Propofol-ketamine or propofol-remifentanil for deep sedation and analgesia in pediatric patients undergoing burn dressing changes: a randomized clinical trial

Comparison of propofol-esketamine versus propofol-sufentanil for deep sedation and analgesia in children with autism: A randomized double-blind clinical trial

Propofol sedation, routinely used for endoscopic procedures, is safe and acceptable for children. Adjuvants, such as esketamine or sufentanil, are commonly added to improve the efficacy and safety of propofol sedation. This study aimed to compare the clinical efficacy and safety of propofol-esketamine (PE) versus propofol-sufentanil (PS) for deep sedation and analgesia in children with autism undergoing colonoscopy procedure. One hundred and twenty-four children with autism undergoing colonoscopy procedure were included in the study. Patients were randomly assigned to receive one of the two adjuvants: esketamine (0.3 mg/kg) or sufentanil (0.2 μg/kg), subsequently administered propofol 2.0 mg/kg to induce anesthesia. Additional doses of propofol (0.5-1.0 mg/kg) were administered as needed to ensure patient tolerance for the remaining duration of the procedure. Movement during the procedure, hemodynamic variables, the total dose of propofol, recovery time, and adverse events were recorded. The PE group exhibited a significantly lower incidence of severe movement during the procedure compared with the PS group (14.52% vs. 32.26%, p = 0.020). The PE group showed significantly lower incidence of respiratory depression, hypotension, and severe injection pain of propofol than the PS group during the procedure (all p < 0.05). The mean arterial pressure (MAP) decreased significantly after anesthesia induction in the PS group and remained lower than baseline (all p < 0.05). Compared with the combination of low-dose sufentanil (0.2 μg/mg) with propofol, the low-dose esketamine (0.3 mg/kg) combined with propofol provided more stable hemodynamics, higher quality of sedation, and fewer adverse events in children with autism undergoing colonoscopy procedure.

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials

BACKGROUND

We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

METHODS

We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

RESULTS

We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

CONCLUSION

When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Effect of hydrocolloid dressing combined with low molecular weight heparin and calcium on scar hyperplasia in burn patients with venous thromboembolism

The purpose of this study is to investigate the effect of hydrocolloid dressing combined with low molecular weight heparin calcium on scar hyperplasia in burn patients with venous thromboembolism. A retrospective analysis was made on 98 patients with burns complicated with venous thromboembolism in Renmin Hospital, Hubei University of Medicine from January 2020 to April 2021. According to different treatment methods, they were divided into a control group (48 cases) and a research group (50 cases), who were given low molecular weight heparin calcium combined with routine treatment and hydrocolloid dressing on the basis of the control group. The wound healing time, dressing change times and infection symptom regression time in the study group were significantly lower than those in the control group (P < .05). After the intervention, the degree of wound pain in both groups was reduced, and the degree of wound pain in the study group was significantly lower than that in the control group, with statistical significance (P < .05). Fibrinogen, activated partial thromboplastin (APPT), D-dimer, fibrinolytic degradation products, prothrombin time and activated partial prothrombin time of the two groups were all improved. The degree of scar hyperplasia in both groups was improved, and the degree of scar hyperplasia in the study group was significantly better than that in the control group, and the difference was statistically significant (P>.05). Complications in the study group were lower than those in the control group, and the difference was statistically significant (P < .05). The hydrocolloid dressing combined with low molecular weight heparin calcium can effectively shorten the wound healing time and infection symptom regression time of burn patients with venous thromboembolism, reduce the number of dressing changes, reduce the degree of pain, have no influence on coagulation function, reduce the degree of scar, and reduce the incidence of complications.

Comparative Assessment of Propofol and Ketamine on Hemodynamic Indices and Cerebral Oximetry of Pediatric Patients Undergoing Cardiac Catheterization

Background

Propofol and ketamine are widely used in the induction and maintenance of anesthesia and sedation with different cardiovascular and respiratory effects. In cardiac anesthesia (including pediatric cardiac catheterization), due to the high risk of neurologic complications, cerebral oximetry can effectively monitor cerebral blood oxygen saturation to prevent neurological and respiratory complications.

Objectives

This study aimed to compare the effect of propofol and ketamine on hemodynamic indices and cerebral oxygenation results in children undergoing cardiac catheterization.

Methods

This clinical trial study was performed on 48 patients who were candidates for cardiac catheterization by easy and continuous sampling. Patients were randomly divided into 2 groups: ketamine and propofol. In the ketamine group, ketamine was injected at a dose of 1 - 2 mg/kg, and in the propofol group, propofol was injected at a dose of 0.5 - 1.5 mg/kg. In both groups, incremental doses were repeated as needed. The hemodynamic indices, including blood pressure, heart rate, and peripheral SpO₂, were recorded. Cerebral regional oxygen saturation (RSO₂) was recorded using infrared spectroscopic sensors. Data were analyzed using chi-square, independent t-test, paired t-test, and 1-way analysis of variance (ANOVA).

Results

The results showed that all demographic characteristics of patients and also the mean duration of catheterization were homogeneous between the 2 groups. Hemodynamic indices (such as systolic, diastolic, and mean arterial blood pressure) did not show a significant difference between the 2 groups; however, in the ketamine group compared to the propofol group, the heart rate was significantly higher, and mean RSO₂ was lower (P = 0.023).

Conclusions

Propofol has fewer complications than ketamine and is a good drug for sedating children undergoing cardiac catheterization.

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.

American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps

The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.

Sedation and Analgesia During Pediatric Burn Dressing Change: A Survey of American Burn Association Centers

Sedation practices for pediatric burn patients during dressing changes vary between institutions and providers. To better understand the current trends in pediatric sedation practice, a survey was conducted among the members of the American Burn Association (ABA). Questions asked about nonoperating room sedation and analgesia practices for burn patients (ages 0-17) having dressing changes in the intensive care unit, inpatient unit, and outpatient clinics. ABA members providing sedation for pediatric patients undergoing burn dressing changes are diverse. Physician respondents included surgeons, critical care intensivists, and anesthesiologists. Others included physician assistants, nurse anesthetists, nurse practitioners, and sedation credentialed nurses. Opioids for pain control were prescribed by 100% of respondents, but use of adjuvant nonopioid analgesics was utilized <50% of the time. Benzodiazepines and ketamine were prescribed more than twice as often as other sedatives. Many noted that up to 50% of children did not have adequately controlled anxiety and pain with initial sedation plans, and escalation of care was needed to complete dressing changes. Self-reported adverse events were infrequent. In outpatient settings, benzodiazepines, ketamine, oral opioids, and topical lidocaine were used frequently, as were nonpharmacologic methods of distraction and comfort. Sedation in pediatric burn patients is challenging. Responses highlighted areas for improvement regarding pain control during dressing changes and increasing use of multimodal analgesia. Commonly used medications including opioids, benzodiazepine, and ketamine are well established in the treatment of burn patients, as are nonpharmacologic methods. A collaborative effort among institutions is needed to formulate practice guidelines for sedation during burn dressing changes.

The Pediatric Burn: Current Trends and Future Directions

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.

Comparison of analgesic and anxiolytic effects of nitrous oxide in burn wound treatment: A single-blind prospective randomized controlled trial

AIM

We compared the effects of 50% N2O and N2O titration in burn management to alleviate pain and anxiety associated with burn dressing.

METHODS

In this single-blind prospective randomized controlled trial, 70 stable adult burn patients were randomized to 2 groups during May 2015 to January 2016. The experimental group was titrated with N2O ranging from 30% to the ideal sedation concentration before dressing change until the end. The control group was treated with 50% N2O 2 minutes before dressing change until the end. Pain, anxiety, vital signs, and the highest concentrations of N2O inhaled were recorded at 1 minute before N2O inhalation (T0), dismantling of outer (T1), inner dressings (T2), debridement (T3), drug-smearing (T4), bandaging (T5), and 10 minutes after completion of the procedure (T6).

RESULTS

The pain and anxiety scores in the experimental group performed significantly less than the control group during T2-T6. The systolic blood pressure in T2 and the heart rate at T2 and T3 varied significantly between the 2 groups. The highest N2O concentrations of the experimental group were mainly 60% to 70% at T2 (87.9%), T3 (87.9%), and T4 (81.8%).

CONCLUSION

N2O titration significantly reduced pain and anxiety in burn patients, with minimal side effects.

Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions

Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.

Considerations for pediatric burn sedation and analgesia

Burn patients experience anxiety and pain in the course of their injury, treatment, and recovery. Hence, treatment of anxiety and pain is paramount after burn injury. Children, in particular, pose challenges in anxiety and pain management due to their unique physiologic, psychologic, and anatomic status. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. The purpose of this review is to describe the challenges associated with management of anxiety, pain, and sedation in burned children and to describe the different options for treatment of anxiety and pain in burned children.

A randomized clinical trial comparing hemodynamic responses to ketamine-propofol combination (ketofol) versus etomidate during anesthesia induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery

INTRODUCTION

Anesthesia induction is often accompanied by a period of hemodynamic instability, which could be a significant problem in patients with compromised ventricular function. The aim of this study is to compare the hemodynamic responses to etomidate versus a combination of ketamine and propofol (ketofol) for anesthetic induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft (CABG) surgery.

MATERIAL AND METHODS

In a double-blind randomized clinical study, a total of 84 patients with ischemic left ventricular dysfunction (EF < 40%) were randomly assigned to two groups (A and B). Patients in group A received etomidate 0.2 mg/kg and a placebo (normal saline); group B received a combination of ketamine (1 mg/kg) and propofol (1.5 mg/kg) at the induction of anesthesia. Two minutes after induction, hemodynamic variables, including systolic, diastolic, mean arterial pressure (SAP, DAP, MAP) and heart rate (HR), were measured immediately before and after the laryngoscopy, and before intubation and post-intubation at 1, 2, and 3 min.

RESULTS

The decrease in all hemodynamic parameters (SBP, DBP, MAP and HR) from induction time to laryngoscopy was greater in the ketofol group (group B) than in the etomidate group (group A) (p < 0.05). The ephedrine prescription rate due to hemodynamic changes was 24.4% (10 patients) and 5% (2 patients) in group B and group A, respectively (p = 0.03).

CONCLUSIONS

We found that etomidate provides superior hemodynamic stability as compared to ketofol in patients with left ventricular dysfunction undergoing CABG surgery under general anesthesia.