/hour) and propofol (100 μg/kg/minute) for maintenance. The ketamine-propofol group (n = 23) received ketamine (1 mg/kg) and propofol (1 mg/kg) for induction, followed by ketamine (1 mg/kg) and propofol (100 μg/kg/minute) for maintenance.

RESULTS

In all, 11 patients in the dexmedetomidine group (47.8%) and one patient (4.3%) in the ketamine group demonstrated a decrease ≥20% from the baseline in mean arterial pressure (p = 0.01). Heart rates decreased ≥20% from the baseline value in 10 patients (43.4%) in the dexmedetomidine group and three patients (13%) in the ketamine group (p = 0.047). Heart rate values were observed to be lower in the dexmedetomidine group throughout the procedure after the first 10 minutes. The number of patients requiring additional propofol was higher in the dexmedetomidine group (p = 0.01). The recovery times were similar in the two groups--15.86 ± 6.50 minutes in the dexmedetomidine group and 19.65 ± 8.19 minutes in the ketamine group; p = 0.09.

CONCLUSION

The ketamine-propofol combination was less likely to induce haemodynamic instability, with no significant change in recovery times, compared with the dexmedetomidine-propofol combination. The ketamine-propofol combination provided good conditions for the intervention.

Ketofol simulations for dosing in pediatric anesthesia

BACKGROUND

Propofol mixed with racemic ketamine (or 'ketofol') is popular for short procedural sedation and analgesia. Use is creeping into anesthesia, yet neither the optimal combination nor infusion rate is known. The EC(50) of propofol's antiemetic effect is reported to be 0.343 mg·l(-1), while ketamine analgesia is thought to persist with concentrations above 0.2 mg·l(-1). We aimed to determine a ketofol dosing regimen for anesthesia 30-min and 1.5-h duration in a healthy child that did not unduly compromise recovery.

METHODS

Pharmacokinetic-pharmacodynamic parameters were used to simulate drug concentration and effect profiles over time for different ratios of propofol to ketamine ratios (1 : 1 to 10 : 1) and rates. The target effect was the 95% probability of loss of response to a 5-s transcutaneous tetanus (P05). Combined effects were additive, with a propofol EC(50) of 3.1 mg·l(-1), ketamine EC(50) of 0.64 mg·l(-1), and slope of 5.4. The time to predicted 50% probability of return of this response after ceasing infusion (P(50)) was determined for a 5-year-old 20-kg healthy child.

RESULTS

The addition of ketamine to propofol infused using a manual infusion regimen (loading dose 3 mg·kg(-1), then 15 mg·kg(-1) ·h(-1) for 15 min, 13 mg·kg(-1) ·h(-1) for 15 min, 11 mg·kg(-1) ·h(-1) for 30 min, and 10 mg·kg(-1) ·h(-1) for 1-2 h) caused prolonged postoperative sedation. The P(50) after a 1.5-h infusion using a 1 : 1 mixture was 4.5 h, 2 : 1 mixture was 3.25 h, 5 : 1 mixture was 1.6 h, and 10 : 1 mixture was 40 min. These P(50) estimates could be reduced by slowing administration infusion rates to 20%, 33%, 50%, 67%, 80%, and 90% for mixtures 1 : 1, 2 : 1, 3 : 1, 5 : 1, 6.7 : 1, and 10 : 1, respectively. These rates achieve a P(50) of approximately 20 min for 30-min duration anesthesia and 60 min for 1.5-h duration anesthesia.

CONCLUSIONS

The addition of ketamine to propofol infusion will prolong recovery unless infusion rates are decreased. We suggest an optimal ratio of racemic ketamine to propofol of 1 : 5 for 30-min anesthesia and 1 : 6.7 for 90-min anesthesia. Delivery of these ratios achieves propofol concentrations above an antiemetic threshold for longer than the ketamine concentration above the analgesic threshold during, potentially reducing postoperative nausea incidence.

The use of basic parameters for monitoring the haemodynamic effects of midazolam and ketamine as opposed to propofol during cardiac catheterization

OBJECTIVE

Our aim is to compare the haemodynamic and adverse effects of propofol versus the mixture of midazolam and ketamine as used in sedation for cardiac catheterization in children.

METHODS

In a prospective randomized trial, we divided patients needing sedation into 72 receiving a mixture of midazolam and ketamine and 42 receiving propofol. Their ages ranged from 6 months to 12 years, and 1 year to 16 years, respectively. We collected data relative to heart rate, mean arterial pressure, respiratory rate, peripheral saturations of oxygen, and adverse effects. We assessed cyanotic patients to establish any relationship between the haemodynamic data and peripheral arterial saturations of oxygen.

RESULTS

Demographic data, including age, gender, and weight, was not statistically different between the groups. In those receiving midazolam and ketamine, mean systemic arterial pressures before, and 30 minutes after, sedation were 64.3, with standard deviation of 9.8, and 62.5, with standard deviation of 10.2, millimetre of mercury (p equals to 0.237). Heart rates were 131.3, with standard deviation of 13.5, and 109.2, with standard deviation of 17.3 beats per minute, (p less than 0.001) whereas in those given propofol the comparable values were 71.2, with standard deviation of 14.4, and 53.6 with standard deviation of 9.7 millimetres of mercury (p less than 0.001), and 115.2, with standard deviation of 13.6, and 100.5 with standard deviation of 20.1 beats per minute (p less than 0.01), respectively. Mean systemic arterial pressures in the subgroups of cyanotic patients before and 30 minutes after sedation were 74.8, with standard deviation of 14.6, and 72.7, with standard deviation of 12.4 millimetres of mercury for those receiving midazolam and ketamine (p equals to 0.544), and heart rates were 119.3, with standard deviation of 12.2, and 104.6 with standard deviation of 16.1 beats per minute (p equals to 0.001). In those given propofol, the comparable values were 71.1 with deviation of 15.5 and 53.9 with deviation of 9.2 millimetres of mercury (p equals to 0.001), and 126.7 with deviation of 20.8 and 107.2 with deviation of 13.5 beats per minute (p equals to 0.001), respectively.

CONCLUSIONS

In cyanotic children, propofol used as a sedative agent during cardiac catheterization causes a decrease in mean arterial pressure and arterial desaturation. Ketamine produces more stable haemodynamic data in children with congenitally malformed hearts.

Case report: airway and concurrent hemodynamic management in a neonate with oculo-auriculo-vertebral (Goldenhar) syndrome, severe cervical scoliosis, interrupted aortic arch, multiple ventricular septal defects, and an unstable cervical spine

We report the challenging case of a 1-week-old, term, 2.4 kg neonate with Goldenhar syndrome (including microcephaly, left microtia, left facial palsy, dextro-scoliosis of the cervical spine, and cervico-thoracic levoscoliosis), multiple ventricular septal defects, a type B interrupted aortic arch, a large patent ductus arteriosis, and radiographic and clinical signs concerning for an unstable cervical spine. Our anesthesia team was consulted for perioperative management of this patient during her surgical repair. This case report describes the use of the Air-Q size 1 laryngeal airway (LA) to assist fiberoptic intubation in an ASA 4 neonate with cardiac disease, an anticipated difficult airway with the addition of an unstable cervical spine, as well as the anesthetic techniques used to maintain hemodynamic stability while the airway was secured.

Is the addition of dexmedetomidine to a ketamine-propofol combination in pediatric cardiac catheterization sedation useful?

Pediatric patients undergoing cardiac catheterization usually need deep sedation. In this study, 60 children were randomly allocated to receive sedation with either a ketamine-propofol combination (KP group, n = 30) or a ketamine-propofol-dexmedetomidine combination (KPD group, n = 30). Both groups received 1 mg/kg of ketamine and 1 mg/kg of propofol for induction of sedation, and the KPD group received an additional 1 μg/kg of dexmedetomidine infusion during 5 min for induction of sedation and a maintenance infusion of 0.5 μg/kg/h. In both groups, 0.2 mg/kg of propofol was administered as a bolus to maintain a Ramsey sedation score (RSS) greater than 4 throughout the procedure. None of the patients in either group required intubation. In the KP group, one patient required mask ventilation. The chin-lift maneuver needed to be performed for eight patients in the KP group and one patient in the KPD group (p < 0.05). Adding dexmedetomidine to the ketamine-propofol combination decreased movement during the procedures. The heart rate in the KPD group was significantly lower after induction of sedation and throughout the procedure (p < 0.05). No significant differences in systolic blood pressure, diastolic blood pressure, or respiration rates were found between the two groups (p > 0.05). The mean recovery time was longer in the KP group (5.86 vs 3.13 min; p < 0.05). Adding dexmedetomidine to a ketamine-propofol combination led to a reduced need for airway intervention and to decreased movement during local anesthetic infiltration and throughout the procedure. The recovery time was shorter and hemodynamic stability good in the KPD group.

Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial

STUDY OBJECTIVE

We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone.

METHODS

Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events.

RESULTS

A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval -9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents.

CONCLUSION

Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.

Current approaches to pediatric heart catheterizations

Sedation for pediatric cardiac catheterization is a common requirement in many institutions. As the field of cardiac catheterization has evolved, the provision of sedation for these procedures has been varied. Increasingly the demand is for dedicated personnel focused on monitoring and delivery of sedation while in the catheterization suite. This article describes the considerations one must use when undertaking these cases.

A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults

OBJECTIVES

The objective was to evaluate the effectiveness, recovery time, and adverse event profile of intravenous (IV) mixed 1:1 ketamine-propofol (ketofol) for adult procedural sedation and analgesia (PSA) in the emergency department (ED).

METHODS

  Prospective data were collected on all PSA events over a 4.5-year period in a trauma-receiving suburban teaching hospital. PSAs using a 1:1 single-syringe mixture of 10 mg/mL ketamine and 10 mg/mL propofol in patients over 21 years of age were analyzed. Physiologic data, drug doses, adverse events, recovery time, patient satisfaction, and staff satisfaction were recorded.

RESULTS

Ketofol PSA was used in 728 patients for primarily orthopedic procedures. Median patient age was 53 years (range = 21 to 99 years, interquartile range [IQR] = 36-70 years). The median dose of ketamine and propofol was 0.7 mg/kg each (range =0.2 to 2.7 mg/kg, IQR = 0.5-0.9 mg/kg), and median recovery time was 14 minutes (range = 3 to 50 minutes, IQR = 10-17 minutes). PSA was effective in 717 cases (98%). Bag-mask ventilation occurred in 15 patients (2.1%; 95% confidence interval [CI] = 1.0% to 3.1%). Recovery agitation occurred in 26 patients (3.6%; 95% CI = 2.2% to 4.9%), of whom 13 (1.8%; 95% CI = 0.8% to 2.7%) required treatment. One patient experienced vomiting and one patient was admitted to the hospital for monitoring of transient dysrhythmia and hypotension. No sequelae were identified. The median staff satisfaction scores were 10 (IQR = 9-10) on a scale of 1 to 10, and 97% of patients would have chosen the same method of PSA in the future.

CONCLUSIONS

  Ketofol is an effective PSA agent in adult ED patients. Recovery times are short and adverse events are few. Patients and ED staff were highly satisfied.

Use of ketofol for procedural sedation and analgesia in children with hematological diseases

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine-propofol admixture ("ketofol") in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration.

METHODS

This was a prospective, observational pilot study. Patients aged between 4 and 12 years requiring sedation for bone marrow aspiration were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was given intravenously in 0.5 mg/kg aliquots each with a 1-min interval and titrated to reach sedation levels of 3 or 4 (Ramsay score). The primary outcome was patient satisfaction with the degree of sedation. Secondary outcomes included injection pain, total sedation time, recovery time, hemodynamic and respiratory parameters, and adverse events.

RESULTS

A total of 20 patients were enrolled in the study. The median total dose of ketofol administered was 1.25 mg/kg each of propofol and ketamine (95%CI 0.77-2 mg/kg). The median score on the visual analog scale was 0 (extremely comfortable) (0-1.5; 95%CI 0.2-2.2). Median recovery time was 23 min (20.5-28 min; 95%CI 17.1-51.2). The incidence of injection pain was 2/20. Two patients had transient diplopia and one child reported dreams. No patients had hypotension, vomiting or required airway intervention.

CONCLUSION

Ketofol provided effective sedation, which was reflected in the high degree of satisfaction recorded by children requiring procedural sedation and analgesia for bone marrow aspiration. We also observed rapid recovery and no clinically significant complications. A large number of patients is required to evaluate and validate these findings.

The Effect of Recorded Maternal Voice on Perioperative Anxiety and Emergence in Children

This study was performed to test if hearing a recorded maternal voice reduces anxiety, emergence agitation and anaesthetic requirements in children. With written informed consent, children scheduled for cardiac catheterisation under intravenous ketamine anaesthesia and their mothers (n=46) were randomly assigned to either the mother-voice (MV) or control group. While the MV group (n=23) listened via headphones to a recording of their mothers’ voices during the perioperative period, the control group (n=23) wore headphones with no auditory stimulation. Ketamine requirements and haemodynamics were recorded. Anxiety of the patients and the parents were measured before and after the procedure with the modified Yale preoperative anxiety scale and Spielberger's State-Trait Anxiety Inventory, respectively. Emergence agitation was graded. The demographic and haemodynamic data were comparable, except for a longer procedure time in the MV group. Mothers’ State-Trait Anxiety Inventory was not different preoperatively between the groups. Mothers’ state and trait anxiety was lower after the procedure in the MV group compared with the preoperative values. In the control group only maternal state anxiety was diminished after the procedure. There was no significant group difference with respect to ketamine requirement (5.1±1.9 mg vs 4.9±1.6 mg, P=0.645). The anxiety score of children was lower in the MV group before the procedure (modified Yale preoperative anxiety scale score 35±12 vs 28±9, P=0.038), but there was no significant difference postoperatively. Emergence agitation was attenuated in the MV group (P=0.005).

Propofol/dexmedetomidine and propofol/ketamine combinations for anesthesia in pediatric patients undergoing transcatheter atrial septal defect closure: a prospective randomized study

BACKGROUND

Children undergoing cardiac catheterization usually need general anesthesia or deep sedation.

OBJECTIVE

This study was performed to compare the effects of propofol/dexmedetomidine and propofol/ketamine combinations on recovery time and hemodynamic parameters in pediatric patients undergoing transcatheter atrial septal defect (ASD) closure.

METHODS

This was a prospective randomized study. Pediatric patients with ASD were randomly assigned into 2 groups to receive propofol/dexmedetomidine or propofol/ketamine. The dexmedetomidine group received an infusion over 10 minutes of dexmedetomidine 1 microg/kg and propofol 2.0 to 2.5 mg/kg bolus for induction, then an infusion of dexmedetomidine 0.5 microg/kg/h and propofol 4 to 6 mg/kg/h for maintenance. In the ketamine group, patients received the same dose of propofol and ketamine 1 mg/kg for induction and 0.5 mg/kg/h by infusion for maintenance. The procedure was performed using both fluoroscopy and transesophageal echocardiography. Hemodynamic data, respiratory rate, and oxygen saturation were recorded before and after induction, 1 and 5 minutes after intubation, every 10 minutes thereafter during the procedure, and after extubation by researchers blinded to the study drugs. Recovery time, the primary outcome, was evaluated by a modified Steward score; a score of >or=6 means that the patient is awake or responds to verbal stimuli, has purposeful motor activity, and coughs on command. The time to reach a modified Steward score of >or=6 was recorded. The secondary outcome was the effects on the hemodynamic variables. Creatine kinase muscle-brain subunit, myoglobin, cardiac troponin I, and brain natriuretic peptide were the biochemical variables measured. Patients were monitored for respiratory (changes in oxygen status) and hemodynamic adverse effects (heart rate changes, blood pressure changes) until the second hour in the intensive care unit after the operation was concluded.

RESULTS

Nine patients each were randomly assigned to propofol/dexmedetomidine and propofol/ketamine. The demographic and clinical parameters were not significantly different between groups. In the dexmedetomidine group, 5 of the patients were male, mean (SD) age was 12.5 (10.4) years, and mean weight was 40.8 (27.8) kg. In the ketamine group, 3 patients were male, mean age was 10.1 (4.5) years, and mean weight was 30.0 (15.2) kg. The recovery time was significantly longer in the ketamine group than in the dexmedetomidine group (10.5 [3.4] vs 5.7 [0.8] minutes; P = 0.01). Systolic and diastolic blood pressure values were not significantly different between groups in any study period. Heart rate values were significantly higher in the ketamine group at 5 minutes after intubation (106.6 vs 84.2 beats/min), 10 minutes (111.8 vs 87.4 beats/min) and 30 minutes (110.0 vs 89.6 beats/min) perioperatively, and after extubation (126.8 vs 92.2 beats/min) (all, P < 0.05). In the dexmedetomidine group, one patient experienced shivering and one reported nausea; in the ketamine group, one patient reported nausea. Neither respiratory depression nor severe hypotension (ie, >20% change over baseline or requiring intervention) was observed in any patient. One patient developed agitation in the ketamine group.

CONCLUSIONS

In this small study, both dexmedetomidine and ketamine in combination with propofol were well tolerated in these pediatric patients who required ASD closure. The recovery period was significantly shorter in the dexmedetomidine group.

Comparison of propofol versus propofol-ketamine combination for sedation during spinal anesthesia in children: randomized clinical trial of efficacy and safety

OBJECTIVES

This study was designed to compare the efficacy and safety of propofol vs propofol-ketamine combination for sedation during pediatric spinal anesthesia.

METHODS

Forty children, aged 3-8 undergoing spinal anesthesia for lower abdominal surgeries were included. Participants were randomly assigned into two groups. Group 1 received propofol bolus of 2 mg.kg(-1) followed by an infusion of 4 mg.kg(-1).h(-1). Group 2 received a combination of 1.6 mg.kg(-1) propofol and 0.4 mg.kg(-1) ketamine followed by an infusion of 3.2 mg.kg(-1).h(-1) and 0.8 mg.kg(-1).h(-1), respectively. The infusion rate was titrated to keep the child sedated at University of Michigan Sedation Score of 3. The heart rate, blood pressure, respiratory rate and oxygen saturation were recorded every 5 min. The episodes of spontaneous body movements and requirement of supplemental sedation were recorded. The postoperative recovery was assessed by modified Aldrette score.

RESULTS

Seventeen patients in group 1 and four patients in group 2 (P < 0.001) required extra boluses of study drug to prevent movements during lumbar puncture. Four patients experienced respiratory depression and three airway obstruction in group 1 when compared to one patient each in group 2 (P < 0.05). The recovery time was similar in both groups. None of the patient had postoperative nausea/vomiting or psychomimetic reactions.

CONCLUSIONS

Propofol-ketamine combination provided better quality of sedation with lesser complications than propofol alone and thus can be a good option for sedation during spinal anesthesia in children.

A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol)

OBJECTIVES

This study evaluated the effectiveness, recovery time, and adverse event profile of intravenous (IV) ketofol (mixed 1:1 ketamine-propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children.

METHODS

Prospective data were collected on all PSA events in a trauma-receiving, community teaching hospital over a 3.5-year period, from which data on all patients under 21 years of age were studied. Patients receiving a single-syringe 1:1 mixture of 10 mg/mL ketamine and 10 mg/mL propofol (ketofol) were analyzed. Patients received ketofol in titrated aliquots at the discretion of the treating physician. Effectiveness, recovery time, caregiver and patient satisfaction, drug doses, physiologic data, and adverse events were recorded.

RESULTS

Ketofol PSA was performed in 219 patients with a median age of 13 years (range = 1 to 20 years; interquartile range [IQR] = 8 to 16 years) for primarily orthopedic procedures. The median dose of medication administered was 0.8 mg/kg each of ketamine and propofol (range = 0.2 to 3.0 mg/kg; IQR = 0.7 to 1.0 mg/kg). Sedation was effective in all patients. Three patients (1.4%; 95% confidence interval [CI] = 0.0% to 3.0%) had airway events requiring intervention, of which one (0.4%; 95% CI = 0.0% to 1.2%) required positive pressure ventilation. Two patients (0.9%; 95% CI = 0.0% to 2.2%) had unpleasant emergence requiring treatment. All other adverse events were minor. Median recovery time was 14 minutes (range = 3 to 41 minutes; IQR = 11 to 18 minutes). Median staff satisfaction was 10 on a 1-to-10 scale.

CONCLUSIONS

Pediatric PSA using ketofol is highly effective. Recovery times were short; adverse events were few; and patients, caregivers, and staff were highly satisfied.

Dexmedetomidine/ketamine for diagnostic cardiac catheterization in a child with idiopathic pulmonary hypertension

The use of a combination of dexmedetomidine and ketamine to provide procedural sedation in a 12-year old boy with a diagnosis of idopathic pulmonary hypertension and a behavioral disorder, undergoing diagnostic cardiac catheterization, is presented. Following a loading dose of ketamine one mg/kg and dexmedetomidine one mcg/kg, an infusion of dexmedetomidine at one mcg/kg/hr was used with the patient breathing spontaneously. Stable hemodynamics were observed throughout the procedure and pulmonary vascular resistance was measured under three conditions. The dexmedetomidine infusion was continued for two hours post-catheterization, facilitating a smooth emergence.

Adverse events and behavioral reactions related to ketamine based anesthesia for anorectal manometry in children

BACKGROUND

Pediatric patients undergoing anorectal manometry require ketamine anesthesia as other anesthetic agents affect the anorectal sphincter tone. The aim of this prospective observational audit was to evaluate our practice and report the occurrence of adverse events and behavioral reactions related to the use of ketamine, propofol, and midazolam combinations.

METHODS

Eighty-two consecutive pediatric patients (mean age 8.06 +/- 3.43 years) undergoing anorectal manometry were audited over a 1-year period. After a routine ketamine anesthetic some children were administered midazolam 0.1 mg.kg(-1), at the discretion of the attending anesthetist. Children requiring anal stretch following manometry studies also received propofol 3-5 mg.kg(-1). Intra- and postoperative adverse events, times to spontaneous awakening and discharge from the PACU were noted. Postoperative behavioral reactions were noted in the PACU and at follow-up interviews on the first postoperative day and after a period of 1 month.

RESULTS

Following completion of the audit, all patients fell into one of the four groups depending on the anesthetic agents they received: K (ketamine only, n = 16), KM (ketamine and midazolam, n = 10), KP (ketamine and propofol, n = 27), and KPM (ketamine, propofol, and midazolam, n = 29). There was no difference in the occurrence of behavioral reactions between the four groups at the three stages of follow-up. Overall, five patients reported 'new onset' nightmares that had resolved completely at the 3-month follow-up. The time to spontaneous awakening was shorter for K group (17.8 min +/- 20.2) vs KPM group (61.7 min +/- 24.4; P < 0.001). The times to discharge in minutes was also shorter in the K group (54.5 min, IQR 30-75 vs 90 min IQR 78-120; P < 0.001). Administration of propofol appeared to have an antiemetic effect [odds ratio (OR) 0.1, 95% confidence intervals (CI) 0.02-0.58, P < 0.009] in the recovery unit.

CONCLUSIONS

Our study findings suggest that, besides significantly prolonging time to spontaneous awakening and PACU discharge, neither the use of midazolam, propofol, or combinations is beneficial in preventing the occurrence of behavioral reactions following ketamine anesthesia. Behavioral reactions were common but did not appear to be long-term. Drug combinations with ketamine may have other benefits such as antiemesis.

Evaluation of propofol-ketamine anesthesia for children undergoing cardiac catheterization procedures

The aim of this study was to assess the safety and efficacy of the continuous intravenous administration of a combination of propofol and ketamine for children undergoing cardiac catheterization procedures (CCP). Thirty-two children scheduled for CCP in a university teaching hospital were included in this prospective randomized study. Patients in group 1 (n = 15) were given a combination of propofol (25 microg/kg per minute) and ketamine (25 microg/kg per minute), whereas patients in group 2 (n = 17) received a combination of propofol (25 microg/kg per minute) and ketamine (12.5 microg/kg per minute) for the maintenance of anesthesia. There were no statistically significant differences with age, weight, duration of the procedure, and the number of diagnostic and interventional procedures between the two groups. There was no hemodynamic instability, airway compromise, excessive salivation, or arterial desaturation in either of the two groups. There was more incidence of movements in patients who received less dose of ketamine; however, it did not reach to statistically significant level. The total dose of ketamine used in group 1 was 309.25 +/- 90.97 microg/min, whereas in group 2, it was 148.06 +/- 34.05 microg/min. The time to awakening was significantly less in group 2 (P < 0.05). We conclude that a combination of propofol (25 microg/kg per minute) and two different doses of ketamine (25 and 12.5 microg/kg per minute, respectively) are safe and efficacious for CCP in children. Although the time to awaken was more in patients receiving 25 microg/kg per minute of ketamine compared to those receiving 12.5 microg/kg per minute of ketamine, it was well within acceptable limits.

Deep sedation with intravenous infusion of combined propofol and ketamine during dressing changes and whirlpool bath in patients with severe epidermolysis bullosa

Continuous i.v. infusion of propofol, or propofol plus ketamine for deep sedation and analgesia was carried out in two patients with severe epidermolysis bullosa (EB) during extensive dressing changes and deep whirlpool baths. Intermittent small doses of narcotics were given as supplement for pain relief as needed. Both patients had typical features of severe EB, including extremity contractures, severe digit deformity, difficult airways, extensive blisters and broken skin with denuded areas and severe wound infections. SpO(2) was roughly estimated by holding the probe around the earlobe periodically and no other monitors could be applied because of the skin conditions and the settings of the procedures. Retrospective anesthesia record review showed that the combined propofol and ketamine infusions provided satisfactory sedation with significantly reduced narcotic requirements compared with propofol alone. There were no noticeable side effects when ketamine was added. Ketamine appears to be a good addition to propofol and narcotics to provide sedation and analgesia when there are great concerns for respiration depression, apnea, difficult pain management and potential unstable hemodynamics during dressing changes and whirlpool baths in severe EB patients.

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

BACKGROUND

There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens.

METHODS

Patients were prospectively randomized to receive either midazolam/fentanyl (M/F) or midazolam/ketamine (M/K) i.v. The Children's Hospital of Wiscosin Sedation Scale was used to score the sedation level.

RESULTS

Fifty seven patients were studied (28 M/F and 29 M/K). Group M/F received midazolam (0.24 +/- 0.11 mg.kg(-1)) and fentanyl (1.68 +/- 0.83 microg.kg(-1)) and group M/K received midazolam (0.26 +/- 0.09 mg.kg(-1)) and ketamine (1.40 +/- 0.72 mg.kg(-1)). The groups were similar in age, weight, risk classification time and sedation level. Median total sedation times for M/F and M/K were 97 vs 105 min, respectively (P = 0.67). Minor complications occurred in 3.5% (M/F) vs 20.7% (M/K) (P = 0.03). M/F promoted a greater reduction in respiratory rate (P = 0.005).

CONCLUSIONS

In this study of nonventilated children in PICU undergoing central line placement, M/F and M/K provided a clinically comparable total sedation time. However, the M/K sedation regimen was associated with a higher rate of minor complications. A longer period of study is required to assess the efficacy and safety of these sedative agents for PICU procedures in nonintubated children.

Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department

OBJECTIVE

To evaluate the efficacy and safety of low-dose intravenous ketamine in addition to intravenous propofol for procedural sedation and analgesia in the emergency department (ED).

DATA SOURCES

Articles were identified using PubMed (1949-February 2007), MEDLINE (1966-February 2007), EMBASE (1980-February 2007), BioMed Central (to February 2007), the Cochrane Library (to February 2007), International Pharmaceutical Abstracts, and Google Scholar (until February 2007). Reference citations from retrieved publications were also reviewed. Search terms included ketamine, propofol, ketamine-propofol, ketofol, combination, sedation, procedural sedation, conscious sedation, and emergency department.

STUDY SELECTION AND DATA EXTRACTION

All articles on prospective procedural sedation that were published or translated into English and that compared combination ketamine-propofol with an appropriate comparator group were included. Clinically relevant safety endpoints included the frequency of significant hemodynamic and respiratory compromise warranting medical intervention, nausea, vomiting, and emergence reactions. Time until hospital discharge criteria were met and patient satisfaction scores were efficacy endpoints of interest.

DATA SYNTHESIS

Of the 11 trials included in this review, most had small sample sizes and were conducted in non-ED settings. The ketamine-propofol combination demonstrated no additional efficacy over propofol in terms of time to discharge. Although fewer patients given the ketamine-propofol combination experienced significant hemodynamic and respiratory compromise, need for active interventions, including fluid or vasopressor administration, supplemental oxygen, or assisted ventilation did not differ between groups. Patients who received higher doses of adjuvant ketamine reported an increased incidence of nausea, vomiting, and emergence reactions following the procedure. Few studies reported patient satisfaction scores postprocedure, and effect of ketaminepropofol on time-to-discharge criteria met was inconclusive.

CONCLUSIONS

At this time, insufficient clinical evidence exists to recommend the routine use of low-dose ketamine with propofol for procedural sedation in the ED setting.

The Anesthesiologist's Role in Adults with Congenital Heart Disease

Anesthesia for adults with congenital heart disease has many challenging physiologic considerations. Collaborative relationships of a multidisciplinary team including cardiology, cardiac surgery, anesthesiology, and intensive care are essential to ensure positive outcomes in this population for noncardiac and cardiac surgery.

Peripheral blood stem cell collection in pediatric patients: feasibility of leukapheresis under anesthesia in uncompliant small children with solid tumors

Leukapheresis demands patient's compliance and adequate vascular accesses, which can require invasive methods in very small children whose treatment protocol includes hemopoietic stem cell collection for myeloablative chemotherapy and stem cell rescue. Since 1998, at the Istituto Nazionale Tumori of Milan, in selected uncompliant small children, the placement of peripheral vascular accesses and leukapheresis have been performed at the same time under general anesthesia. Peripheral venous cannulas were positioned for blood collection, while blood was returned through either peripheral cannulas or mono-lumen central catheters previously installed for chemotherapy. A continuous-flow cell separator was used for leukapheresis. Between 1998 and 2003, 47 children with solid tumors underwent anesthesia for a total of 54 leukaphereses. The patients' age ranged from 12.7 to 93 months (median 30.3) and their weight ranged from 7 to 20 kg (median 14.1). Neither metabolic nor anesthesiological complications were recorded. In 89% of cases, the CD 34(+) cell target was achieved at a single harvest; the median number of CD 34(+) cells was 10.8 x 10(6)/kg/leukapheresis (range 1-117) and the median collection efficiency was 63.4% (range 25-100.6). Leukapheresis under anesthesia is feasible and safe in very low-weight children whose compliance is lacking due to age and disease.

Propofol metabolism is enhanced after repetitive ketamine administration in rats: the role of cytochrome P-450 2B induction

BACKGROUND

In a series of ex vivo and in vivo studies we investigated the ability of repetitive ketamine administration to alter the metabolism and anaesthetic effect of propofol and the role of ketamine-mediated P-450 2B induction in rats.

METHODS

Male Wistar rats were pretreated with 80 mg kg(-1) ketamine i.p. twice daily for 4 days. Pentoxyresorufin O-dealkylation (PROD), P-450 2B protein and mRNA were determined. Residual propofol concentration was measured after incubating hepatic microsomes with 100 muM propofol. Sleeping times induced by i.p. 80 mg kg(-1) propofol were determined. Orphenadrine, a P-450 2B inhibitor, was added in both ex vivo and in vivo studies. Finally, serial whole blood propofol concentrations were determined after i.v. infusion of 15 mg kg(-1) propofol.

RESULTS

Ketamine pretreatment produced 5.4-, 3.4- and 1.7-fold increases in hepatic PROD activity, P-450 2B protein and mRNA, respectively. Residual propofol concentration was 46% lower after incubation with microsomes from ketamine-pretreated rats than in the control group. The addition of orphenadrine to ketamine-pretreated microsomes produced an increase in residual propofol concentration in a concentration-dependent manner. Ketamine pretreatment reduced propofol sleeping time to 12% of the control, which was reversed by orphenadrine. The whole blood propofol concentration in ketamine-pretreated rats was significantly lower than that of control rats at 1, 2, 4 and 8 min after cessation of propofol infusion.

CONCLUSIONS

Repetitive ketamine administration enhances propofol metabolism and reduces propofol sleeping time in rats. We suggest that P-450 2B induction may produce ketamine-propofol interaction in anaesthetic practice.

Dexmedetomidine-Ketamine and Propofol-Ketamine Combinations for Anesthesia in Spontaneously Breathing Pediatric Patients Undergoing Cardiac Catheterization

OBJECTIVE

The purpose of this study was to compare the effects of dexmedetomidine-ketamine and propofol-ketamine combinations on hemodynamics, sedation level, and the recovery period in pediatric patients undergoing cardiac catheterization.

DESIGN

Prospective, randomized trial.

SETTING

University hospital.

PARTICIPANTS

Children (n = 44) undergoing cardiac catheterization.

INTERVENTIONS

The dexmedetomidine plus ketamine group (group 1, n = 22) received an infusion over 10 minutes of 1 microg/kg of dexmedetomidine and ketamine, 1 mg/kg, as a bolus, for induction. The patients then received an infusion of 0.7 microg/kg/h of dexmedetomidine and 1 mg/kg/h of ketamine for maintenance. The propofol plus ketamine group (group 2, n = 22) received 1 mg/kg of propofol and 1 mg/kg of ketamine for induction. The patients received 100 microg/kg/min of propofol and 1 mg/kg/h of ketamine by infusion for maintenance. Additional doses of ketamine, 1 mg/kg, were administered when a patient showed discomfort in both groups.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic data, respiratory rate, bispectral index, and sedation scores were recorded after induction and every 15 minutes thereafter. The time to reach a Steward recovery score of 6 was recorded. The heart rate in group 1 was significantly lower (average 10-20 beats/min) than group 2 after induction and throughout the procedure. Ketamine consumption in group 1 was significantly more than in group 2 (2.03 mg/kg/h v 1.25 mg/kg/h) for maintenance (p < 0.01). The recovery time was also longer in group 1 than in group 2 (49.54 v 23.16 minutes, respectively; p < 0.01).

CONCLUSIONS

The dexmedetomidine-ketamine combination was not superior to a propofol-ketamine combination because of insufficient sedation and analgesia and a longer recovery time.