Comparison of Propofol and Ketamine Combination (Ketofol) and Propofol and Fentanyl Combination (Fenofol) on Quality of Sedation and Analgesia in the Lumpectomy: A Randomized Clinical Trial

Effect of esketamine on the ED50 of propofol for successful insertion of ureteroscope in elderly male patients: a randomized controlled trial

BACKGROUND

Propofol is effective and used as a kind of routine anesthetics in procedure sedative anesthesia (PSA) for ureteroscopy. However, respiratory depression and unconscious physical activity always occur during propofol-based PSA, especially in elderly patients. Esketamine has sedative and analgesic effects but without risk of cardiorespiratory depression. The purpose of this study is to investigate whether esketamine can reduce the propofol median effective dose (ED50) for successful ureteroscope insertion in elderly male patients.

MATERIALS AND METHODS

49 elderly male patients undergoing elective rigid ureteroscopy were randomly divided into two groups: SK Group (0.25 mg/kg esketamine+propofol) and SF Group (0.1 µg/kg sufentanil+propofol). Patients in both two groups received propofol with initial bolus dose of 1.5 mg/kg after sufentanil or esketamine was administered intravenously. The effective dose of propofol was assessed by a modified Dixon's up-and-down method and then was adjusted with 0.1 mg/kg according to the previous patient response. Patients' response to ureteroscope insertion was classified as "movement" or "no movement". The primary outcome was the ED50 of propofol for successful ureteroscope insertion with esketamine or sufentanil. The secondary outcomes were the induction time, adverse events such as hemodynamic changes, hypoxemia and body movement were also measured.

RESULT

49 patients were enrolled and completed this study. The ED50 of propofol for successful ureteroscope insertion in SK Group was 1.356 ± 0.11 mg/kg, which was decreased compared with that in SF Group, 1.442 ± 0.08 mg/kg (P = 0.003). The induction time in SK Group was significantly shorter than in SF Group (P = 0.001). In SK Group, more stable hemodynamic variables were observed than in SF Group. The incidence of AEs between the two groups was not significantly different.

CONCLUSION

The ED50 of propofol with esketamine administration for ureteroscope insertion in elderly male patients is 1.356 ± 0.11 mg/kg, significantly decreased in comparsion with sufentanil.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, No: ChiCTR2300077170. Registered on 1 November 2023. Prospective registration. http://www.chictr.org.cn .

Effective dose of propofol combined with a low-dose esketamine for gastroscopy in elderly patients: A dose finding study using dixon’s up-and-down method

Objective: This study aimed to determine the optimal dose of propofol combined with esketamine to inhibit the response to gastroscope insertion in elderly patients.

Methods: This is a prospective, non-controlled, non-randomized, single-center study. Elderly patients aged 65–80 years were enrolled in the study with the American society of anesthesiologists (ASA) physical status I or II undergoing elective gastroscopy. All patients were administered propofol after an intravenous esketamine at the dosage of 0.3 mg/kg 30 s, the subsequent dose of propofol was determined by the response of the previous patient to gastroscope insertion (choking, body movement, etc.) using Dixon’s up-and-down method. The initial dose of propofol administered to the first elderly patient was 3.0 mg/kg, and the standard ratio of propofol dose in adjacent patients was 0.9. At least six crossover points were obtained before the conclusion of the study. By using Probit analysis the median effective dose (ED₅₀), 95% effective dose (ED₉₅), and the corresponding 95% confidence interval (CI) for propofol were determined.

Results: The study continued until we obtained seven crossover points and 32 elderly patients (17 males and 15 females) were collected. The ED₅₀ of propofol combined with esketamine inhibiting response to gastroscope insertion in elderly patients were found to be 1.479 mg/kg (95% CI 1.331–1.592 mg/kg), and ED₉₅ was found to be 1.738 mg/kg (95% CI 1.614–2.487 mg/kg).

Conclusion: According to the present study, propofol combined with 0.3 mg/kg esketamine is safe and effective for elderly patients undergoing gastroscopy. The ED₅₀ and ED₉₅ doses of propofol inhibiting response to gastroscope insertion in elderly patients when combined with 0.3 mg/kg esketamine were 1.479 and 1.738 mg/kg, respectively, without apparent adverse effects.

Procedural Sedation Using Two Different Proportions of Ketamine-Propofol Combination in Short Gynecological Procedures: A Randomized Controlled Trial

Background: Procedural sedation with a combination of propofol and ketamine for short-duration surgeries is a convenient technique of anesthesia as it has a faster recovery avoiding the side effects of general anesthesia. The aim of this study was to compare the sedative and analgesic effects of two different proportions of ketamine and propofol combination in patients undergoing short gynecological procedures.

Methods: A randomized double-blind study was conducted in 140 patients posted for elective gynecological procedures with a duration equal to or less than 30 minutes. After premedication of all participants, sedation was induced with bolus administration (0.1 mL/kg) of the study drugs to achieve desired Ramsay sedation score (RSS) of 6, followed by infusion at 0.3 mL/kg/h (Group A, ketamine:propofol in the ratio of 1:4 and Group B, ketamine:propofol in the ratio of 1:2). The adequacy of sedation, volume of drug to induce the patient, time to achieve desired RSS, time for first bolus dose, the total volume of the drugs, hemodynamic variables, awakening time, and side effects were observed.

Results: The incidence of movement of lower extremities was found to be significantly lower in the higher concentration ketamine group (Group B, P - 0.028). The volume of a drug for induction and the duration to reach RSS of 6 were significantly lower in Group B with P-values of 0.002 and <0.001, respectively. Hemodynamic variables, awakening time, and side effects were not statistically significant between the two groups.

Conclusion: Ketamine-propofol combination in the ratio 1:2 provides better sedation and analgesia with no increased side-effects compared to ketamine-propofol in the ratio 1:4 for short outpatient gynecological procedures.

Perioperative complications of pediatric otorhinolaryngological operations

BACKGROUND

The identification of risk factors for the development of perioperative complications is one of the most important problems of pediatric anesthesiology.

PURPOSE

To identify risk factors for the development of perioperative complications in children undergoing ambulatory surgical interventions on ENT organs.

METHODS

Total of 141 patients were examined at the age from 7 to 17 years. Depending on the presence of complications all patients were divided into three groups: «No complications» (n = 64), «One complication» (n = 55) and «Two or more complications» (n = 22). The study was carried out in the following areas: Preoperative clinical status, intraoperative and postoperative complications. The severity of nasal breathing disorders was determined rhinomanometrically. 31 children underwent somnography. In the study of heart rate variability was evaluated. Intraoperative complications included: Cardiac arrhythmias, arterial hypertension and desaturation less than 90%. Postoperative complications included: Cardiorespiratory complications, pain, delirium, postoperative nausea and vomiting.

RESULTS

The most significant complication in the intraoperative period is desaturation below 90%, in the postoperative period they are pain, nausea and vomiting. Risk factors for the development of complications in the perioperative period are a decrease in the thyromental distance, hyperplasia of the tonsils of the third degree, Malampati score ≥ to 2 points, parents' bad habits, combined neurological and respiratory pathologies in a child, an assessment of the class «allergology» of the ASPOND scale is not less than 180 points and the prevalence of vagal influences.

CONCLUSIONS

The obtained results indicate that the presence of risk factors for perioperative complications during operations on ENT organs in children are associated with the initial autonomic status and the predominance of the parasympathetic nervous system as well as with clinical markers.

Total intravenous anaesthesia with tumescent infiltration anaesthesia without definitive airway for early excision and skin grafting in a major burn - A prospective observational study

Background and Aims:

Patients with major burns posted for early tangential excision and skin grafting pose peculiar challenges for anaesthesiologists. The purpose of the study was to assess safety and efficacy of total intravenous anaesthesia (TIVA) with tumescent infiltration anaesthesia (TIA) for these burn procedures.

Methods:

This observational single-arm study was conducted on 48 cases of a tertiary centre burn unit, requiring early tangential excision and skin grafting between third and fifth days of burn injury. TIVA was administered using a combination of intravenous (iv) infusion of injection dexmedetomidine and iv boluses of fentanyl, ketamine, propofol, midazolam and paracetamol. TIA was administered in burn wounds after aseptic preparation. Spontaneous breathing was maintained with oxygen supplementation. Haemodynamic and respiratory monitoring was done intraoperatively every 15 minutes and for 6 hours postoperatively. Modified Aldrete's score was calculated at 10 minutes after completion of surgery. Statistical analysis was done using statistical package for the social science software (version 16). Descriptive statistics were used for quantitative variables.

Results:

Baseline mean HR was 106.95 ± 11.17 bpm (beats per minute). HR settled at 73.17 ± 6.97 bpm during the intraoperative period. The baseline mean arterial pressure (MAP) of 82.42 ± 10.04 mmHg was maintained at 81 ± 7.32 mmHg during the intraoperative period. In all, 95.8% achieved early recovery with mean modified Aldrete's score of ≥9 at 10 minutes post-surgery. There was no episode of apnoea or desaturation.

Conclusion:

TIVA in combination with TIA minimally interferes with homeostasis and promotes early recovery in patients undergoing early excision and grafting in major burns.

Procedural Sedation Using a Propofol-Ketamine Combination (Ketofol) vs. Propofol Alone in the Loop Electrosurgical Excision Procedure (LEEP): A Randomized Controlled Trial

Background: Although the loop electrosurgical excision procedure (LEEP) is a brief procedure, it can cause severe pain and discomfort to patients in the absence of adequate sedation. An admixture of ketamine with propofol (ketofol), may reduce patient movement due to insufficient sedation while providing hemodynamic and respiratory stability. This study evaluated the ability of two ratios of a propofol–ketamine combination, compared with propofol alone, to reduce patient movement during procedural sedation for LEEPs. Methods: One hundred and twenty women scheduled for a LEEP were randomly assigned to three groups. Anesthesia was induced with 1 mg/kg propofol (group P), 1 mg/kg propofol and 0.33 mg/kg ketamine (group K1), or 1 mg/kg propofol and 0.66 mg/kg ketamine (group K2). The primary outcome was the incidence of adduction motion in the lower extremities during the procedure. The requirements for respiratory interventions, changes in vital signs, sedation score, additional anesthetic usage, and surgeon and patient satisfaction were also evaluated. Results: The incidence of adduction motion was significantly lower in groups K1 and K2 than in group P (overall p-value <0.001) but did not differ significantly in groups K1 and K2. Group K2 needed more jaw thrust maneuvers than group K1. Additional propofol usage was lower and surgeon satisfaction scores higher in groups K1 and K2 than in group P. Conclusion: A propofol–ketamine combination is more effective than propofol alone in reducing procedural interference during LEEPs. However, increasing the dose of ketamine showed no additional benefit.