ketamine and propdfofol in circumsicion

7/24/2019 Ketamine and Propdfofol in Circumsicion

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Rev Bras Anestesiol. 2015;65(5):367---370

REVISTA

BRASILEIRA DE

ANESTESIOLOGIA Official Publicationofthe BrazilianSociety ofAnesthesiologywww.sba.com.br

SCIENTIFIC ARTICLE

Ketamine---propofol sedation in circumcision

Handan Gulec, Saziye Sahin, Esra Ozayar, Semih Degerli, Fatma Bercin, Osman Ozdemir

Kecioren Training Hospital,Ankara, Turkey

Received 23 January 2014; accepted 10 March 2014

Available online 31 March 2014

KEYWORDSKetamine---propofol;Sedation;Circumcision

Abstract

Backgroundandobjective:To compare the therapeutic effects ofketamine alone or ketamine

plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with

midazolam---ketamine---atropin who are prepared circumcision operation.

Methods: 60 American Society ofAnaesthesiologistsphysical status I---II children, aged between

3 and 9 years, undergoing circumcision operations under sedation were recruited according

to a randomize and double-blind institutional review board-approved protocol. Patients were

randomized into two groups via sealed envelope assignment. Both groups were administered

a mixture ofmidazolam 0.05mg/kg+ketamine 3mg/kg +atropine 0.02mg/kg intramuscularly

in the presence of parents in the pre-operative holding area. Patients were induced with

propofol---ketamine in Group I or ketamine alone in Group II.

Results: In the between-group comparisons, age, weight, initial systolic blood pressure, a dif-ference in terms ofthe initialpulse ratewas observed (p> 0.050). Initial diastolic blood pressure

and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic

blood pressure and pulse rate in ketamine group were significantly higher (p< 0.050).

Conclusion: Propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy

than ketamine alone in pediatric circumcision operations. We did not observe significant

complicationsduring sedation in these two groups. Therefore, ketofol appears to be an effective

and safe sedation method for circumcision operation.

2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights

reserved.

PALAVRAS-CHAVECetamina-propofol;Sedaco;Circunciso

Sedaco com cetamina-propofol em circunciso

Resumo

Justificativa e objetivo: Comparar os efeitos teraputicos da cetamina isolada ou combinaco

de cetamina-propofol em analgesia, sedaco, tempo de recuperaco e efeitos colaterais em

criancas pr-medicadas com midazolam-cetamina-atropina programadas para procedimentos

de circunciso.

Corresponding author.E-mail: [email protected] (H. Gulec).

http://dx.doi.org/10.1016/j.bjane.2014.03.0020104-0014/ 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
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368 H. Gulec et al.

Mtodos: Sessenta criancas, estado fsico ASA I-II (de acordo com a classificaco da Sociedade

Americana de Anestesiologistas), com idades entre trs e nove anos, submetidas a procedimen-

tos de circunciso sob sedaco, foram recrutadas de acordo com um protocolo de randomizaco

duplo-cego aprovado pelo Conselho de Reviso Institucional. Os pacientes foram randomizados

e alocados em dois grupos com o uso do mtodo de envelopes lacrados. Ambos os grupos rece-

beram umamistura de midazolam0,05mgkg1 + cetamina3mgkg1 + atropina0,02mgkg1 por

via intramuscular, na presenca dos pais na rea de intervences pr-operatrias. A induco foi

realizada com propofol-cetamina no Grupo I ou cetamina isolada no Grupo II.

Resultados: Nas comparaces entre os grupos foram observadas a idade, o peso, a pressoarterial sistlica inicial e a diferenca em relaco taxa de pulso inicial (p> 0,050). A presso

arterial diastlica inicial e as mensuraces seriadas subsequentes nos minutos 5, 10, 15 e 20 da

presso arterial sistlica, presso arterial diastlica e taxa de pulso do grupo cetamina foram

significativamentemaiores (p


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Ketamine---propofol sedation in circumcision 369

the patient moved, additional boluses ofpropofol---ketaminewas administered in Group I or ketamine was administeredin Group II. Supplemental drug requirements were noted.We also noted the adverse symptoms including desaturation(SpO2< %90), apnea (>15 s), rash, agitation, vomiting, andincreased secretions. All patients received oxygen supple-mentation via nasal cannula or by blow-by with a gas flowrate of 2 L/min throughout the procedure. All operations

were performed by the same surgeon.The Ramsay sedation scale used to determine the

response to sedation and analgesia is graded as 5, deep seda-tion: 1, patient awake: 6, patient asleep with no responseto any stimuli.

When the procedure was complete, the patients weretransferred to the recovery room and their levels of seda-tion, discharge time, and adverse events were assessed at5min intervals. Discharge criteria were as follows: airwaypatent with adequate oxygenation; awake or easily aroused(minimal tactile or vocal stimulation might be necessary);swallowing reflex present, demonstrating ability to swallowclear liquids while protecting the airway; presedation levelofresponsiveness achieved.

Statistical analysis was made using Statistical Packagefor the Social Sciences15.0 (SPSS 15.0, SPSS Inc., Chicago,IL) software. All quantitative data were analyzed withthe Kolmogorov---Smirnov test to show distribution. Datawith normal distribution were expressed as mean standarddeviation and data with non-normal distribution as median(inter quartile range). According to the distribution sta-tus of quantitative data independent sampling t-test orMann---Whitney U-test was used. The Chi-square test wasused to compare categorical data. A confidence interval of95% was defined and a value ofp < 0.05 was accepted asstatistically significant.

Results

In the between-group comparisons, age, weight, initial sys-tolic blood pressure, a difference in terms of the initialpulse rate was observed (p > 0.050). Initial diastolic bloodpressure and subsequent serial measurements of5, 10, 15,20thmin, systolic blood pressure (Fig. 1), diastolic bloodpressure (Fig. 2) and pulse rate (Fig. 3) in ketamine groupwere significantly higher (p < 0.050). Follow-up time in termsof the need for additional analgesic in ketofol group used

132

130

128

126

124

122

120

118

116

114

1120 5 10 15 20 25

113

115115

118

121

124

131

129128

127

Group 1

Group 2

Figure 1 Comparison of systolic blood pressure levels

between groups.

100

90

80

70

60

50

40

30

20

10

00 5 10 15 20 25

68

8184

878982

75 7573 71

Group 1

Group 2

Figure 2 Comparison of diastolic blood pressure levels

between groups.

160

140

111

108106

122 129

109 109

136138

115120

100

80

60

40

20

00 5 10 15 20 25

Group 1

Group 2

Figure 3 Comparison ofheart rates between groups.

significantly fewer analgesics (p < 0.050). Both groups weresimilar in terms ofcomplications (p > 0.050).

Discussion

According to American Society of Anaesthesiologists (ASA)data (2006), high doses of sedation have been reported tolead to respiratory depression and are an important rea-son for unexplained malpractice.12 Anesthesia is a balancebetween the patients state of wakefulness and the needfor anesthetic medication. Ifan insufficient dose is adminis-tered, the patients wakefulness increases while a high dosecauses hemodynamic instability, prolonged time to wakingand other complications.13 In relation to the response tosedation and analgesia, it was decided to use the Ramsayscale in the current study because it is easy to apply.14---16

The ideal sedative agent for regional anesthesia should havea rapid onset of action, produce a level of sedation suf-

ficient for patient comfort, and have a short duration ofaction.10 Generally, the intermittent intravenous applica-tion in sedation does not allow for the adjustment of theplasma concentration level of the medication and extendsthe time to waking.17

A pharmacological disadvantage of propofol is its rel-atively narrow therapeutic range. Unlike opioids andbenzodiazepines, an antagonist is not available to reversethe effects. Despite its high potential to induce respiratorydepression and cardiovascular instability, propofol has beenroutinely administered by anesthesiologist.18

In this prospective, randomized study, we comparedthe safety and efficacy of ketamine/propofol combination


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ketamine and propdfofol in circumsicion

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