|Year : 2016 | Volume
| Issue : 2 | Page : 245-249
Ketamine-propofol sedation versus propofol-pethidine sedation for minor plastic surgery procedures
Hoda Shokri MD, PhD
Department of Anesthesiology, Ain Shams University, Cairo, Egypt
|Date of Submission||07-Jun-2015|
|Date of Acceptance||03-Apr-2016|
|Date of Web Publication||11-May-2016|
Department of Anesthesiology, Ain Shams University, Cairo, 11772
Source of Support: None, Conflict of Interest: None
The aim of the study was to compare the efficacy of ketamine-propofol (KP) sedation versus propofol-pethidine (PP) sedation for minor plastic surgery procedures.
Patients and methods
This prospective study was conducted by randomization of 60 patients undergoing minor plastic surgery procedures.
Patients were randomly divided into two groups by means of the sealed envelope technique: the KP group (n = 30) and the PP group (n = 30). In the former group, patients received induction with a bolus dose of ketamine 1 mg/kg dissolved in 10 ml saline, and in the latter group patients received induction with a bolus dose of 1 mg/kg pethidine dissolved in 10 ml saline intravenously. In both groups propofol was given as 1 mg/kg propofol, intravenous, bolus dose, additional doses of propofol 30 mg IV were given if sedation score was less than 4 in both groups followed by 5 mg/kg/h intravenous infusion.
Sedation score, pain score, mean arterial blood pressure, total dose of propofol, conversion to general anesthesia, postoperative patient satisfaction score, and incidence of postoperative complications such as hypotension, oxygen desaturation, and vomiting were all recorded.
Intraoperative pain scores, mean arterial blood pressure, and postoperative patient satisfaction scores were significantly higher in the PP group compared with the KP group. The sedation score was significantly higher in the KP group than in the PP group. Total dose of propofol was significantly lower in the KP group than in the PP group. There was no significant difference between the study groups regarding conversion to general anesthesia. Recovery time was significantly longer in the KP group compared with the PP group. There were significant differences in the incidence of complications such as oxygen desaturation and postoperative vomiting among the study groups.
The KP combination provides an attractive combination for procedural sedation compared with PP combination in terms of better sedation, hemodynamic stability, and lower incidence of complications.
Keywords: ketamine, pethidine, plastic surgery, procedural sedation, propofol
|How to cite this article:|
Shokri H. Ketamine-propofol sedation versus propofol-pethidine sedation for minor plastic surgery procedures. Ain-Shams J Anaesthesiol 2016;9:245-9
|How to cite this URL:|
Shokri H. Ketamine-propofol sedation versus propofol-pethidine sedation for minor plastic surgery procedures. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 18];9:245-9. Available from: http://www.asja.eg.net/text.asp?2016/9/2/245/182265
| Introduction|| |
Propofol is a nonopioid, nonbarbiturate, sedative-hypnotic agent with rapid induction and recovery times and antiemetic effect . However, adverse effects include dose-dependent cardiorespiratory depression, injection pain, and lack of analgesic properties [2,3]. Also, it can cause unwanted responses such as coughing, hiccups, and movements .
In contrast, ketamine is an N-methyl-d-aspartate receptor antagonist. It produces dissociative anesthesia. In contrast to other anesthetic agents, ketamine increases arterial blood pressure, heart rate, and cardiac output. It should be avoided in patients with coronary artery disease, uncontrolled hypertension, congestive heart failure, increased intracranial pressure, and arterial aneurysms . It has been proved that ketamine causes little or no cardiorespiratory depression and, unlike propofol, has pain-relieving properties. Ketamine use is limited by emergence hallucinations and elevation of blood pressure and heart rate due to its sympathomimetic effects, as well as increased intracranial pressure [6,7]. The incidence of its psychotomimetic effects can be reduced by coadministration of benzodiazepine, barbiturate, or propofol .
It was observed that a ketamine-propofol (KP) combination reduced consumption of propofol and opioids and ensured better hemodynamic and respiratory stability in patients [8-10].
Effectiveness of the two agents - propofol and ketamine - in combination (ketofol) has been recently demonstrated and may provide a novel induction agent with favorable hemodynamics and reduced side effects attributed to either drug . It is also reported that if ketamine and propofol are mixed in a polypropylene syringe they are physically compatible and chemically stable, and they can be stored at room temperature and under light. Ketofol has successfully been used in brief, painful interventions in emergency departments, for sedation in pediatric cases, for regional anesthesia, and in anesthesia applications in electroconvulsive therapy [12-15].
The aim of this study was to compare the effect of procedural sedation with KP versus propofol-pethidine (PP) in minor plastic surgery procedures.
| Patients and methods|| |
After obtaining the approval of the medical ethical committee of Ain Shams University, this prospective randomized double-blinded trial was conducted on 60 patients between the ages of 30 and 56 years, who were of ASA physical status I and II, undergoing short surgical procedures such as minor plastic surgery procedures at Ain Shams University hospitals from December 2013 till January 2015. Written informed consent was obtained from all patients before enrolling them in the study. Patients undergoing emergency surgery, opiate-dependent patients, pregnant women, patients of ASA status III and IV, those with any known contraindication to the study drugs, with left ventricular dysfunction, cerebrovascular disorders, respiratory or hepatic diseases, and patients who refused the study protocol were excluded.
Patients were randomly divided into two groups by means of the sealed envelope technique. In the KP group (n = 30), patients were induced with a bolus dose of ketamine 1 mg/kg dissolved in 10 ml saline intravenously. In the PP group (n = 30), patients received induction with a bolus dose of 1 mg/kg pethidine dissolved in 10 ml saline intravenously.
In both groups propofol was given as a bolus dose of 1 mg/kg intravenously. Additional doses of propofol 30 mg intravenous were given if sedation score was less than 4 in both groups. Then 5 mg/kg/h intravenous infusion was started by the anesthesia assistant not involved in the study. The anesthesiologist who gave the drugs and assessed the parameters was blinded to the study procedure and to the study drug identity. Propofol was administered in both study groups.
Preanesthetic check was done on the night of surgery in the induction room. The anesthesiologist secured an 18-G cannula and gave midazolam 0.05 mg/kg, intravenous, to all patients before transferring them to the operating room where standard monitoring devices such as ECG, noninvasive blood pressure monitor, and pulse oximetry were set up and supplemental oxygen 3 l/min was administered through nasal prongs. Patients' vital signs such as mean arterial blood pressure and heart rate were recorded at induction and then every 5 min. Sedation scores and pain scores were recorded every 10 min until completion of surgery. Complaint of pain was treated with rescue dose of fentanyl intravenous (50 µg). Acetaminophen 1 g was given routinely to all patients.
Primary outcome measures
Primary outcome measures included patient tolerability to the procedure and their satisfaction, which was ranked as follows: 1: very satisfied; 2: satisfied; 3: neutral; and 4: unsatisfied.
Secondary outcome measures
The secondary outcome measures included the level of sedation and the level of pain. Sedation was assessed every 10 min. Additional doses of propofol were given to maintain sedation in both groups, which was graded as follows: 1: awake; 2: drowsy; 3: arousable to command; 4: brisk response to physical or verbal stimulus; 5: sluggish response to physical or verbal stimulus; 6: deep sleep .
Pain was graded on a four-point scale as 0: none; 1: mild; 2: moderate; and 3: severe .
Total dose of propofol rescue sedation was recorded
Hypotension was considered when the mean arterial blood pressure reduced by more than 20% of the baseline, and it was managed with fluid bolus or vasopressors. Oxygen saturation was monitored continuously throughout the procedure. Episodes of oxygen desaturation, defined as a 10% decrease in SpO 2 compared with the baseline, were recorded. The time taken for the participant to open his eyes upon command was recorded as the recovery time. Rate of switching to general anesthesia after incidence of sedation-related complications such as hypoxemia, hypoventilation, apnea, dysrhythmia, hypotension, and vasovagal episodes was recorded.
The incidence of any episode of postoperative vomiting was recorded, which was controlled with ondansetron 0.1 mg/kg.
Finally patients were considered ready for discharge when they had stable vital signs, were oriented, were able to ambulate unassisted, had no vomiting attacks, and had minimal pain.
Finding a difference of at least 2 out of 5 in the mean satisfaction scores (40% change) between the two groups was regarded as a clinically significant difference. A sample size of 30 patients in each group was needed .
All statistical calculations were performed using statistical package for the social sciences (SPSS) software (version 17.0; SPSS Inc., Chicago, Illinois, USA), with type I error of 5% and type II error of 10% and power of test 80%. Data were presented as mean ± SD or median (range). Quantitative variables were compared using the independent t-test, and qualitative data were compared using the c2 -test. P values less than 0.05 were considered significant.
| Results|| |
Patients' characteristics and surgical factors are presented in [Table 1].
Nonsignificant difference was found between the two study groups regarding demographic data and surgical factors.
Intraoperative pain scores were significantly higher in the PP group compared with the KP group at all time points except for the first 10 min, as shown in [Table 2].
The sedation score was significantly higher in the KP group compared with the PP group at all time points except for the first 10 min, as shown in [Table 3].
Intraoperative mean arterial blood pressure was significantly higher in the KP group compared with the PP group at all time points, as shown in [Table 4].
|Table 4 Comparison of mean arterial blood pressure between the study groups|
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Total dose of propofol was significantly lower in the KP group compared with the PP group, as shown in [Table 5].
|Table 5 Comparison of the total dose of propofol and switch to general anesthesia between the study groups|
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There was no significant difference between the study groups regarding incidence of switching to general anesthesia, as shown in [Table 5].
Regarding postoperative patient satisfaction it was significantly higher in the PP group compared with the KP group, as shown in [Table 6].
Recovery time was significantly longer in the KP group compared with the PP group, as shown in [Table 7] and [Table 8].
|Table 8 Comparison of the incidence of complications between the study groups|
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| Discussion|| |
The KP combination for procedural sedation resulted in significant analgesia, shorter total sedation time, less total dose of propofol, dramatically fewer side effects, and higher satisfaction scores than did the use of PP according to this randomized controlled study.
There are sound theoretical reasons to believe that the two agents had synergistic effects and counteracted the side effects of each other, preserving the sedative efficacy.
The KP combination for performing procedural sedation theoretically may be advantageous as using lower doses of each agent may result in a reduction in the adverse drug effects while maintaining an acceptable condition for colonoscopy . It is noteworthy to mention that a low plasma level of ketamine can inhibit nociceptive central sensitization and has a preemptive analgesic effect  especially in the emergency department and in pediatric patients and has thus become popular. The PP combination for procedural sedation produced significantly higher degree of patient satisfaction but with higher incidence of sedation-related complications rather than the combination of midazolam and fentanyl .
The results of a study by Khajavi et al.  revealed that injecting a bolus dose of KP is not only an acceptable sedative option but may be superior to the other commonly used combination of propofol-fentanyl for sedation of patients during colonoscopy. In addition, the KP combination may be the factor that contributed to the low incidence of psychotomimetic reactions of ketamine that occurs during administration of large doses of ketamine .
In the study by William and Andofatto  ketofol was administered to 114 patients for procedural sedation for orthopedic procedures and none of the patients suffered from vomiting, which is in line with our results.
Andolfatto et al.  showed that ketofol for emergency department procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol. This study did not agree with our findings, except for sedation depth.
Another study by Hasanein and El-Sayed  found that KP combination 1 : 4 provided better sedation quality than fentanyl-propofol combination with fewer side effects and can be safely used for sedating obese patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).
This agreed with the results of our study.
| Conclusion|| |
The combination of ketamine-propofol provides an attractive combination for procedural sedation compared with PP combination in terms of better sedation, hemodynamic stability, and lower incidence of complications.
The author would like to thank all her collegues in Department of Anesthesiology who supported this work.
This work was supported by both, the Department of Anesthesiology and the Department of General Surgery at Ain Shams University.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]