Dexmedetomidine-ketamine versus propofol-ketamine for sedation during upper gastrointestinal endoscopy in hepatic patients (a comparative randomized study)

Abstract

ABSTRACT Background Cirrhotic patients are more vulnerable to sedation-related complications than the general population, and there is no consensus on sedation during endoscopic procedures for these patients, whose numbers are increasing globally. Our study compared the efficacy of sedation, hemodynamic, respiratory effects, the incidence of side effects, and patient and endoscopist satisfaction with dexmedetomidine-ketamine versus propofol-ketamine during upper gastrointestinal endoscopy (UGIE) in hepatic patients with Child-Pugh classification A & B. Patients and Methods Seventy adult hepatic patients with Child-Pugh classification class A and B scheduled for UGIE were randomly assigned to one of two groups: The ketamine/dexmedetomidine (KD) group received an IV loading of 1 mg/kg ketamine and 1 µg/kg dexmedetomidine over 10 minutes, followed by 0.1 mg/kg/hr ketamine and 0.1 µg/kg/hr dexmedetomidine maintenance. Ketamine/propofol (KP) group received an IV loading of 1 mg/kg ketamine and 1 mg/kg propofol over 10 minutes, followed by 0.1 mg/kg/hr ketamine and 0.1 mg/kg/hr propofol. Heart rate (HR), respiratory rate (RR), mean arterial pressure (MAP), and peripheral oxygen saturation (SpO2) were measured every 5 minutes (min) until the procedure was completed. The time required to reach the target Ramsay Sedation Score (RSS) (3–4) which is called the induction time, the time required to recover (the recovery time), and the occurrence of side effects were all recorded. The mini-mental state examination (MMSE) at baseline and 2 hours after recovery were measured. Results Demographic data showed no significant differences between the two groups. HR changes in the KD group were significantly lower than in the KP group at T1 (after the loading dose), T2 (after the endoscopy was inserted), and at all time points until the procedure was completed. MAP values were lower in the KD group compared to the KP group, but this difference was not statistically significant. Induction and recovery times were longer in the group (KD) than in group (KP), with (8.00 ± 1.26 min in the group (KD) vs 3.00 ± 1.14 min in the group (KP) for induction and (19.00 ± 1.53 min in the group (KD) vs 9.00 ± 1.41 min in the group (KP) for recovery. The prevalence of oxygen desaturation was higher in the group (KP) than in group (KD) (“9” pts in the group (KP) vs “3” pts in the group(KD)) (KD). However, unwanted movements were statistically more common in group KD than in group KP (6 patients versus two patients, respectively). Baseline MMSE and MMSE at PACU values were comparable within and between the two groups. The levels of satisfaction among patients and endoscopists were comparable in both groups. Conclusion The dexmedetomidine/ketamine combination is as effective as the propofol/ketamine combination in terms of sedation efficacy, with more hemodynamic and respiratory stability, but it has longer induction and recovery times with comparable results in terms of ketamine bolus consumption, MMSE scores after recovery, and patient and endoscopist satisfaction.