Ketamine-Propofol (Ketofol) as a Viable Alternative in a Septic Patient with Mediastinal Mass Requiring General Anesthesia for Endoscopic Retrograde Cholangio-Pancreatography

Surjya Prasad Upadhyay,Nisha Rajmohan,Anvar Sadath,Felix Nelson,Hassy Prakassam

doi:10.15436/2377-1364.16.050

Surjya Prasad Upadhyay, Nisha Rajmohan + Show 3 more

Open Access

https://doi.org/10.15436/2377-1364.16.050

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Abstract

&emp;Airway compromise and cardiovascular collapse can be anticipated in a patient with mediastinal mass due to aneurysm of ascending and arch of aorta during any stage of anesthesia. Presence of septic shock limits the use of anesthetic agents. The adverse effects of ketamine or propofol are dose dependent and tend to oppose each other cardiovascular effects. The combination of ketamine and propofol may potentially balance each other’s haemodynamic adverse effects and therefore, offer a safer alternative for procedural sedation in critically ill. An elderly emaciated lady diagnosed with acute cholecystitis and cholangitis in septic shock had fusiform aneurysm of ascending aorta and arch of aorta with mediastinal compression. She underwent endoscopic retrograde cholangiopancreatogram (ERCP) under total intravenous anesthesia with a combination of propofol and ketamine which preserved spontaneous ventilation. Haemodynamics were maintained with the judicious use of intravenous fluids and vasopressors.

Highlights

Airway management in a case of mediastinal compression with septic shock is a challenging task to the anesthesiologist in view of the difficulty in maintaining airway, spontaneous ventilation and hemodynamics parameters[1,2,3]
Presence of a mediastinal mass with or without evidence of compression of the mediastinal structures or trachea can result in catastrophes at any time during anesthesia[1,2,3,4,5]
We encountered a patient of acute cholecystitis with cholangitis due to biliary obstruction in sepsis for urgent endoscopic retrograde cholangio pancreatography (ERCP) and clearance/stenting of common bile duct (CBD)

Summary

Introduction

Airway management in a case of mediastinal compression with septic shock is a challenging task to the anesthesiologist in view of the difficulty in maintaining airway, spontaneous ventilation and hemodynamics parameters[1,2,3]. We encountered a patient of acute cholecystitis with cholangitis due to biliary obstruction in sepsis for urgent endoscopic retrograde cholangio pancreatography (ERCP) and clearance/stenting of common bile duct (CBD). Patient was found to have mediastinal mass due to fusiform aneurysm of ascending and arch of aorta causing tracheobronchial shifting to the right.

Results

Conclusion