Ketofol (mixture of ketamine and propofol) administration in electroconvulsive therapy

Prognostic Factors and Incidence for Postictal Agitation After Electroconvulsive Therapy: A Systematic Review and Meta-analysis

ABSTRACT

Postictal agitation (PIA) is an adverse effect of electroconvulsive therapy (ECT) and is known to predict other side effects of ECT, but inconsistencies in the literature remain regarding PIA prognostic factors and incidence. Therefore, a systematic review and meta-analysis were conducted (1) to identify prognostic factors for PIA following ECT and (2) to elucidate the diverse incidences of PIA following ECT based on demographic and clinical characteristics. Specifically, electronic databases were searched for retrospective observational studies and randomized controlled trials (RCTs) that objectively reported PIA incidence. Additional inclusion criteria encompassed studies involving patients 18 years or older and allowed for the extraction of PIA prognostic factors. This resulted in the inclusion of 21 articles with 66,047 patients in total. A total of 35 prognostic factors were identified for PIA after ECT, consisting of 8 anesthesia-related, 19 patient-related, and 8 ECT-related prognostic factors. A meta-analysis was conducted for 7 prognostic factors. None of the prognostic factors demonstrated a significant effect on reducing or increasing PIA incidence. Mean PIA was 13.9% (18.0% adjusted) at the patient level and 12.4% (16.5% adjusted) at the session level. Overall risk of bias was generally moderate to low, except in the outcome measurement domain, where 43% of the studies had a high risk of bias. Although none of the prognostic factors in meta-analysis were significant, several other prognostic factors consistently indicated increased or decreased risk, providing direction for future research. A scarcity of (high-quality) data emphasizes the need for additional research on this topic to be conducted.

Ketamine, an Old-New Drug: Uses and Abuses

Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.

Quiescence during burst suppression and postictal generalized EEG suppression are distinct patterns of activity

OBJECTIVE

Periods of low-amplitude electroencephalographic (EEG) signal (quiescence) are present during both anesthetic-induced burst suppression (BS) and postictal generalized electroencephalographic suppression (PGES). PGES following generalized seizures induced by electroconvulsive therapy (ECT) has been previously linked to antidepressant response. The commonality of quiescence during both BS and PGES motivated trials to recapitulate the antidepressant effects of ECT using high doses of anesthetics. However, there have been no direct electrographic comparisons of these quiescent periods to address whether these are distinct entities.

METHODS

We compared periods of EEG quiescence recorded from two human studies: BS induced in 29 healthy adult volunteers by isoflurane general anesthesia and PGES in 11 patients undergoing right unilateral ECT for treatment-resistant depression. An automated algorithm allowed detection of EEG quiescence based on a 10-microvolt amplitude threshold. Spatial, spectral, and temporal analyses compared quiescent epochs during BS and PGES.

RESULTS

The median (interquartile range) voltage for quiescent periods during PGES was greater than during BS (1.81 (0.22) microvolts vs 1.22 (0.33) microvolts, p < 0.001). Relative power was greater for quiescence during PGES than BS for the 1-4 Hz delta band (p < 0.001), at the expense of power in the theta (4-8 Hz, p < 0.001), beta (13-30 Hz, p = 0.04) and gamma (30-70 Hz, p = 0.006) frequency bands. Topographic analyses revealed that amplitude across the scalp was consistently higher for quiescent periods during PGES than BS, whose voltage was within the noise floor.

CONCLUSIONS

Quiescent epochs during PGES and BS have distinct patterns of EEG signals across voltage, frequency, and spatial domains.

SIGNIFICANCE

Quiescent epochs during PGES and BS, important neurophysiological markers for clinical outcomes, are shown to have distinct voltage and frequency characteristics.

The superiority of ketofol and etomidate against propofol or thiopental anesthesia for ECT

OBJECTIVES

Most anesthetic drugs used for electroconvulsive therapy (ECT) have dose-dependent anticonvulsive effects, counter-acting seizure induction, lowering seizure quality. However, a consummate drug for ECT anesthesia has not yet been established. Therefore, in this study, we aimed to investigate the effects of etomidate, thiopental, propofol and co-administration of ketamine-propofol (ketofol) on seizure quality and hemodynamic safety.

METHODS

Registries of 121 patients (1077 sessions) were retrospectively evaluated. The effects of anesthetics on ECT-related parameters (stimulation charge, central seizure duration, number of failed stimulation trials, mean arterial pressure, and peak heart rate) were analyzed via linear mixed-effects models.

RESULTS

Overall, the seizure duration decreased, and the stimulation charge increased in time with continuing sessions within a course of ECT. The decrease in seizure duration and the increase in required stimulation charge was significantly lower with etomidate and ketofol. Additionally, ketofol was significantly related to a lower number of failed stimulation trials compared to propofol. Ketofol and propofol use was associated with a significantly lower postictal mean arterial pressure.

CONCLUSION

Ketofol and etomidate were equivalently superior in the rate of decrease in seizure duration and the required elevation in stimulus charge, which would interpret into valuable clinical guidance, especially for "seizure resistant" patients, and their use may potentially lower ECT related cognitive side effects.

The Cardiovascular Side Effects of Electroconvulsive Therapy and Their Management

ABSTRACT

Electroconvulsive therapy (ECT) remains stigmatized in the broader medical community because of misunderstandings about treatment procedures, mortality rates, and cardiovascular complications. Electroconvulsive therapy causes periprocedural hemodynamic variability because of the surges in parasympathetic and sympathetic nervous systems after the administration of the electrical charge. Patients experience an increase in cardiac workload, which is potentially dangerous for patients with preexisting heart disease. Several findings suggest that cardiac complications occur most frequently in patients with underlying cardiovascular disease. We describe the cardiovascular complications that may result from ECT treatment and offer insight on how to mitigate these concerns if they occur. PubMed was queried using terms "electroconvulsive therapy" and "cardiovascular adverse effects." A table is provided with the common cardiovascular side effects of ECT and the most recent evidence-based treatment strategies to manage them. Generally, ECT is a safe procedure in which complications are minor and manageable. Most major complications caused by ECT are related to the cardiovascular system; however, with an appropriate pre-ECT evaluation and a comprehensive multidisciplinary team approach, the cardiovascular complications can be well managed and minimized. Providing proper cardiac clearance can prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide.

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials

BACKGROUND

The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear.

METHODS

Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction.

RESULTS

Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51).

CONCLUSION

This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Comparison of Ketofol (Combination of Ketamine and Propofol) and Propofol Anesthesia in Aneurysmal Clipping Surgery: A Prospective Randomized Control Trial

Background:

The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms.

Materials and Methods:

Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups.

Results:

The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone (P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference (P > 0.05).

Conclusion:

Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

Effects of Ketamine Anesthesia on Efficacy, Tolerability, Seizure Response, and Neurocognitive Outcomes in Electroconvulsive Therapy: A Comprehensive Meta-analysis of Double-Blind Randomized Controlled Trials

Electroconvulsive therapy (ECT) remains the most effective treatment for major depressive disorder. Ketamine is an anesthetic gaining attention for its rapid antidepressant effect. Numerous randomized controlled trials have investigated the effect of ketamine anesthesia in ECT on various clinical outcomes. Previous systematic reviews have not found benefit for overall depression response, although some have found evidence of benefit early in the ECT course. Clear quantitative conclusions have not been established regarding other outcomes, particularly while only using data from high-quality studies. We aimed to examine all data from double-blind randomized controlled trials comparing ketamine to other anesthetics via meta-analysis, to make recommendations regarding ECT practice and future research. Data were extracted for depressive symptoms, seizure duration and electrical dose, neuropsychological performance, and adverse effects. Effect sizes were calculated using Hedge's g and odds ratios. Eighteen studies (n = 915) were included in the meta-analysis. Ketamine was not found to enhance improvement of depressive symptoms, either early in ECT course or at end of study. Ketamine had a large effect on increasing seizure duration both overall (Hedge's g = 0.71, P = 0.038) and in the subgroup receiving ketamine in combination with another anesthetic (Hedge's g = 0.78, P < 0.01), and on decreasing electrical dose (Hedge's g = 1.98, P = 0.039). There was no significant effect of ketamine on any individual neuropsychological domain. Ketamine was not associated with increased adverse effects, except for hypertension in patients receiving ketamine monotherapy. Significant heterogeneity was present for many outcomes, and sensitivity analyses suggested a relation to methodological variation in most cases. This study supports the finding that ketamine does not enhance ECT's antidepressant effect, including on early improvement, but provides substantial evidence for enhancing seizure duration and reducing electrical dose. No significant benefit was found on neurocognitive outcomes, but analysis was limited by small sample sizes and high heterogeneity. Ketamine is generally safe in ECT, particularly as a coanesthetic. Our findings provide meta-analytic support to the recommendations in ECT clinical guidelines for use of coadjuvant ketamine in ECT where seizures are suboptimal. Further studies targeting neurocognitive outcomes are encouraged.

Adjunctive ketamine and electroconvulsive therapy for major depressive disorder: A meta-analysis of randomized controlled trials

BACKGROUND

Adjunctive ketamine with electroconvulsive therapy (ECT) has been investigated for treating major depressive disorder (MDD), but the findings have been inconsistent.

AIM

This is an updated meta-analysis of the efficacy and safety of ketamine augmentation of ECT in the treatment of MDD.

METHODS

Randomized controlled trials (RCTs) reporting on the efficacy and safety of ketamine and ECT were identified and analyzed.

RESULTS

Seventeen RCTs (n = 1,035) compared ketamine alone or ketamine plus other anesthetic drugs (n = 557) with other anesthetic agents (n = 478) in MDD patients who received ECT. Ketamine+other anesthetic drugs was superior in improving depressive symptoms over other anesthetic medications at early study time point, but not at post-ECT or end of study time points. Ketamine alone was not more efficacious in treating depressive symptoms than other anesthetic drugs at early study, post-ECT and end of study time points. Sensitivity analysis and 19 of the 20 subgroup analyses also confirmed the lack of significance of these findings. Eleven RCTs testing the effects of ketamine on neurocognitive functions with various test batteries found mixed results. Ketamine alone significantly increased blood pressure more than other anesthetic drugs in MDD treated with ECT.

CONCLUSION

Compared to other anesthetic agents, ketamine alone does not appear to improve the efficacy of ECT. However, ketamine+other anesthetic combinations may confer a short-term advantage in improving depressive symptom at the early stages of ECT.

Efficacy of Adding Low-Dose Ketamine to Dexmedetomidine Versus Low-Dose Ketamine and Propofol for Conscious Sedation in Patients Undergoing Awake Fiber-optic Intubation

Background and Aims:

Conscious sedation is the key for successful AFOI. This trial was conducted to compare the effectiveness of dexmedetomidine and low dose of ketamine against propofol and low dose ketamine.

Materials and Methods:

Sixty patients subjected for general anesthesia were invited to participate in the study and randomly allocated into two equal groups: D-K (n = 30) had been received a bolus dose of both ketamine 0.5mg /kg and dexmedetomidine 1ug/kg over 10 min. Then continuous infusion of ketamine 0.5mg /kg and dexmedetomidine 1ug/kg. The second group (P-K group) (n = 30): had been received a bolus dose of both ketamine 0.5mg/kg and propofol 1mg/kg over 10 min. Then continuous infusion of ketamine 0. 5mg/kg and propofol 1mg/kg.

Results:

The intubation time was statistically significant shorter within the D-K group (58.9 ± 6.1) versus P-K group (63.4 ± 5.3) with p-value 0.02. The shorter time needed to achieve the OAA/S score = 2 was in the D-K group (2.25 ± 0.75) versus (2.9 ± 0.79) in P-K group with (P-value 0.004). The intubation scores were insignificant different between both groups except vocal cord opening which was statistical better among D-K group with P-value 0.03. The significant hypotensive recorded data were among P-K group while the decreased heart rate were recorded in D-K group. Eighty percentages of patients had excellent score of satisfaction within the D-K gp against 47% among the patients within P-K gp with P-value 0.01.

Conclusion:

The concomitant administration of low dose of ketamine with dexmedetomidine had better intubation time and sedation scores with higher patient satisfaction scores than the combination of propofol and low dose of ketamine.

Safety of Pediatric Peripheral Blood Stem Cell Harvest in Daycare Setting: An Institutional Experience

Introduction

Children serving as a donor for their siblings will require anesthesia or sedation. In view of shortage of time and space in operating room setting, peripheral blood stem cell (PBSC) harvest is performed as a daycare procedure.

Aim

This study aims to find out whether performing PBSC harvest in hematology blood collection area as a daycare procedure is safe or not.

Settings and Design

This secondary analysis included 164 pediatric PBSC harvest (154 pediatric donors, of which 10 had repeat harvesting done) donors, performed under anesthesia, in the Department of Hematology, between January 2009 and June 2017.

Materials and Methods

Donors were examined, informed consent was obtained, and adequate premedications were ensured. Induction was intravenous for cooperative donors or inhalational sevoflurane followed by intravenous maintenance infusion using either face mask or a laryngeal mask airway (LMA). During the procedure, vitals are monitored with a noninvasive monitor. Normal hemodynamics were ensured before transferring the children to the ward.

Statistical Analysis

Statistical analysis was performed using SPSS 16.0 statistical software. Descriptive statistics and frequencies were used for the data description.

Results

A total of 137 donors (median age of 5 years) were induced with sevoflurane and LMA was used in 84 children and face mask in 53. Twenty-seven children cooperated for intravenous induction. Various combinations of propofol, dexmedetomidine, and ketamine were used with respiratory and hemodynamic stability. The median duration of anesthesia was 250 (165-375) min. The recovery from anesthesia was smooth with a median wake-up time of 20 (5-60) min.

Conclusion

This retrospective analysis demonstrates that nonoperating room anesthesia for pediatric age group for PBSC harvest can be safely and successfully accomplished outside the operation room setting by a consultant anesthesiologist.

Effect of different charges of modified electroconvulsive seizure on the cognitive behavior in stressed rats: Effects of GluR1 phosphorylation and CaMKIIα activity

Electroconvulsive therapy (ECT) is an efficient therapy for major depression and modern ECT requires anesthesia to enhance safety. However, the commonly used anesthetic, propofol, may weaken the treatment efficacy. A recent study confirmed that ketamine rapidly reduced the symptoms of depression in affected patients. A previous study found that electroconvulsive seizure (ECS), the animal model for ECT, under anesthesia of low-dose ketamine combined with propofol could enhance the antidepressant efficacy and improve the cognitive performance. The present study aimed to investigate the responses to different charges (0, 60, 120, 180 or 240 mC) of ECS under compound anesthetics, ketamine combined with propofol, in stressed rats and the underlying mechanisms to aid in optimization of treatment regimens. The results indicated that ECS exhibited an improved antidepressant effects at 120 mC compared with 60 mC, however, no significant differences in antidepressant effects were identified among the 120, 180 and 240 mC groups. Furthermore, rats subjected to ECS at 120 mC exhibited the best cognitive performance. The phosphorylation levels of calcium/calmodulin-dependent protein kinase IIα (CaMKIIα) at Thr286, glutamate receptor 1 (GluR1) at Ser831 and cAMP-response element-binding protein (CREB) at the Ser133 were higher in the 120-mC group compared with all other groups. These results indicated that the ECS at medium intensity (120 mC) with administration of compound anesthetics may exert an improved therapeutic effect on depression compared with other intensities (0, 60, 180 and 240 mC). The results also suggested that the improvement in cognitive function in stressed rats may be attributed to the phosphorylation of CaMKIIα (Thr286), GluR1 (Ser831) and CREB (Ser133).

Anaesthesia for electroconvulsive therapy - new tricks for old drugs: a systematic review

OBJECTIVE

The objective of this review is to investigate existing literature in order to delineate whether the use of anaesthesia and timing of seizure induction in a new and optimised way may improve the efficacy of electroconvulsive therapy (ECT).

METHODS

PubMed/MEDLINE was searched for existing literature, last search on 24 June 2015. Relevant clinical studies on human subjects involving choice of anaesthetic, ventilation and bispectral index (BIS) monitoring in the ECT setting were considered. The references of relevant studies were likewise considered.

RESULTS

Propofol yields the shortest seizures, etomidate and ketamine the longest. Etomidate and ketamine+propofol 1 : 1 seems to yield the seizures with best quality. Seizure quality is improved when induction of ECT is delayed until the effect of the anaesthetic has waned - possibly monitored with BIS values. Manual hyperventilation with 100% O2 may increase the pO2/pCO2-ratio, which may be correlated with better seizure quality.

CONCLUSION

Etomidate or a 1 : 1 ketamine and propofol combination may be the best method to achieve general anaesthesia in the ECT setting. There is a need for large randomised prospective studies comparing the effect of methohexital, thiopental, propofol, ketamine, propofol+ketamine 1 : 1 and etomidate in the ECT treatment of major depressed patients. These studies should investigate safety and side effects, and most importantly have antidepressant efficacy and cognitive side effects as outcome measures instead of seizure quality.

The use of ketamine in ECT anaesthesia: A systematic review and critical commentary on efficacy, cognitive, safety and seizure outcomes

OBJECTIVES

This review will discuss ECT efficacy and cognitive outcomes when using ketamine as an ECT anaesthetic compared to other anaesthetics, taking into account important moderator variables that have often not been considered to date. It will also include information on safety and other ECT outcomes (seizure threshold and quality).

METHODS

A systematic search through MEDLINE, PubMed, PsychINFO, Cochrane Databases and reference lists from retrieved articles was performed. Search terms were: "ketamine" and "Electroconvulsive Therapy", from 1995 to September 2016. Meta-analyses, randomised controlled trials, open-label and retrospective studies published in English of depressed samples receiving ECT with ketamine anaesthesia were included (n = 24).

RESULTS

Studies were heterogeneous in the clinical populations included and ECT treatment and anaesthetic methods. Frequently, studies did not report on ECT factors (i.e., pulse-width, treatment schedule). Findings regarding efficacy were mixed. Tolerance from repeated use may explain why several studies found that ketamine enhanced efficacy early in the ECT course but not at the end. The majority of studies did not comprehensively examine cognition and adverse effects were not systematically studied. Only a minority of the studies reported on seizure threshold and expression.

CONCLUSIONS

The routine use of ketamine anaesthesia for ECT in clinical settings cannot yet be recommended based on published data. Larger randomised controlled trials, taking into account moderator variables, specifically reporting on ECT parameters and systematically assessing outcomes are encouraged.

Significant treatment effect of add-on ketamine anesthesia in electroconvulsive therapy in depressive patients: A meta-analysis

Add-on ketamine anesthesia in electroconvulsive therapy (ECT) has been studied in depressive patients in several clinical trials with inconclusive findings. Two most recent meta-analyses reported insignificant findings with regards to the treatment effect of add-on ketamine anesthesia in ECT in depressive patients. The aim of this study is to update the current evidence and investigate the role of add-on ketamine anesthesia in ECT in depressive patients via a systematic review and meta-analysis. We performed a thorough literature search of the PubMed and ScienceDirect databases, and extracted all relevant clinical variables to compare the antidepressive outcomes between add-on ketamine anesthesia and other anesthetics in ECT. Total 16 articles with 346 patients receiving add-on ketamine anesthesia in ECT and 329 controls were recruited. We found that the antidepressive treatment effect of add-on ketamine anesthesia in ECT in depressive patients was significantly higher than that of other anesthetics (p<0.001). This significance persisted in both short-term (1-2 weeks) and moderate-term (3-4 weeks) treatment courses (all p<0.05). However, the side effect profiles and recovery time profiles were significantly worse in add-on ketamine anesthesia group than in control group. Our meta-analysis highlights the significantly higher antidepressive treatment effect of add-on ketamine in depressive patients receiving ECT compared to other anesthetics. However, clinicians need to take undesirable side effects into consideration when using add-on ketamine anesthesia in ECT in depressive patients.

Which anesthetic agents for ambulatory electro-convulsive therapy?

PURPOSE OF REVIEW

There have been a considerable number of research articles published in the last 10 years outlining possible advances in the provision of electro-convulsive therapy (ECT) anaesthesia. This has resulted in a range of new drugs having been proposed as useful in the ECT setting. In particular, the use of adjuvant drugs that might improve outcomes to treatment has been investigated.

RECENT FINDINGS

There is a high level of interest in ketamine and remifentanil as agents that may alter response in ECT anaesthesia, by reducing cognitive effects, and minimizing the dose of induction agent. The numbers of patients involved in current trials have been small, and it is not possible to give a definitive answer as to the usefulness of these drugs at this stage.

SUMMARY

This review covers the major recent trials involving new and emerging treatments in ECT, and brings the reader up to date with state of knowledge of ECT anaesthesia and pharmacology.

Comparative study of hyoscine doses as antisialagogue for patients receiving ketofol sedation undergoing colonoscopy procedures

Objective:

To compare the effects of different regimens of hyoscine as antisialagogue in patients undergoing ketofol sedation for colonoscopy procedures.

Patients and Methods:

In this prospective double-blind randomized controlled trial 200 American Society of Anesthesiologists I-II aged 20–60-year-old undergoing colonoscopy were randomly assigned into four equal groups, group A received 5 mg hyoscine intravenous, group B received 10 mg, group C received 20 mg intravenous, and control group (D) that was received saline. All patients were sedated using ketofol titrated to achieve Ramsey Sedation Score 4, hemodynamic variables and occurrence of increased secretions were evaluated and recorded.

Results:

Hyoscine in a dose of 10 mg was the optimum dose to achieve least salivation with the least side effect while hyoscine 5 mg was not efficient to achieve dry field or good surgical conditions. However, hyoscine 20 mg achieved dry field and fair surgical conditions in expenses of tachycardia.

Conclusion:

Hyoscine 10 mg was the least effective dose that significantly reduced hypersalivation in patients receiving ketofol sedation for colonoscopy procedures, this dose was as effective as 20 mg in draying secretion but with significantly less tachycardia.

Effect of Etomidate Versus Combination of Propofol-Ketamine and Thiopental-Ketamine on Hemodynamic Response to Laryngoscopy and Intubation: A Randomized Double Blind Clinical Trial

BACKGROUND

Laryngoscopy and intubation frequently used for airway management during general anesthesia, is frequently associated with undesirable hemodynamic disturbances.

OBJECTIVES

The aim of this study was to compare the effects of etomidate, combination of propofol-ketamine and thiopental-ketamine as induction agents on hemodynamic response to laryngoscopy and intubation.

PATIENTS AND METHODS

In a double blind, randomized clinical trial a total of 120 adult patients of both sexes, aged 18 - 45 years, scheduled for elective surgery under general anesthesia were randomly assigned into three equally sized groups. Patients in group A received etomidate (0.3 mg/kg) plus normal saline as placebo. Patients in group B and C received propofol (1.5 mg/kg) plus ketamine (0.5 mg/kg) and thiopental sodium (3 mg/kg) plus ketamine (0.5 mg/kg), respectively for anesthesia induction. Before laryngoscopy and tracheal intubation, immediately after, and also one and three minutes after the procedures, hemodynamic values (SBP, DBP, MAP and HR) were measured.

RESULTS

A repeated measurement ANOVA showed significant changes in mean SBP and DBP between the time points (P < 0.05). In addition, the main effect of MAP and HR were statistically significant during the course of study (P < 0.05). Furthermore, after induction of anesthesia, the three study groups had significantly different SBP, DBP and MAP changes overtime (P < 0.05). However, HR changes over time were not statistically significant (P > 0.05). Combination of propofol-ketamine had superior hemodynamic stability compared to other induction agents.

CONCLUSIONS

Combination of propofol-ketamine may be recommended as an effective and safe induction agent for attenuating hemodynamic responses to laryngoscopy and intubation with better hemodynamic stability. Although, further well-designed randomized clinical trials to confirm the safety and efficacy of this combination, especially in critically ill patients or patients with cardiovascular disease, are warranted.

Antidepressant Effect of Combined Ketamine and Electroconvulsive Therapy on Patients With Major Depressive Disorder: A Randomized Trial

BACKGROUND

One of the shortcomings of the available treatments for major depressive disorder (MDD) is the time delay between starting the treatment and achieving an antidepressant response.

OBJECTIVES

We aimed to determine the effect of Ketamine as a synergistic antidepressant and anesthetic agent on MDD in electroconvulsive therapy (ECT).

PATIENTS AND METHODS

Twenty-two patients with MDD received Ketamine and Propofol as anesthetic agents compared with 20 patients as the control group who received Propofol in a double-blind randomized clinical trial. The Hamilton rating scale for depression was used to determine the changes in symptoms severity during ECT and a 2-week follow-up.

RESULTS

Both groups showed a reduction in depression severity, but there was no significant difference between the groups in the recovery process (P = 0.92). However, the cognitive performance recovery time in the Ketamine group was lower than that in the control group (P = 0.042).

CONCLUSIONS

This study could not show the effect of Ketamine on depression recovery in a 2-week follow-up period. Nevertheless, Ketamine may provide a better cognitive performance in patients under ECT.

Ketamine: Current applications in anesthesia, pain, and critical care

Ketamine was introduced commercially in 1970 with the manufacturer's description as a "rapidly acting, nonbarbiturate general anesthetic" and a suggestion that it would be useful for short procedures. With the help of its old unique pharmacological properties and newly found beneficial clinical properties, ketamine has survived the strong winds of time, and it currently has a wide variety of clinical applications. It's newly found neuroprotective, antiinflammatory and antitumor effects, and the finding of the usefulness of low dose ketamine regimens have helped to widen the clinical application profile of ketamine. The present article attempts to review the current useful applications of ketamine in anesthesia, pain and critical care. It is based on scientific evidence gathered from textbooks, journals, and electronic databases.

An Audit of the Statistical Validity of Conclusions of Clinical Superiority in Anaesthesia Journals

Making a statistically valid conclusion of the superiority of a clinical intervention in a clinical trial requires not only a statistically significant P value, but also adequate a priori power and an observed effect size larger than the clinically important value specified in the sample size calculation. We scrutinised the five most highly cited clinical trials reporting one or more conclusions of clinical superiority published in Anesthesiology, the British Journal of Anaesthesia, Anaesthesia, Anesthesia and Analgesia and Anaesthesia and Intensive Care in 2011 or 2012 to determine how many met all three requisite criteria. In the 25 articles, there were a total of 36 unconditional conclusions of the superiority of a clinical intervention. All were supported by a statistically significant P value. However, only 15 (41.6%) met all three requisite statistical criteria to support clinical superiority. The remainder included secondary outcomes without specific reference to their observational nature, and primary outcomes whose observed effect size was smaller than the clinically important value specified in the sample size calculation. These findings indicate that clinicians should closely scrutinise conclusions of clinical superiority in anaesthesia journals. Many will be ‘hypothesis-generating observations’ without adequate statistical support for a conclusion of clinical superiority in their own right.

Different regimens of intravenous sedatives or hypnotics for electroconvulsive therapy (ECT) in adult patients with depression

BACKGROUND

Depression is a common mental disorder. It affects millions of people worldwide and is considered by the World Health Organization (WHO) to be one of the leading causes of disability. Electroconvulsive therapy (ECT) is a well-established treatment for severe depression. Intravenous anaesthetic medication is used to minimize subjective unpleasantness and adverse side effects of the induced tonic-clonic seizure. The influence of different anaesthetic medications on the successful reduction of depressive symptoms and adverse effects is unclear.

OBJECTIVES

This review evaluated the effects of different regimens of intravenous sedatives and hypnotics on anti-depression efficacy, recovery and seizure duration in depressed adults undergoing ECT.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12); MEDLINE via Ovid SP (from 1966 to 31 December 2012); and EMBASE via Ovid SP (from 1966 to 31 December 2012). We handsearched related journals and applied no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cross-over trials evaluating the effects of different intravenous sedatives and hypnotics for ECT. We excluded studies and trials using placebo or inhalational anaesthetics and studies that used no anaesthetic.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When possible, data were pooled and risk ratios (RRs) and mean differences (MDs), each with 95% confidence intervals (CIs), were computed using the Cochrane Review Manager statistical package (RevMan).

MAIN RESULTS

We included in the review 18 RCTs (599 participants; published between 1994 and 2012). Most of the included trials were at high risk of bias.We analysed the results of studies comparing six different intravenous anaesthetics.Only a few studies comparing propofol with methohexital (four studies) and with thiopental (three studies) could be pooled.No difference was noted in the reduction of depression scores observed in participants treated with propofol compared with methohexital (low-quality evidence). These four studies were not designed to detect differences in depression scores.The duration of electroencephalograph (EEG) and of motor seizures was shorter in the propofol group compared with the methohexital group (low-quality evidence). No difference was seen in EEG seizure duration when propofol was compared with thiopental (low-quality evidence).Time to recovery (following commands) was longer among participants after anaesthesia with thiopental compared with propofol (low-quality evidence).For the remaining comparisons of anaesthetics, only single studies or insufficient data were available. Adverse events were inadequately reported in eligible trials, and none of the included trials reported anaesthesia-related mortality.

AUTHORS' CONCLUSIONS

Most of the included studies were at high risk of bias, and the quality of evidence was generally low. The studies were not designed to detect clinically relevant differences in depression scores. Anaesthetic agents should be chosen on the basis of adverse effect profile, emergence and how these medications affect seizure duration. If it is difficult to elicit an adequately long seizure, methohexital may be superior to propofol (low-quality evidence). If a patient is slow to recover from anaesthesia, propofol may allow a faster time to follow commands than thiopental (low-quality evidence). A factor of clinical concern that was not addressed by any study was adrenal suppression from etomidate. Optimal dosages of intravenous sedatives or hypnotics have not yet been determined.Larger well-designed randomized studies are needed to determine which intravenous anaesthetic medication leads to the greatest improvement in depression scores with minimal adverse effects.

Comparison of Propofol and Ketamine-Propofol Mixture (Ketofol) on Laryngeal Tube-Suction II Conditions and Hemodynamics: A Randomized, Prospective, Double-Blind Trial

OBJECTIVE

The aim of our study is to compare the effect of ketamine-propofol mixture (ketofol) and propofol on the laryngeal tube-Suction II (LTS II) insertion conditions and hemodynamics.

METHODS

Eighty American Society of Anesthesiologists class 1 and 2 patients were divided into 2 random groups to receive either 1 µg/kg remifentanil and propofol 2 mg/kg in Group P (n = 40), or 1 µg/kg remifentanil and ketofol (using a 1:1 single syringe mixture of 5 mg/mL ketamine and 5 mg/mL propofol) in Group K (n = 40) before induction of anesthesia. After induction, LTS II was inserted. Heart rate and noninvasive blood pressure were recorded before induction of anesthesia (t0); immediately following induction (t1); immediately after LTS II insertion (t2); and 3 minutes (t3), 5 minutes (t4), and 10 (t5) minutes after LTS II insertion. Conditions of insertion of LTS II were assessed and scored 1 to 3 using 6 variables as follows: mouth opening, swallowing, coughing, head and body movements, laryngospasm, and ease of LTS II insertion by the same experienced anesthesiologist who did not know the agents. LTS II insertion summed score was prepared depending upon these variables.

RESULTS

In regard to LTS II insertion summed score, Group K was more favorable than Group P (P < 0.05). Apnea duration was longer in Group P (385.0 seconds [range = 195.0-840.0 seconds]) compared with Group K (325.50 seconds [range = 60.0-840.0 seconds]) but this was not statically significant. The heart rate values were significantly lower at all measurement intervals in both groups compared with the baseline values (P < 0.05). There was no difference in heart rate between Group P and Group K. The mean arterial pressure values were significantly lower at all measurement intervals in Group P compared with baseline values (P < 0.05). In Group K, the mean arterial pressure values were significantly lower at all measurement intervals compared with the baseline values, except t2 (P < 0.05). There was a significant difference between Group P and Group K in terms of mean arterial pressure at t3 (P < 0.05).

CONCLUSIONS

We found that ketofol provided better insertion summed score for LTS II than propofol, with minimal hemodynamic changes.

The antimicrobial effects of ketamine combined with propofol: An in vitro study

BACKGROUND AND OBJECTIVES

Ketamine and propofol are the general anesthetics that also have antimicrobial and microbial growth-promoting effects, respectively. Although these agents are frequently applied together during clinical use, there is no data about their total effect on microbial growth when combined. In this study, we investigated some organisms' growth in a ketamine and propofol mixture.

METHOD

We used standard strains including Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans in this study. Time-growth analysis was performed to assess microbial growth rates in 1% propofol. Antimicrobial activity of ketamine, alone and in propofol was studied with microdilution method.

RESULTS

In propofol, studied strains grew from 10(3)-10(4) cfu/mL to ≥10(5) cfu/mL concentrations within 8-16 hours depending on the type of organism. Minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) (for candida, minimal fungicidal concentration) of ketamine were determined as follows (MIC, MBC): E.coli 312.5, 312.5 μg/mL; S.aureus 19.5, 156 μg/mL; P.aeruginosa 312.5, 625 μg/mL; and C.albicans 156, 156 μg/ml. In ketamine+propofol mixture, ketamine exhibited antimicrobial activity to E.coli, P.aeruginosa and C.albicans as MBCs at 1250, 625 and 625 μg/mL, respectively. Growth of S. aureus was not inhibited in this mixture (ketamine concentration=1250 μg/mL).

CONCLUSION

Ketamine has sustained its antimicrobial activity in a dose-dependent manner against some organisms in propofol, which is a strong microbial growth-promoting solution. Combined use of ketamine and propofol in routine clinical application may reduce the risk of infection caused by accidental contamination. However, one must keep in mind that ketamine cannot reduce all pathogenic threats in propofol mixture.

Effects of Ketamine-Propofol Mixture on Intraocular Pressure and Haemodynamics in Elderly Patients: A Randomised Double-Blind Trial

OBJECTIVE

The aim of this study was to compare the effects of a ketamine-propofol mixture (ketofol) and propofol on intraocular pressure (IOP) and haemodynamics in elderly patients during anaesthetic management at each repeated measurement times.

METHODS

Forty elderly ASA I and II patients were divided into two random groups and received either propofol (1.5 mg kg(-1); group P, n=20) or ketofol (1:1 single syringe mixture of 5 mg mL(-1) ketamine and 5 mg mL(-1) propofol; group KP, n=20). A proseal laryngeal mask airway (PLMA) was inserted 60 seconds after induction of anaesthesia. IOP, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) values were recorded at preinduction (t0), immediately following induction (t1), and at 1 (t2), 3 (t3), and 5 (t4) minutes after induction. Haemodynamic complications and the need for ephedrine were also recorded.

RESULTS

Patient characteristics at the beginning of the procedure were similar between the groups. SBP and HR were significantly increased in group KP compared to group P at t1 and t4 (p=0.044). Induction of both anaesthetic agents significantly decreased the IOP values from the t0 (p=0.026). A significant decrease in IOP was found at t1 and t4 in group P compared to group KP (p=0.018). The total dose of ephedrine was statistically different in group P (p=0.034).

CONCLUSION

Ketofol can be an alternative agent to provide haemodynamic stability with a moderate decrease in IOP during anaesthesia induction in elderly patients.