Total Propofol Research Articles

Outcome of four pretreatment regimes on hemodynamics during electroconvulsive therapy: A double-blind randomized controlled crossover trial.

Context:Electroconvulsive therapy (ECT) is associated with tachycardia and hypertension.Aims:The aim of this study was to compare two doses of dexmedetomidine, esmolol, and lignocaine with respect to hemodynamics, seizure duration, emergence agitation (EA), and recovery profile.Methodology:Thirty patients undergoing ECT were assigned to each of the following pretreatment regimes over the course of five ECT sessions in a randomized crossover design: Group D1 (dexmedetomidine 1 μg/kg), Group D0.5 (dexmedetomidine0.5 μg/kg), Group E (esmolol 1 mg/kg), Group L (lignocaine 1 mg/kg), and Group C (saline as placebo) before induction. Heart rate (HR), mean arterial pressure (MAP), seizure duration, EA, and time to discharge were evaluated.Results:Groups D1, D0.5, and esmolol had significantly reduced response of HR, MAP compared to lignocaine and control groups at 1, 3, 5 min after ECT (P < 0.05). Motor seizure duration was comparable in all groups except Group L (P = 0.000). Peak HR was significantly decreased in all groups compared to control. Total propofol requirement was reduced in D1 (P = 0.000) and D0.5 (P = 0.001) when compared to control. Time to spontaneous breathing was comparable in all the groups (P > 0.05). Time to eye opening and time to discharge were comparable in all groups (P > 0.05) except Group D1 (P = 0.001). EA score was least in Group D1 (P = 0.000).Conclusion:Dexmedetomidine 1 μg/kg, 0.5 μg/kg, and esmolol produced significant amelioration of cardiovascular response to ECT without affecting seizure duration, results being best with dexmedetomidine 1 μg/kg. However, the latter has the shortcoming of delayed recovery.

Comparison of hemodynamic response for intubation and propofol pain caused by lidocaine administration with infusion and tourniquet

Propofol is one of the most widely used i.v. anesthetic agent. Nevertheless, pain following i.v. administration of propofol is an important problem in anesthesia induction. A wide range of studies have been performed related to lidocaine effects on propofol injection pain and hemodynamic response to intubation. However, effect of both situations are seldomly studied in the literature. In our study we compare lidocaine effects on propofol injection pain and hemodynamic response to intubation which is given by infusion or under tourniquet as i.v. bolus. 70 patients attended to the study are separated randomly into two groups of 35 patients. Prior to induction, lidocaine has been infused with infusion pump as to be completed in 2 minutes with concentration of 2%, total dosed 1mg/kg in infusion group (Group I, n=35). In this group, after half of the total lidocaine dose is infused (1st minute), anesthesia induction has been started by giving 40 mg propofol of 1% in 10 seconds with infusion pump. In tourniquet group (Group T, n=35) prior to induction 1mg/kg lidocaine has been given as bolus by applying tourniquet with 70 mm/Hg pressure to the arm that is established vascular access and tourniquet has been remained for 60 seconds. After opening the tourniquet, induction has been started by giving 40 mg propofol of 1% in 10 seconds with infusion pump. During induction, patient‟s consciousness was evaluated by questioning his/her name and age after administering 1/4 (VRS0), 1/2 (VRS1), and 3/4 (VRS2) of total propofol dose. Confused patients were eliminated and the sense of pain caused by propofol was evaluated in study patients. The results were recorded according to four-point categorical verbal rating scale (VRS). For groups, the pulse rates and mean arterial pressures before lidocaine administration (T0), after lidocaine (T1), immediately after intubation (T2) and 10th minute after intubation (T3) were recorded. No differences detected among the groups with regards to demographic data and side effects. (p>0.05). No significant differences statically detected when comparing the heart rate (HR), mean arterial pressure (MAP) and pain scores of groups for all times (p>0.05). It is concluded that administering lidocaine by infusion technic may be an alternative method for tourniquet method on suppressing hemodynamic response related to tracheal intubation and on preventing injection pain related to propofol.

Intermittent Bolus versus Continuous Infusion of Propofol for Deep Sedation during ABR/Nuclear Medicine Studies.

Objective A comparison of intermittent bolus (IB) versus continuous infusion of propofol for deep sedation. Material and Methods A retrospective review of patients sedated for Auditory Brainstem Response (ABR)/nuclear medicine studies between September 2008 and February 2015. A ketamine bolus (0.5 mg/kg < 20 kg, 0.25 mg/kg > 20 kg) followed by propofol bolus of 1 mg/kg over 2 minutes. In the IB group, maintenance of deep sedation was with incremental bolus of 10 to 20 mg of propofol. In continuous infusion group (CG), maintenance was with a continuous infusion of 83 mcg/kg/min of propofol. Results Of the 326 cases completed, 181 were in CG group and 145 were in IB group. There were no statistical differences in patient's age, weight, and American Society of Anesthesiologist (ASA) classification. The cardiovascular and respiratory parameters in the two groups were not different statistically. Mean total propofol dose was higher in CG group versus IB group (CG 7.6 mg ± 3.6 mg, IB 6.5 mg ± 3.6 mg; p = 0.008). Procedure time in CG group was longer by 8 minutes compared with IB group (CG 49.8 min ± 25.4 min versus 42.3 min ± 19.2 min; p = .003). CG group has both shorter recovery time (CG 8.1 min ± 4.7 min versus IB 10.0 min ± 8.5 min; p = 0.01) and discharge time. Conclusion Satisfactory sedation and completion of the procedure was accomplished with both sedation protocols.

Bispectral Index Monitoring Reduces the Dosage of Propofol and Adverse Events in Sedation for Endobronchial Ultrasound

Background: Current guidelines recommend monitoring the anesthetic depth of sedation during respiratory endoscopy by using clinical scales despite their subjective nature and the potential change in the level of sedation caused by frequent stimulation. Monitoring by means of the bispectral index (BIS) has shown its utility in reducing the use of drugs and their adverse events in general anesthesia, but evidence in prolonged sedation is insufficient. Objective: Our objective was to evaluate BIS in patients undergoing endobronchial ultrasound (EBUS). Methods: A randomized cohort study of 90 patients with mediastinal lymph node involvement and/or lung or mediastinal lesions for whom EBUS was indicated, comparing the modified observer's assessment of alertness/sedation scale clinical evaluation (n = 45) versus the BIS evaluation (n = 45) of sedation with propofol-remifentanil, was conducted in order to evaluate the clinical parameters, doses used, adverse events, and tolerance of the procedure. Results: We found a shorter waking time and a significantly lower dose of total propofol in the BIS group. Significantly fewer overall adverse events were recorded in the BIS group and included desaturation, hypotension, and bradypnea. Tolerance was better in the BIS group. No significant differences were found in terms of cough, memory of the procedure, or the level of difficulty of EBUS on the part of the pulmonologists. Conclusions: BIS monitoring of sedation in EBUS makes it possible to reduce the dosage of propofol, thereby shortening the waking time and reducing adverse events. This form of monitoring should be taken into consideration in the future for systematic use in prolonged sedation, as in the case of EBUS.

Magnetic endoscope imaging for routine colonoscopy: impact on propofol dosage and patient safety - a randomized trial.

The use of magnetic endoscope imaging (MEI) has been previously shown to facilitate colonoscopy procedures. We aimed to evaluate the benefits of MEI in terms of reduction in propofol dosage in patients undergoing routine colonoscopy. We conducted a randomized prospective trial in a university hospital in Germany. Endoscopists were randomly assigned 1:1 to use MEI during colonoscopy (MEI arm) or to conduct colonoscopy without the use of MEI (standard arm). The desired level of sedation was conscious sedation as assessed using the Observer's Assessment of Alertness and Sedation scores. After complete recovery, patient satisfaction was assessed using a numeric rating scale (NRS) ranging from 1 to 10 points. The primary outcome was total propofol dosage. Secondary outcome measures were patient satisfaction, patients' cooperation, and complication rates, as well as cecal intubation time and adenoma detection. Among 334 randomized patients, no severe adverse events were observed. Median propofol dosage was significantly lower in the MEI arm compared with the standard arm (150 mg vs. 180 mg; P = 0.04). Deep sedation was observed in 7.8 % of patients in the MEI group and 3.6 % in the standard arm (P = 0.10). Patient satisfaction scores were higher in the MEI arm compared with standard procedures (9.0 vs. 8.5; P = 0.04). No significant differences in patients' cooperation, cecal intubation time, and adenoma detection were observed between the study arms. The use of MEI may be useful in reducing propofol dosage for colonoscopy and improving patient satisfaction.ClinicalTrials.gov identifier: NCT02121704.

Alveolar ventilation in children during flexible bronchoscopy.

Hypoxia and hypercarbia complicate flexible bronchoscopy (FB). Unlike oxygenation by pulse-oximetry, alveolar ventilation is not routinely monitored during FB. The aim of this study was to investigate ventilation in children undergoing FB by measuring carbon-dioxide (CO2 ) levels using the transcutaneous technique. Children admitted for FB were recruited. In addition to routine monitoring, transcutaneous CO2 (TcCO2 ) levels were recorded. All were sedated using the same protocol. Ninety-five children were studied. There was no association between peak TcCO2 or rise in TcCO2 and age, weight percentile, bronchoscope size, or diagnosis. Median baseline TcCO2 was 36 mmHg (IQR 32,40), median peak TcCO2 was 51 mmHg (IQR 43,62) with median TcCO2 rise of 17 mmHg (IQR 6.5,23.7). A rise of 15 mmHg or higher was recorded in 55% (n = 52) patients. Children requiring total propofol dose over 3.5 mg/kg had a significantly higher TcCO2 peak of 57.6 mmHg (IQR 47.8,66.7) compared to 47.1 mmHg (IQR 40,57) (P = 0.004) and a higher rise in TcCO2 22.5 mmHg (IQR 17,33.9) compared to 13.6 mmHg (6,22) (P = 0.001). Results were not affected by intranasal midazolam and broncho-alveolar lavage. No complications were reported. Non clinically significant (i.e., not lower than 90%) brief drops in oxygen saturation were observed. A large proportion of children undergoing FB have significant alveolar hypoventilation indicated by a rise in TcCO2 . Monitoring ventilation with TcCO2 is feasible and should be added during FB particularly in cases that are expected to require large amounts of sedation and patients susceptible to complications from respiratory acidosis. Pediatr Pulmonol. 2016;51:1177-1182. © 2016 Wiley Periodicals, Inc.

Epidural ropivacaine with dexmedetomidine reduces propofol requirement based on bispectral index in patients undergoing lower extremity and abdominal surgeries.

Background and Aim:To assess the amount of propofol required for induction based on bispectral index (BIS) after administering epidural anesthesia with ropivacaine alone and ropivacaine with dexmedetomidine in patients undergoing lower extremities and abdominal surgeries.Subjects and Methods:A double-blinded randomized clinical trial was carried out in 60 patients over a period of 2 years in a tertiary care hospital. American Society of Anaesthesiologists I or II in age group 18–65 years were included in the study. Group R received epidural anesthesia with ropivacaine alone, and Group D received ropivacaine and dexmedetomidine. General anesthesia was induced with propofol under BIS monitoring after 15 min. Onset of sensory and motor block, time for loss of consciousness and total amount of propofol used during induction to achieve the BIS value < 55 were recorded. Student's t-test and Chi-square test were used to find the significance of study parameters.Results:Time of onset of sensory block (Group R 11.30 ± 1.64/Group D 8.27 ± 0.83 min), motor block (Group R 14.16 ± 1.33/Group D 12.63 ± 1.22 min), time for loss of consciousness (Group R 90.57 ± 11.05/Group D 73.67 ± 16.34 s), and total amount of propofol (Group R 129.83 ± 22.38/Group D 92.13 ± 12.93 s) were reduced in Group D which was statistically significant with P < 0.001.Conclusion:Epidural ropivacaine with dexmedetomidine significantly reduces the total propofol dose required for induction of anesthesia. Also, it decreases the onset time of sensory and motor block and provides good hemodynamic stability.

DOSE-FINDING STUDY AND PHARMACODYNAMIC ASSESSMENT OF PROPOFOL FOR (SEMI-)ELECTIVE INTUBATION IN NEONATES

IntroductionThe optimal propofol dose and its safety for procedural sedation in neonates is controversial. The aim of this study was to perform a prospective propofol dose-finding study with pharmacodynamic (PD) assessment during (semi-)elective intubation in neonates.MethodsPatients were stratified in 4 groups by postmenstrual and postnatal age. The first patient in each group received 1 mg/kg intravenous propofol bolus. Dosing for the next patient was determined using the up-and-down method. Propofol ED50 doses [effective dose for successful intubation (as well as extubation in INSURE -intubation, surfactant, extubation-cases) in 50% of patients] were calculated, with simultaneous assessment of clinical scores, continuous vital sign monitoring and propofol blood concentrations (3 and 12h after dosing).ResultsThirty-five neonates (weight 540–3290 g) were included. Using initial and total propofol dose ranges of 0.5–2 and 0.5–4.5 mg/kg respectively, median propofol ED50 range for preterm neonates &lt;10 days was 0.480–1.287 mg/kg. Clinical recovery was not attained at the end of the scoring period (21 minutes). A median decrease in mean arterial blood pressure (MABP) between −29.41% and −39.09% from baseline, and a short-lasting decrease in peripheral (SaO2) and regional cerebral (rScO2) oxygen saturation was documented. Variability in MABP, SaO2 and rScO2 was not explained by weight, age or propofol concentrations.ConclusionsLow propofol doses sufficiently sedate neonates for intubation, but clinical recovery takes time and is accompanied by permissive hypotension. Propofol ED50 doses are provided and need integration in a prospective validation approach. Finally, feasibility of continuous monitoring for neonatal pharmacodynamic research was demonstrated.

EFEITOS HEMODINÂMICOS DA INFUSÃO CONTÍNUA DE BUTORFANOL EM CÃES ANESTESIADOS COM PROPOFOL

Resumo Objetivou-se avaliar os efeitos hemodinâmicos decorrentes da anestesia total intravenosa com propofol e butorfanol em cães. Para tal, foram utilizados 20 animais adultos hígidos, sem raça definida, distribuídos em dois grupos, designados como GB e GP, induzidos à anestesia com propofol (10 mg/kg). Após a intubação orotraqueal, instituiu-se ventilação controlada com oxigênio a 60% e fluxo de 30 mL/kg/min em circuito fechado, com volume controlado. A manutenção anestésica foi realizada com a administração de 0,6 mg/kg/min de propofol. O grupo butorfanol (GB) recebeu butorfanol 0,1 mg/kg IV, seguido de infusão contínua (40 μg/kg/h). O grupo placebo (GP) recebeu somente NaCl 0,9% em bolus, seguido de infusão venosa, em volume idêntico ao do GB. As variáveis hemodinâmicas foram avaliadas antes da aplicação do opioide ou da solução de NaCl a 0,9% (M0) e imediatamente após, em intervalos de 15 minutos (M15 a M75). A administração de butorfanol resultou em redução da resistência periférica total (RPT), das pressões arteriais (PAS, PAD e PAM) e do débito cardíaco (DC), sem relevância clínica. Os resultados permitem concluir que a associação proporciona anestesia segura para pacientes com suporte ventilatório.

The Effects of Intrathecal Fentanyl on Sedation Depth and Postoperative Recovery Room Delirium

Background/Aim. Intrathecal anaesthesia has been shown to increase sedation level. This study aimed to evaluate the effects of intrathecal applied fentanyl with levobupivacaine on intraoperative sedation and recovery room delirium. Materials and Methods. The study included 68 patients, ASA I–III, 55–85 years. One day preoperatively, the Confusion Assessment Method (CAM) and the Mini Mental Status Test (MMST) were applied and patients were separated into two groups. In Group L 2.5 mL levobupivacaine and in Group LF 2 mL levobupivacaine and 0.5 mL fentanyl were applied intrathecally. In a supine position, following a propofol IV 1 mg kg−1 bolus to obtain Bispectral Index (BIS) of 70–85, propofol infusion was started (1 mg kg−1 st−1). With observation of SpO2, BIS, and the Observer Assessment and Alertness/Sedation Scale (OAA/SS) with the haemodynamic values, the total propofol amount was calculated. Evaluations were made of pain severity (VAS), analgesic use, transfusion requirement, and recovery room delirium. Results. In the comparison within the groups, a significant decrease was determined in HR and MAP compared to the initial values (p&lt;0.05). A positive correlation was found between the BIS and OAA/SS values. The amounts of propofol used were similar between the groups. Conclusions. Intrathecal fentanyl and levobupivacaine had the same effect on sedation or BIS and fentanyl did not cause delirium.

Propofol Combined With Benzodiazepines Is Not Superior to Propofol Alone in Sedation Protocols for Therapeutic Endoscopy: A Meta-analysis

Introduction: Therapeutic endoscopic procedures using Propofol (P) is associated with increased incidence of transient adverse events. The addition of benzodiazepines (B) as a part of the sedation protocol in this setting may reduce the incidence of adverse events by reducing the total dosage of Propofol while at the same time increasing the efficacy of sedation. We carried out systematic analysis of randomized controlled trials examining the effects of Propofol alone versus that with benzodiazepine combinations. Methods: Systematic search of databases in the English literature till March 2015 identified six randomized controlled trials (RCTs) examining the combination of Propofol with benzodiazepines versus Propofol alone in therapeutic endoscopic procedures. Statistical analysis was performed using Comprehensive Meta-Analysis software v3.3.070. Fixed or random-effects method based on heterogeneity (X2- test and I2 statistics) was used. Results are reported as odd's ratio or mean difference with 95% CI. Potential publication bias was examined by funnel plot. Outcome measures: Total Propofol dosage, procedure duration, sedation related adverse events (SRAEs), recovery time and patient satisfaction. Results: Six original RCTs with a total of 1085 patients [548 P arm; 537 (P+B) arm] were included in the meta-analysis. Pooled mean difference in procedure duration between P arm and P+M arm was -0.049 [95% CI: -0.219 to 0.121, p=0.573], showing no significant difference between the groups. No difference noted in the pooled mean difference of Propofol dosage [0.171, 95% CI -0.216 to 0.558, p=0.387] between the groups. Increased recovery time noted in the P+B arm with pooled mean difference of 0.961 [95% CI: 0.297 to 1.626,p = 0.005]. No significant difference in the SRAEs (hypoxia and hypotension) and patient satisfaction scores (three studies) were seen between the groups. Conclusion: The addition of benzodiazepines to Propofol in the sedation protocol for therapeutic endoscopy did not reduce the total dose of Propofol or the incidence of SRAEs. Recovery time was increased when benzodiazepines were used as an adjunct to Propofol.Figure 1Figure 2Figure 3

Predictive Factors of Atelectasis Following Endoscopic Resection.

Atelectasis is one of the pulmonary complications associated with anesthesia. Little is known about atelectasis following endoscopic procedures under deep sedation. This study evaluated the frequency, risk factors, and clinical course of atelectasis after endoscopic resection. A total of 349 patients who underwent endoscopic resection of the upper gastrointestinal tract at a single academic tertiary referral center from March 2010 to October 2013 were enrolled. Baseline characteristics and clinical data were retrospectively reviewed from medical records. To identify atelectasis, we compared the chest radiography taken before and after the endoscopic procedure. Among the 349 patients, 68 (19.5 %) had newly developed atelectasis following endoscopic resection. In univariate logistic regression analysis, atelectasis correlated significantly with high body mass index, smoking, diabetes mellitus, procedure duration, size of lesion, and total amount of propofol. In multiple logistic regression analysis, body mass index, procedure duration, and total propofol amount were risk factors for atelectasis following endoscopic procedures. Of the 68 patients with atelectasis, nine patients developed fever, and six patients displayed pneumonic infiltration. The others had no symptoms related to atelectasis. The incidence of radiographic atelectasis following endoscopic resection was nearly 20 %. Obesity, procedural time, and amount of propofol were the significant risk factors for atelectasis following endoscopic procedure. Most cases of the atelectasis resolved spontaneously with no sequelae.

Impact of the Cytochrome P450 2B6 (CYP2B6) Gene Polymorphism c.516G>T (rs3745274) on Propofol Dose Variability.

Propofol is the most commonly used hypnotic worldwide, but its effective dose varies greatly between individuals. The present study sought to investigate the relationship between the c.516G>T polymorphism in the CYP2B6 (cytochrome P450 2B6) gene and the required propofol dose. One hundred and eight patients treated with propofol were recruited, and environmental, clinical and surgical data were collected. Genotyping for the c.516G>T polymorphism was performed by real-time PCR. Multiple linear regression analysis was performed to estimate the predictive variables of the total propofol dose. For patients under general anaesthesia, the predictive variables of the total propofol dose were surgery duration (partial R (2)=19.9%), age (partial R (2)=10.5%), weight (partial R (2)=10.1%) and presence of the T allele (partial R (2)=6.8%). From the estimated coefficient of regression values, the surgery duration and weight were the factors that increased the propofol dose, while age and presence of the T allele decreased the total dose of the drug needed. The total propofol doses based on the GG or GT/TT genotypes were 151.5±64.2mg and 129.3±44.6mg, respectively (p=0.043). Our results indicate that 34% of the variance in the required propofol dose may be explained by these factors and that CYP2B6 c.516G>T polymorphism, which decreases the metabolism of the drug, accounts for approximately 7% of the drug dosage. Our results show the possible influence of CYP2B6 c.516G>T genetic variant on propofol dose in patients under general anaesthesia.

Confounding factors to predict the awakening effect-site concentration of propofol in target-controlled infusion based on propofol and fentanyl anesthesia.

We conducted a large retrospective study to investigate the confounding factors that predict Ce ROC under propofol-based TIVA with TCI. We recorded sex, age, height, weight, Ce LOC, Ce ROC, total propofol and fentanyl consumption dose, and anesthetic time. Simple linear regression models were used to identify potential predictors of Ce ROC, and multiple linear regression models were used to identify the confounding predictors of Ce ROC. We found that Ce ROC correlated with age, sex, Ce LOC, and both total fentanyl and propofol consumption dose. The prediction formula was: Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC + 0.04 (if fentanyl consumption > 150 μg; if not, ignore this value) + 0.07 × (1 or 2, according to the total propofol consumption dose, 1 for a propofol amount 1000-2000 mg and 2 for a propofol amount > 2000 mg). We simplified the formula further as Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC. In conclusion, Ce ROC can be predicted under TCI with propofol- and fentanyl-based TIVA. The confounding factors that predicted propofol Ce ROC are age, sex, Ce LOC, and total consumption dose of propofol and fentanyl.

Propofol dexmedetomidine versus propofol ketamine for anesthesia of endoscopic retrograde cholangiopancreatography (ERCP) (A randomized comparative study)

ObjectivesThe aim of this study was to compare the effects of propofol/dexmedetomidine and propofol/ketamine combinations for anesthesia in patients undergoing ERCP regarding hemodynamic changes, propofol requirements and the recovery criteria.Patient and methodsSixty patients aged 20–50 years ASA II or III scheduled for ERCP were enrolled in this study. Patients were randomly allocated into two equal groups: dexmedetomidine/propofol (DP) group and ketamine/propofol (KP) group. DP patients received a loading dose of iv dexmedetomidine 1 μg/kg over 15 min then maintained by a 0.5 μg/kg/h. Group KP patients received a loading dose of iv ketamine 1 mg/kg over15 min then maintained by 0.5 mg/kg/h. Induction of anesthesia was achieved with propofol 2 mg/kg, atracurium 0.5 mg/kg to facilitate endotracheal intubation. Anesthesia was maintained by propofol infusion 5 mg/kg/h, intermittent iv propofol boluses (0.5 mg/kg) were administered if needed. MAP and HR were recorded before loading of study drugs (baseline) and recorded every 5 min after beginning of loading throughout the procedure and just after intubation, then every 15 min for one hour post-operative. Total propofol consumption, recovery time, VAS and postoperative complications (PONV, cognitive dysfunction, and respiratory complications) were recorded.ResultsThe intra-procedural HR and MAP showed high statistical significant differences between both groups throughout the procedure with lower values in DP group (p < 0.01 or <0.001). During the post-procedural period, the HR and MAP were significantly lower in DP group. Propofol consumption was comparable in both groups (268.0 ± 122.3 mg) in DP group versus (304.7 ± 142.0 mg) in KP group. Postprocedural recovery time was significantly shorter in DP group (5.7 ± 1.7 min) compared with (22.2 ± 8.2 min) KP group (p < 0.01). VAS was comparable in the two groups. PONV was 46.67% of KP group, while it was absent in DP group. Post-operative cognitive disorders showed a high statistical significant difference between both groups (p < 0.001) with no cases was reported in DP group. No respiratory complications in both groups.ConclusionDexmedetomidine–propofol combination as TIVA during ERCP showed better intra-and post-procedural hemodynamic stability, less PONV, less postoperative cognitive dysfunctions and shorter recovery time when compared with ketamine–propofol combination.

Is there an appropriate bispectral index for upper gastrointestinal endoscopy in spontaneous breathing in the pediatric patient?

ObjectiveThe bispectral index (BIS) values that predict appropriate anaesthetic level to perform an upper gastrointestinal endoscopy in spontaneous breathing are not well established in Pediatrics. The objective of this study is to determine whether it is possible to find an appropriate, less profound, BIS level in the pediatric patient that would enable an upper gastrointestinal endoscopy (UGE) to be performed in spontaneous breathing without causing gag reflex or motor response. Materials and methodsA prospective study was designed and included 61 patients from 12 to 167months old, and an ASA I–II who needed a diagnostic UGE. The study was conducted from October 2011 to March 2013. InterventionUGE performed with an anaesthetic protocol using propofol. The vital signs measured were heart and respiratory rate, pulse oximetry, non-invasive blood pressure. The sedation level score (Ramsay scale) and BIS values were also measured. The first attempt was performed at BIS level 60–69, and this was not feasible, then the anaesthetic was deepened and a second attempt made at BIS level 50–59. If this was still not possible a deeper anaesthetic level was then achieved and a third attempt made at BIS level 45–49. Variables of interest were: effective BIS level (eBIS), BIS level at which UGE was performed without gag reflex or motor response; propofol total dose (mgkg−1), induction time (time from onset of sedation to effective start of UGE). A logistic regression analysis was performed to obtain an equation to estimate the possibility of UGE success. ResultsThe distribution of the patient was: male 40%, female 60%, with 11 (18%) patients under 36 months. The statistical values are expressed as mean and standard deviation, with following results; age (months): 95.9±45.86; weight (kg): 30.5±14.68; effective BIS: 56.41±4.63; induction time (minutes): 11.07±2.69; total propofol dose (per kg): 4.86±1.21. An additional intra-procedure propofol bolus was given in 38 patients (62%), with 7/38 of them (18%) due to movement, and 31/38 (82%) due to BIS level increase. No statistical differences were found in effective BIS level between older and younger patients. ConclusionsAccording to the results, BIS levels below 59 predict UGE success, with 72.13% sensitivity and 88.06% specificity in the pediatric population studied.

A comparison of different proportions of a ketamine-propofol mixture administered in a single injection for patients undergoing colonoscopy

IntroductionIn this study, we aimed to determine the appropriate proportion of ketamine-propofol (ketofol), which was prepared in two different proportions for colonoscopy procedures.Material and methodsThis is a prospective and randomized trial. Group 1 was administered a mixture of 100 mg ketamine and 200 mg propofol. Group 2 was administered 50 mg ketamine and 200 mg propofol. Additional doses of 0.5 mg/kg bolus propofol without ketamine were administered to both groups to stabilize the bispectral index at 70–80 and with a Ramsey sedation score of 3–4. The pulse rate, mean arterial pressure (MAP), peripheral oxygen saturation values, colonoscopy period, adverse events, recovery time, discharge time, additional propofol doses, total propofol doses, colonoscopist and patient satisfaction were recorded.ResultsIn group 2, the 1 min MAP mean was significantly lower than the initial, 10, 15 and 20 min MAP means (p = 0.014, p = 0.002). The 20 min PR mean of group 2 was statistically significantly higher than group 1 (p = 0.045). The 15 min PR mean of group 2 was significantly lower than the initial and the 1 min PR means (p = 0.023, p = 0.006). The total propofol dose mean of group 2 was significantly higher than group 1 (p = 0.0001). The presence of adverse events in group 2 was significantly lower than that in group 1 (p = 0.0001). The mean colonoscopist satisfaction in group 2 was significantly lower than that in group 1 (p = 0.047).ConclusionsIn colonoscopy, a ketofol mixture prepared in the proportion 1 : 2 provides appropriate hemodynamic conditions and sufficient sedation.

The dexmedetomidine "augmented" sedato analgesic cocktail: An effective approach for sedation in prolonged endoscopic retrograde cholangio-pancreatography.

Background and Aims:In absence of any published standard guideline for sedation or anesthesia practice for prolonged therapeutic “endoscopic retrograde cholangio-pancreatography (ERCP)”, safe and cost-effective sedation protocol is the need of the hour. Our study aims to evaluate the efficacy of a dexmedetomidine as an add-on for prolonged deep sedation for ERCP and to compare three deep sedation regimens regarding safety and efficacy.Material and Methods:Forty-five consecutively enrolled patients planned for therapeutic ERCP and assumed to have prolonged procedural duration (>50 min) were divided into three groups in a randomized assessor blinded fashion. Group 1 received propofol and midazolam, Group 2 received the sedato-analgesic cocktail containing ketamine-propofol-midazolam-pentazocine, and the Group 3 received sedate-analgesic cocktail plus dexmedetomidine infusion under monitoring of vital parameters and according to the judgment of the concerned anesthesiologist. Total propofol requirement, episodes of gagging, oxygen desaturation, changes in mean blood pressure (MBP), recovery and satisfaction score of endoscopist, anesthetist and patient were noted and analyzed statistically using one way ANOVA with Bonferroni correction and Chi-square test.Results:Mean propofol requirement, incidences of gagging and oxygen desaturation was significantly less in Group 2 and 3 compared to Group 1. MBP was more stable and recovery was faster in Group 3. Anesthetist's satisfaction was more with Group 2 and even more with Group 3.Conclusions:The sedato-analgesic cocktail was superior to the conventional propofol-midazolam regimen, dexmedetomidine as add-on increased the efficacy and safety of sedate-analgesic cocktail. It reduces propofol requirement, helps to maintain the patient in a safe and more stable level of sedation and increases satisfaction of the anesthetist.

BIS Targeted Propofol Sparing Effects of Dexmedetomidine Versus Ketamine in Outpatient ERCP: A Prospective Randomised Controlled Trial.

Endoscopic Retrograde Cholangio Pancreatography (ERCP) is routinely performed under propofol sedation. Adjuvant drugs have improved the quality of propofol sedation while minimizing complications. The aim of the study was to compare the propofol consumption, recovery and hemodynamic profiles of dexmedetomidine versus ketamine against a placebo control with BIS targeted in the sedative range for outpatient ERCP procedures. The study comprised of 72 patients undergoing ERCP, who were randomly allocated into one of the 3 groups: Group Dexmedetomidine (n =24) receiving a bolus and infusion of dexmedetomidine (1μg/kg and 0.5μg/kg/hr); Group Ketamine (n = 24) receiving a bolus and infusion of ketamine (0.25mg/kg and 5μg/kg/min) and Group Control (n =24) receiving saline placebo as a bolus and infusion with variable propofol boluses administered in all groups targeting BiSpectral Index between 60-70. The total propofol consumption was significantly lower in both Dexmedetomidine (162.5 ± 71.7 mg ) and Ketamine groups (158.3 ± 66.89 mg) when compared with Control group (255.83 ± 114.12 mg)(p=0.001) .Time taken (minutes) to achieve Modified Aldrette Score (MAS) >9 and Observer Assessment of Alertness and Sedation (OAAS) score >4 was significantly prolonged in Dexmedetomidine group (MAS 16.6 ± 3.18 and OAAS 16.67 ± 2.82) compared to Ketamine (MAS 10 ± 4.17 and OAAS 8.75 ± 3.68) and Control (MAS 7.5 ± 3.29 and OAAS 6.88 ± 2.47) (p<0.001). Hemodynamic profiles were comparable although patients in dexmedetomidine had a statistically significant lower heart rate (p<0.001) although without clinical significance. Low dose ketamine with background propofol boluses resulted in lesser propofol consumption, with earlier recovery and favourable hemodynamics when compared with Dexmedetomidine and control group in outpatient ERCP.

Effects of pressure support ventilation mode on emergence time and intra-operative ventilatory function: a randomized controlled trial.

We tested the hypothesis that pressure-support ventilation (PSV) allows a reduction in emergence time and laryngeal mask airway (LMA) removal time after general anesthesia compared to volume-controlled mechanical ventilation (CMV). Because spontaneous breathing (SB) is often used with LMA under general anesthesia, patients were allocated randomly to three groups (CMV, SB and PSV). Thirty-six consecutive ASA I–II patients scheduled for knee arthroscopic surgery under general anesthesia with a LMA and breathing throughout the ventilator circuit were included. Hemodynamic and ventilatory variables were recorded before and 10-min after general anesthesia-induction, at the surgical incision, at the end of anaesthetic drugs infusion and when the patient was totally awake (which defines emergence time). LMA removal time, drug consumption were recorded at the end of the surgical procedure. Leak fraction around the LMA was also evaluated. LMA removal time was significantly higher in the CMV-group (18±6 min) compared to both SB (8±4 min) and PSV (7±4 min, P<0.05) groups as well as for emergence time: CMV-group (32±12 min), SB (17±7 min) and PSV (13±6 min, P<0.05) groups. Total propofol consumption was significantly lower in the PSV-group (610±180 mg) than in both CMV (852±330 mg) and SB (734±246 mg, P<0.05) groups. Air leaks around the LMA was significantly higher in the CMV-group than in the SB and PSV groups (16% vs 3% and 7%, all P<0.05). In conclusion, in knee arthroscopic surgery, in comparison to CMV, PSV use during general anesthesia in unparalyzed patients decreases LMA removal time, propofol consumption and leaks around LMA while improving ventilatory variables without adverse effects.Trial RegistrationControlled-Trials.com ISRCTN17382426