Effect of Combination of Ketamine and Propofol (Ketofol) on Cerebral Oxygenation in Neurosurgical Patients: A Randomized Double-Blinded Controlled Trial

Comparison of the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) on postoperative analgesia and intraoperative hemodynamics in patients undergoing spine surgery: A prospective randomized double-blind controlled trial

Background

Opioids form the basis of perioperative pain management but are associated with multiple side effects. In opioid-free anesthesia (OFA), several non-opioid drugs or neuraxial/regional blocks are used as substitutes for opioids. Ketamine, a N-methyl-d-aspartate antagonist, provides intense analgesia. However, there is a shortage of literature on the effects of ketamine-based OFA on hemodynamics (HD) and postoperative analgesia in patients undergoing thoracolumbar spine surgery.

Materials and Methods

This prospective randomized controlled trial included 60 adult patients. The patients in Group OFA (n = 30) received OFA with ketamine and ketofol (1:5) infusion, and those in Group OBA (n = 30) received opioid-based anesthesia (OBA) with fentanyl and propofol infusion. The postoperative pain-free period, pain scores, rescue analgesia, intraoperative HDs, and postoperative complications were assessed.

Results

The mean pain-free period in Group OFA (9.86 ± 1.43 hr) was significantly higher than that in Group OBA (6.93 ± 1.93 hr) (P = 0.002). During the postoperative 48 hours, the total requirement of fentanyl was considerably lower in Group OFA (P < 0.05). There was a significantly higher incidence of hypertension in Group OFA (46%) and hypotension (43%) in Group OBA (43%), respectively. Postoperative nausea vomiting (PONV) was more common in Group OBA at the 2nd and 6th hr (P = 0.046 and P = 0.038).

Conclusion

OFA with ketamine and ketofol provided adequate postoperative analgesia with a lower incidence of PONV after spine surgery. However, hypertension in the ketamine group and hypotension in the propofol group required fine titration of the infusion rate of drugs during the intraoperative period.

Ketofol as an Anesthetic Agent in Patients With Isolated Moderate to Severe Traumatic Brain Injury: A Prospective, Randomized Double-blind Controlled Trial

BACKGROUND

The effects of ketofol (propofol and ketamine admixture) on systemic hemodynamics and outcomes in patients undergoing emergency decompressive craniectomy for traumatic brain injury (TBI) are unknown and explored in this study.

METHODS

Fifty patients with moderate/severe TBI were randomized to receive ketofol (n=25) or propofol (n=25) for induction and maintenance of anesthesia during TBI surgery. Intraoperative hemodynamic stability was assessed by continuous measurement of mean arterial pressure (MAP) and need for rescue interventions to maintain MAP within 20% of baseline. Brain relaxation scores, serum biomarker-glial fibrillary acidic protein levels, and extended Glasgow Outcome Scale (GOSE) at 30 and 90 days after discharge were also explored.

RESULTS

MAP was lower and hemodynamic fluctuations more frequent in patients receiving propofol compared with those receiving ketofol (P<0.05). MAP fell >20% below baseline in 22 (88%) patients receiving propofol and in 10 (40%) receiving ketofol (P=0.001), with a greater requirement for vasopressors (80% vs. 24%, respectively; P=0.02). Intraoperative brain relaxation scores and GOSE at 30 and 90 day were similar between groups. Glial fibrillary acidic protein was lower in the ketofol group (3.31±0.43 ng/mL) as compared with the propofol (3.41±0.17 ng/mL; P=0.01) group on the third postoperative day.

CONCLUSION

Compared with propofol, ketofol for induction and maintenance of anesthesia during decompressive surgery in patients with moderate/severe TBI was associated with improved hemodynamic stability, lower vasopressor requirement, and similar brain relaxation.

Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?"

Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.

Efficacy of Ketofol in Blunting Hypotensive Effects of Propofol during Induction and Its Effect on Intraoperative Anesthetic Requirements and Recovery Profile

BACKGROUND

Major disadvantage of propofol is dose-dependent hypotension.

AIM OF THE STUDY

The aim of the study was comparison of changes in heart rate (HR) and mean arterial pressure (MAP) after induction with propofol versus ketofol (a combination of ketamine and propofol).

SETTINGS AND DESIGN

This was a prospective randomized study conducted in a tertiary care institute.

SUBJECTS AND METHODS

Sixty patients were recruited. Group A patients were induced with 1.5-2.5 mg.kg-1 propofol. In Group B, ketamine 1 mg.kg-1 was given intravenously followed by propofol 1-2 mg.kg-1. All patients received standardized intraoperative management.

STATISTICAL TESTS USED

Chi-square test, independent sample t-test, and paired t-test were used for statistical analysis.

RESULTS

Baseline HR and HR immediately after induction were comparable in both groups. There was a significant decrease in mean HR at 3 min postinduction in Group A compared to Group B (65.7 ± 5.4 vs. 80.8 ± 12.4). At 1 min postintubation, there was a significant rise in HR in Group A (103.5 ± 12.4 vs. 84.8 ± 9.5). HR remained comparable in both groups at other timelines. Baseline MAP was comparable between groups. Mean MAP in Group A was significantly lower than Group B immediately after induction and at 3 min postinduction. MAP was significantly higher in Group A at 1 min postintubation and remained comparable at other time points. The incidence of hypotension was significantly higher in Group A compared to Group B.

CONCLUSION

Combining ketamine 1 mg.kg-1 to propofol blunted hypotensive and bradycardic effects of propofol. Ketofol effectively attenuated hemodynamic responses to intubation and was associated with reduced intraoperative opioid consumption with no added risks of excessive postoperative sedation or emergence delirium.