Propofol-ketamine and propofol-fentanyl combinations for nonanesthetist-administered sedation

Propofol Sedation in Pediatric Upper Endoscopy: A Study of Pharmacodynamics and the Effects of Gastroenterologists, Anesthesiologists, and Supervised Participants on the Procedure Time and Sedation Time

Background and aims Propofol combined with fentanyl is a commonly used sedative for pediatric upper endoscopies (UEs). The primary aim was to study the association between propofol dose and procedure and sedation time. The secondary aims were to assess the pharmacodynamics of propofol use with fentanyl and evaluate if gastroenterologists' and anesthesiologists' years of experience or the presence of supervised participants (such as students, residents, and fellows) have any influence on the procedure and sedation time. Methods A retrospective study was performed at the Children's Hospital of Michigan on patients under 18 years who underwent UEs with propofol sedation with fentanyl over a two-year period. Results A correlation was found between the propofol amount used expressed per body mass index (BMI)/body surface area (BSA), procedure time, and sedation time (p < 0.0001). Throat pain was the most common post-procedural adverse event (4.48%). The impact of psychoactive drugs on these events was not statistically significant, but attention-deficit/hyperactivity disorder (ADHD) medication use was related to increased post-procedural pain complaints. The use of prescribed psychoactive medications was associated with larger propofol dose usage (p = 0.007) without a significant increase in sedation time. Individual gastroenterologists, their years of experience, and the presence of supervised participants were associated with different procedure times (p <0.0001, <0.0001, 0.01). Fellow participation was associated with a 1.11-minute procedure time increase (p = 0.04). Individual anesthesiologists, their years of experience, and the presence of supervised participants were associated with different sedation times (p <0.0001, <0.0001, 0.01). Conclusion We found a novel correlation between propofol dosing expressed by the BMI/BSA and sedation time. The UE procedure time and sedation time are associated with individual gastroenterologists and anesthesiologists, their years of experience, and the presence of supervised participants.

Safety and tolerability of esketamine in propofol based sedation for endoscopic variceal ligation with or without injection sclerotherapy: Randomized controlled trial

OBJECTIVES

Esketamine is an S (+) enantiomer of ketamine with greater potency and similar psychomimetic effects compared to racemic ketamine. We aimed to explore the safety of esketamine in different doses as an adjuvant to propofol in patients undergoing endoscopic variceal ligation (EVL) with or without injection sclerotherapy.

METHODS

One hundred patients were randomized to receive sedation with propofol 1.5 mg/kg in combination with sufentanil 0.1 μg/kg (group S), esketamine 0.2 mg/kg (group E0.2), esketamine 0.3 mg/kg (group E0.3), or esketamine 0.4 mg/kg (group E0.4) for EVL (n = 25 each). Hemodynamic and respiratory parameters were recorded during the procedure. The primary outcome was the incidence of hypotension; secondary outcomes included the incidence of desaturation, positive and negative syndrome scale (PANSS) after the procedure, pain score after the procedure, and secretion volume.

RESULTS

The incidence of hypotension was significantly lower in groups E0.2 (36%), E0.3 (20%), and E0.4 (24%) than in group S (72%). The incidence of SpO2  ≤94% was significantly lower in group E0.4 (4%) than in group S (32%). No significant intergroup difference was found in the PANSS assessment.

CONCLUSIONS

Combining 0.4 mg/kg esketamine with propofol sedation was optimal to facilitate EVL with stable hemodynamic status and better respiratory function during the procedure, without significant psychomimetic side-effects.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Trial ID: ChiCTR2100047033, http://www.chictr.org.cn/showproj.aspx?proj=127518).

Efficacy and safety of subanesthetic doses of esketamine combined with propofol in painless gastrointestinal endoscopy: a prospective, double-blind, randomized controlled trial

Background

Painless gastrointestinal endoscopy is widely used for the diagnosis and treatment of digestive diseases. At present, propofol is commonly used to perform painless gastrointestinal endoscopy, but the high dose of propofol often leads to a higher incidence of cardiovascular and respiratory complications. Studies have shown that the application of propofol combined with ketamine in painless gastrointestinal endoscopy is beneficial to reduce the dosage of propofol and the incidence of related complications. Esketamine is dextrorotatory structure of ketamine with a twice as great anesthetic effect as normal ketamine but fewer side effects. We hypothesized that esketamine may reduce the consumption of propofol and to investigate the safety of coadministration during gastrointestinal endoscopy.

Methods

A total of 260 patients undergoing painless gastrointestinal endoscopy (gastroscope and colonoscopy) were randomly divided into P group (propofol + saline), PK1 group (propofol + esketamine 0.05 mg/kg), PK2 group (propofol + esketamine 0.1 mg/kg), and PK3 group (propofol + esketamine 0.2 mg/kg). Anesthesia was achieved by 1.5 mg/kg propofol with different doses of esketamine. Propofol consumption per minute was recorded. Hemodynamic index, pulse oxygen saturation, operative time, induction time, awakening status, orientation recovery time, adverse events, and Mini-Mental State Examination (MMSE) were also recorded during gastrointestinal endoscopy.

Results

Propofol consumption per minute was 11.78, 10.56, 10.14, and 9.57 (mg/min) in groups P, PK1, PK2, and PK3, respectively; compared with group P, groups PK2 and PK3 showed a decrease of 13.92% (P = 0.021) and 18.76% (P = 0.000), respectively. In all four groups, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), but not pulse oxygen saturation (SpO₂) significantly decreased (P = 0.000) immediately after administration of induction, but there were no significant differences between the groups. The induction time of groups P, PK1, PK2, and PK3 was 68.52 ± 18.394, 64.83 ± 13.543, 62.23 ± 15.197, and 61.35 ± 14.470 s, respectively (P = 0.041). Adverse events and psychotomimetic effects were observed but without significant differences between the groups.

Conclusions

The combination of 0.2 mg/kg esketamine and propofol was effective and safe in painless gastrointestinal endoscopy as evidenced by less propofol consumption per minute, shorter induction time, and lower incidence of cough and body movement relative to propofol alone. The lack of significant differences in hemodynamic results, anesthesia-related indices, adverse events, and MMSE results showed the safety to apply this combination for painless gastrointestinal endoscopy.

Trial registration This study was registered with China Clinical Trial Registration on 07/11/2020 (registration website: chictr.org.cn; registration numbers: ChiCTR https://clinicaltrials.gov/ct2/show/2000039750).

Sedative and analgesic effects of propofol–ketamine versus propofol–fentanyl for emergency department procedures

Background:

To manage and reduce painful procedures in the emergency wards, procedural sedation as well as analgesia can be used. Propofol combinations are the most common short-acting intravenous sedative drugs in the field of emergency medicine.

Objectives:

This research aimed to compare the effectiveness, safety, and complications of intravenous infusion of ketofol with fentofol in painful emergency procedures.

Methods:

This study was a randomized, double-blind clinical trial. Sampling was simple and used random assignment; 196 participants were randomly assigned to two groups of 98 patients each. In each group, injection was done with fentanyl–propofol or ketamine–propofol. For data gathering, pre-procedure, and procedure, modified Aldrete’s scoring checklist was used. In order to determine the levels of sedation, we used the Ramsay Sedation Scale. Data analysis was performed via SPSS Version 20 using statistical tests such as mean ± standard division, t-test, chi-square test, and analysis of variance.

Results:

Among the participants in this study, shoulder procedure was performed more than other procedures (56.6%). The mean of recovery time was significantly different in the two groups (ketofol: 5.65 ± 0.35 vs fentofol: 9.33 ± 0.78); the recovery time in group B (fentofol) was longer than that in group A (ketofol) (p = 0.001). Drug complications were statistically significant in the two groups, and complications by ketofol were less than those by fentofol (p = 0.001). “Hypotension and bradycardia” were observed with fentofol and “tachycardia” was observed with ketofol. The performance of these two drugs was not the same when subject to various procedures.

Conclusion:

Results of this study revealed that ketofol provided better analgesia and sedation, faster recovery time, lesser complications and adverse events, and reduced bradycardia and hypotension.

Ketofol for Procedural Sedation and Analgesia in the Pediatric Population

ABSTRACT

The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol.

Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis

BACKGROUND

Drugs such as propofol and ketamine are used alone or in combination to provide sedation for medical procedures in children. The purpose of this systematic review was to compare the safety and effectiveness of propofol and ketamine to other drug regimens.

METHODS

We searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Web of Science, and the grey literature (meta-Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar) for randomized controlled studies comparing intravenous propofol and ketamine to any other single or combination drug regimen administered to children undergoing diagnostic or therapeutic procedures. Meta-analyses were performed for primary (hemodynamic and respiratory adverse events) and secondary outcomes using RevMan 5.3. We assessed the risk of bias and the certainty (quality) evidence for all outcomes using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Twenty-nine studies were included for analysis. Based on low-to-moderate quality evidence, we concluded that the use of propofol and ketamine may result in a slight-to-small reduction in the risk of hypotension, bradycardia, and apnea, and a slight increase in the risk of tachycardia, hypertension, and other respiratory adverse events, such as cough or laryngospasm. The ratio of propofol to ketamine and comparator drug regimen subgroups effects were important for desaturation and some secondary outcomes.

CONCLUSIONS

The use of propofol and ketamine had a minimal effect on the incidence of adverse events and other secondary outcomes. Large-scale studies are required to more accurately estimate adverse event rates and the effects of propofol and ketamine on patient-important outcomes.

Safety and Efficacy of Procedural Sedation and Analgesia in Pediatric Oncology Patients

Objective Procedural sedation and analgesia are the standard of care for painful procedures in children that require immobility. The aim is to assess the safety and efficacy of procedural sedation and analgesia in pediatric oncological patients in a large tertiary care hospital. Method An observational study performed to review medical records of children who received procedural sedation and analgesia (PSA) for pediatric oncological procedures from July 2018 to September 2018. Patients undergoing oncology procedures (lumbar puncture, intrathecal chemotherapy, bone marrow aspiration +/- trephine) were included, and non-anesthesiologist (intensive care physician/emergency physician certified in pediatric advanced life support) provided PSA. Patients were assessed according to PSA protocol guidelines by the American Society of Anesthesiology (ASA). Low-dose ketamine (0.5 mg/kg) and propofol (2 mg/kg) were administered. Results A total of 565 children underwent 1216 procedures in whom the median age was 7.4 years, and the majority (65.1%) were males. The most common procedure was the lumbar puncture (n = 956; 78.6%) followed by bone marrow aspirate only (n = 137, 11.3%) and both (n = 123, 10.1%). Eight (0.7%) patients developed transient oxygen desaturation only as an adverse effect of ketamine-propofol drug combination with 50% procedures utilizing propofol 1 mg/kg for sedation. Conclusion According to the results of our study, the majority of the pediatric patients responded and reported no adverse events during the procedure with ketamine and propofol. Therefore, we conclude that ketamine and propofol are safe and effective as both sedative and an analgesic in procedures on pediatric oncology patients.

A comparison of ketamine + midazolam to propofol for procedural sedation for lumbar puncture in pediatric oncology by nonanesthesiologists-a randomized comparative trial

BACKGROUND

Both ketamine-midazolam and propofol are frequently used in pediatric oncology units for procedural sedation. However, there are no prospective, randomized comparative trials (RCT) comparing the two groups when the procedure is performed by nonanesthesiologists.

OBJECTIVE

To compare ketamine + midazolam (group A) and propofol (group B) as sedative agents for intrathecal chemotherapy with regard to efficacy, side effects, time to induction, time to recovery, and smoothness of recovery.

METHODS

A partially-blinded RCT was conducted between August 2015 and March 2017 after gaining institutional ethics committee approval. Children aged 1-12 years requiring intravenous sedation for intrathecal chemotherapy were included. Patients were allocated to two treatment arms using computer-generated randomization tables, after obtaining written consent. The initial doses used were: ketamine 2 mg/kg, midazolam 0.2 mg/kg, and propofol 2.5 mg/kg, as per standard recommendations. The patient, parents, and person analyzing the data were blinded. Time to sedation, dose required, depth of sedation, vital parameters, time and smoothness of recovery, and emergence phenomena were documented.

RESULTS

We enrolled 152 patients (76 each in group A and B). Nine patients had a failure of sedation (all in group B). Mean time to sedation and recovery was shorter in group B (P < 0.001). Transient drop in saturation was more frequent in group B, without statistical significance (P = 0.174). Mean depth of sedation was greater in group A (P < 0.001). Emergence symptoms were more frequently experienced in group A (P < 0.001).

CONCLUSIONS

Ketamine-midazolam combination is safer and more effective. Propofol is faster in onset and recovery, and has smoother emergence with poor efficacy at recommended initial doses.

Induction Dosage of Propofol for Repeated Sedations in Children With Hematological Disorders

Pediatric patients with hematologic malignancies require several procedural sedations by means of propofol infusion. We retrospectively analyzed the medical records of leukemic pediatric patients who had undergone procedural sedations at an Italian tertiary referral center (San Gerardo Hospital, Monza) from January 2011 to November 2013. We retrieved the following: demographics; diagnosis; chemotherapy phase; use of corticosteroids; induction dosage of propofol, fentanyl and/or ketamine; and the type of procedure. We used a multivariate linear mixed model to evaluate the factors affecting induction propofol dose. We analyzed 1459 procedures (59% lumbar punctures, 31% bone marrow aspirations) performed on 96 children (7 [4-10] y old, 24 [16-34] kg, 37% female) admitted for acute lymphoblastic leukemia (80%), lymphoma (11%), and acute myeloid leukemia (7%). The induction propofol dose increased by 0.03 mg/kg per each procedure (P<0.05), from 2.6 (2.0-3.2) to 3.5 (2.6-4.3) mg/kg at the first and the last procedure, respectively. Higher age, weight, and use of ketamine were associated to lower propofol dosage (P<0.01), while combined procedures increased propofol dosage (P<0.01). In a large cohort of leukemic pediatric patients undergoing procedural sedation, the induction dose of propofol was increased over time, regardless of weight, age, use of corticosteroids, diagnosis, and treatment phase.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Supplemental Digital Content is available in the text.

Alfentanil versus ketamine combined with propofol for sedation during upper gastrointestinal system endoscopy in morbidly obese patients

Objectives:

To observe the effects of both propofol/alfentanil and propofol/ketamine on sedation during upper gastrointestinal system endoscopy in morbidly obese patients (UGSEMOP).

Methods:

In a prospective, double-blinded, randomized clinical study, 52 patients scheduled for UGSEMOP were assigned to either group A (n=26; 10 µg/kg intravenous [IV] alfentanil) or group K (n=26; 0.5 mg/kg IV ketamine). Each patient was administered 0.7 mg/kg propofol for induction. If it was needed, the patients were administered an additional dose of IV propofol. This study was performed in Sehitkamil State Hospital, Gaziantep, Turkey, between January 2014-2015. Total propofol consumption, time to achieve Modified Aldrete Scores (MAS) of 5 and 10 following the procedure, physician and patient satisfaction scores, and instances of side effects, such as bradycardia and hypotension were recorded.

Results:

Time to onset of sedation and duration of sedation were both significantly shorter in group A. Patients in group A also required less time to achieve an MAS of 5. Total propofol consumption was significantly lower in group A.

Conclusion:

Both propofol/alfentanil and propofol/ketamine combinations provided appropriate hypnosis and analgesia during UGSEMOP. However, propofol consumption was significantly higher using the propofol/ketamine combination.

Prevention of anesthesia-induced injection pain of propofol in pediatric anesthesia

Objective:

Propofol is a new anesthetic agent in clinical practice, but randomized double-blinded prospective studies on its role in pediatric anesthesia remain limited. We aimed to compare the preventive effects of pre-injected lidocaine or ketamine and its pre-mixture on the anesthesia-induced injection pain of propofol using a randomized double-blinded prospective method, and to compare the outcomes with those of medium-/long-chain propofol (M/LCT).

Methods:

A total of 360 pediatric patients (aged 5-12 years old) who received elective surgery were randomly divided into six groups (n= 60) as follows. S group: control group; L group: lidocaine group; L + P group: lidocaine + propofol group; K group: ketamine group; K + P group: ketamine + propofol group; M group: M/LCT group. After the drug fluid completely entered the cubital vein, the venous access was closed. During propofol injection, the injection pain was scored using the VRS 4-point scale. Meanwhile, the heart rates before and during injection were recorded, the adverse reactions during and after injection were observed, and the incidence rate and degree of pain were evaluated.

Results:

The VRS 4-point scale showed that the incidence rates of injection pain of S group, L group, L + P group, K group, K + P group and M group were 78.3%, 66.67%, 51.66%, 43.33%, 48.33% and 45% respectively. The incidence rates of injection pain of all experimental groups were significantly lower than that of S group (P<0.01). The incidence rates of injection pain of L + P group, K group, K + P group and M group were significantly lower than that of L group (P<0.05). The differences among the other groups were not statistically significant.

Conclusions:

Intravenous pre-injection of lidocaine, ketamine or those mixed with propofol can all significantly reduce the incidence rate of injection pain of propofol.