Benefits Of Ketamine Versus Propofol In Acute Traumatic Brain Injuries With Elevated Intracranial Pressure

Ketamine is a widely used medication that can be administered for the delivery of anesthesia as well as analgesia while supporting hemodynamics. A commonly taught concept based on early research is that ketamine should not be administered to those with acute brain injuries. Early research had stated that ketamine can cause a dangerous increase in intracranial pressure (ICP) and thus a decrease in cerebral perfusion and oxygenation in those with traumatic brain injuries (TBI) (Takeshita et al., 1972). More recent research has shown that ketamine may be efficacious for patients with TBIs and can decrease ICP (Dengler et al., 2022). In comparison, the use of propofol for induction is a widely accepted and much more common practice for induction with the benefits of possibly avoiding a detrimental increase in ICP (Adembri et al., 2007). This literature review was conducted to identify the benefits and safety of cerebral hemodynamics with the use of ketamine versus propofol for induction in the adult population presenting for decompressive craniotomy. A literature review of confounding evidence has been conducted, including electronic bibliographic databases, relevant articles, and several anesthesia textbooks. In searching the databases the focus was on studies using ketamine and propofol with acute brain injuries and their effects on intracranial pressure in patients presenting for decompressive craniotomies. There are currently 31 research studies and systematic reviews included. Positive clinical outcomes, such as decreased ICP, hemodynamic control, and ideal pain control, were noted in many of the studies and within the literature. It appears that the use of ketamine does not increase ICP and may be just as efficacious as propofol for those presenting with TBI (Breindahl et al., 2021)

Comparison of effects of propofol and ketofol (Ketamine-Propofol mixture) on emergence agitation in children undergoing tonsillectomy

Background: The aim of this study was to compare the effect of propofol and ketofol (ketamine-propofol mixture) on EA in children undergoing tonsillectomy.Method: In this randomized clinical trial, 87 ASA class I and II patients, aged 3-12 years, who underwent tonsillectomy, were divided into two groups to receive  either propofol 100 µg/kg/min (group p, n=44) or ketofol : ketamine 25 µg/kg/min + propofol 75 µg/kg/min (group k, n= 43). Incidence and severity of EA was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scales on arrival at the recovery room, and 10 and 30 min after that time.   Results: There was no statistically significant difference in demographic data between the two groups. In the ketofol group, the need for agitation treatment and also mean recovery duration were lower than in the propofol group (30 and 41%, and 29.9 and 32.7 min), without statistically significant difference (P value=0.143 and P value=0.187). Laryngospasm or bronchospasm occurred in 2 patients in each group and bleeding was observed in only one individual in the ketofol group.Conclusion: Infusion of ketofol in children undergoing tonsillectomy provides shorter recovery time and lower incidence of EA despite the non significant difference with propofol.Keywords:  Emergence agitation, ketofol, propofol

Efecto de una dosis de lidocaína y ketamina sobre el consumo intraoperatorio de opioides en pacientes sometidas a cirugía ginecológica electiva bajo anestesia general. Estudio piloto aleatorizado y controlado con placebo

Background and goal of study: there is evidence that perioperative intravenous ketamine and lidocaine reduce postoperative pain, postoperative opioids consumption, shortens hospital stay and accelerates intestinal function recovery. However, it has not been studied the beneficial effects in the intraoperative period. The aim of this study was to evaluate the effect of a single dose of lidocaine and ketamine on intraoperative opioids requirements in patients undergoing elective gynecological laparotomies under general anesthesia. Materials and methods: we performed a single-centre, prospective, randomized, double-blinded, placebo-controlled study. We included 33 patients (11 in the ketamine group, 11 in the lidocaine group and 11 in the placebo group). Postoperative analgesia was accomplished by patient-controlled morphine. Patients were randomly assigned to receive either a 1.5 mg/kg of 2% lidocaine, 0.5 mg/kg of 5% ketamine or 0.9% saline bolus. The primary outcome was the opioids consumption during surgery. The secondary outcomes included: emergence time, pain scores, opioids consumption within 24 h after surgery and side effects. Results: decreased intraoperative opioids requirements were noted in the experimental groups (ketamine: 402.3±106.3 and lidocaine: 397.7±107.5, compared with saline: 561.4±97.1); p=0.001. We found a positive correlation between intraoperative opioids consumption and emergence time (r=0.864, p<0.001). There was no significant difference between the groups in VAS pain scores at rest within the first 24 postoperative hours. Total morphine consumption within 24 h after surgery did not differ significantly among the groups (placebo: 27.54±11.75; ketamine: 30.95±7.88; lidocaine 34.77±10.25; p=0.26). Postoperative nausea and vomiting were more common in placebo group (it was observed in 3 subjects in ketamine group, in 5 subjects in lidocaine group and in 9 subjects in placebo group; p=0.027). Conclusion: our results do not support the use of intraoperative single dose of lidocaine or ketamine to reduce postoperative pain and postoperative opioids consumption after open gynecological surgery. However, they seem to decrease intraoperative opioids requirements and shorten emergence time. Nevertheless, these findings should be validating in further studies with large sample size.Introducción y objetivos del estudio: existe evidencia de que la administración perioperatoria de ketamina y lidocaína intravenosa reduce el dolor y el consumo de opioides postoperatorio, acorta la estancia hospitalaria y acelera la recuperación de la función intestinal. Sin embargo, no se han estudiado los efectos beneficiosos en el período intraoperatorio. El objetivo de este estudio fue evaluar el efecto de una única dosis de lidocaína y ketamina sobre el consumo intraoperatorio de opioides en pacientes sometidas a cirugía ginecológica electiva bajo anestesia general. Material y métodos: estudio prospectivo, aleatorizado, doble ciego, controlado con placebo en un solo centro. Se incluyeron 33 pacientes (11 en el grupo ketamina, 11 en el grupo lidocaína y 11 en el grupo placebo). Para la analgesia postoperatoria se utilizó una bomba PCA (Analgesia Controlada por el Paciente ) de morfina. Los pacientes fueron asignados al azar a uno de los tres grupos de estudio: 1,5 mg/kg de lidocaína al 2%, 0,5 mg/kg de ketamina al 5% o solución salina 0.9%. La variable principal del estudio fue el consumo de opioides durante la cirugía. Las variables secundarias fueron: tiempo de educción de la anestesia, intensidad del dolor, consumo de opioides en las 24 horas posteriores a la cirugía y efectos adversos. Resultados: se observó una disminución del consumo intraoperatorio de opioides en los grupos ketamina (402,3 ± 106,3) y lidocaína (397,7 ± 107,5) frente al grupo placebo (561,4 ± 97,1); p = 0,001. Se encontró una correlación positiva entre el consumo intraoperatorio de opioides y el tiempo de despertar (r = 0,864, p <0,001). No hubo diferencias significativas respecto a la intensidad del dolor en reposo en las 24 horas posteriores a la cirugía. El consumo total de morfina en las primeras 24 horas tras la cirugía no difirió significativamente entre los grupos (placebo: 27,54 ± 11,75; ketamina: 30,95 ± 7,88; lidocaína 34,77 ± 10,25; p = 0,26). Las náuseas y vómitos postoperatorios fueron más frecuentes en el grupo placebo (se observó en 3 pacientes del grupo ketamina, en 5 del grupo lidocaína y en 9 del grupo placebo; p = 0,027). Conclusión: Nuestros resultados no apoyan el uso de una única dosis intraoperatoria de lidocaína o ketamina para disminuir el dolor postoperatorio y el consumo de opioides tras cirugía ginecológica abierta. Sin embargo, si parece disminuir los requerimientos intraoperatorios de opioides y acortar el tiempo de educción de la anestesia. No obstante, estos resultados deben ser validados en futuros estudios con mayor tamaño muestral

Uses of Ketamine in the Paediatric Population

General anesthesia in pediatric patients can vary from light sedation to complete anesthesia with unconsciousness, amnesia and muscle relaxation. A wide variety of procedures are done under general anesthesia in children ranging from surgeries done for correction of congenital defects, cardiac surgeries, scoliosis surgery, hernia surgery etc. to procedures done outside the operating room (OR) for diagnostic and therapeutic purposes. Non-Operating room Anesthesia (NORA) may include painless procedures like CT scan, MRI, radiotherapy for cancer treatment etc. or painful procedures like biopsy, lumbar puncture, securing IV access, insertion of central line etc. done in ICU which requires a cooperative child. Ketamine has an important role in the pediatric population, both as an induction agent and as a sedative-analgesic drug especially in countries where newer drugs are not readily available. Ketamine helps to alleviate separation anxiety. Even procedures done under regional techniques in some older children require use of sedation. Ketamine can be administered through various routes-IV, IM, intranasal etc. It can be used along with other groups of drugs like Benzodiazepines, Barbiturates, Alpha 2 agonists, Propofol etc. Thus Ketamine is a versatile drug with various indications for use in the pediatric population which will be discussed in the current chapter

Evaluation of the variability of anesthetic practice in a single institution

Anesthetics are provided to millions of patients every year in the United States mostly by anesthesiologists. However, there is a lack of literature or documentation on how anesthetics are administered by various anesthesia providers. In order to have a better understanding on the pattern, we performed retrospective chart review on anesthetic practice for surgical atrial septal defect repair procedures performed in Boston Children's Hospital. Our collected data included: premedication, anesthesia induction methods, anesthesia maintenance methods, choice of vasoactive agents, analgesics, and intravenous accesses, extubation in the operating room, postoperative sedation, and choice of antiemetics and postoperative nausea and vomiting. In addition, the studied patients were divided into two groups based on the institutional initiation of the Fast-track protocol: before and after the implementation of the Fast-track protocol (the Non-fast-track group and the Fast-track group). Some results fell under expectation; for example, in the Non-fast-track group, all patients who were induced intravenously were older than 10 years old, and received propofol for induction, which is the most popular choice of intravenous induction drug. The Fast-track group showed a similar trend; 80% of all intravenously induced patients were 10 years or older and induced with propofol. Also, in both groups, anesthesia was maintained with the combination of IV and volatile anesthetics. An anticipated change in practice pattern was seen in the Fast-track group for the choice of analgesics and postoperative sedation for non-extubated patients; acetaminophen was introduced as an adjunct to other analgesics, and propofol infusion was introduced as a standard drug of postoperative sedation for non-extubated patients, both of which are part of the Fast-track protocol. Interestingly, however, overall intraoperative opioid doses did not show any change. The variation in the choice of intravenous access showed difference before and after the Fast-track implementation; in the Non-fast-track group, extra jugular vein was accessed as the most popular choice, whereas in the Fast-track group, central venous line was the most popular choice. Also, the incidence of postoperative nausea and vomiting was notably lower in patients who were not given anti-emetics after the Fast-track protocol implementation. This calls for a need for a future research on what part of the Fast-track protocol could have resulted this improvement without intraoperative administration of regular anti-emetics. Overall, our results provide future directions for researches on anesthetic practice that may help improve patient safety and efficiency beyond the practice in Boston Children's Hospital

Histomorphological Effect of Centella Asiatica on Swiss Albino Mice Brain upon Ketamine Anesthetic Induced Memory Impairment

Introduction: Ketamine is a medication mainly used for starting and maintaining anesthesia. It induces a trance-like state while providing pain relief, sedation and memory loss. Ketamine causes morphological changes in the neuronal cells of growing rodent. Centella asiatica is used for memory enhancement in the ayurvadic system of medicine. It has been shown to be useful in improving learning and memory. Centella asiatica leaf extract treatment enhances neuronal dendritic  arborization in hippocampus of growing rodent.Materials and Methods: Swiss albino mice were used for our experiment. Ketamine was administered subcutaneously and Centella-asiatica leaf extract was administered orally. Mice brain collected, grossed, processed and finally stained by Hematoxylin and Eosin (H&amp;E) staining process for viewing cellular and tissue structure detail by pathologists. Results: Focal cellular damage was seen in CA2 and CA4 area of cornu ammonis (CA), expanded cytoplasmic eosinophilia saw in the pyramidal cell layers (PY) of CA2, expanded cytoplasmic eosinophilia found with obliteration of neurifibrilary components (NFE), typical pyramidal cell (NPY) in the CA4, ordinary engineering of dentate granule layers (DG) and hardly any cells were found with diminished size in regards to granule layer cells (GC) in the brain hippocampus of the high ketamine prompted mice. In the mouse brain hippocampus for high ketamine-Centella asiatica summed up cell destruction found in the CA1 to CA4 of CA. Expanded cytoplasmic eosinophilia found in the pyramidal cell layers of CA2 than high dose ketamine group. The vast majority of the pyramidal cells were necrotic (PYN) with annihilation of neurofibrilary components (NFE) in the pyramidal cell layers of CA4. Keywords: Centella asiatica, Ketamine and memory impairment. DOI: 10.7176/ALST/82-02 Publication date:October 31st 202

Comparison of effects of propofol and ketofol (Ketamine-Propofol mixture) on emergence agitation in children undergoing tonsillectomy

Background: The aim of this study was to compare the effect of propofol and ketofol (ketamine-propofol mixture) on EA in children undergoing tonsillectomy. Method: In this randomized clinical trial, 87 ASA class I and II patients, aged 3-12 years, who underwent tonsillectomy, were divided into two groups to receive either propofol 100 \ub5g/kg/min (group p, n=44) or ketofol : ketamine 25 \ub5g/kg/min + propofol 75 \ub5g/kg/min (group k, n= 43). Incidence and severity of EA was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scales on arrival at the recovery room, and 10 and 30 min after that time. Results: There was no statistically significant difference in demographic data between the two groups. In the ketofol group, the need for agitation treatment and also mean recovery duration were lower than in the propofol group (30 and 41%, and 29.9 and 32.7 min), without statistically significant difference (P value=0.143 and P value=0.187). Laryngospasm or bronchospasm occurred in 2 patients in each group and bleeding was observed in only one individual in the ketofol group. Conclusion: Infusion of ketofol in children undergoing tonsillectomy provides shorter recovery time and lower incidence of EA despite the non significant difference with propofol. DOI: https://dx.doi.org/10.4314/ahs.v19i1.50 Cite as: Jalili S, Esmaeeili A, Kamali K, V R. Comparison of effects of propofol and ketofol (Ketamine-Propofol mixture) on emergence agitation in children undergoing tonsillectomy. Afri Health Sci. 2019;19(1). 1736-1744. https://dx.doi. org/10.4314/ ahs. v19i1.5

Acute Post-Operative Pain Management: Preventing Overuse of Opioids

Background: Surgical pain management with opioids is common. The use of multimodal analgesia has been proposed in order to provide opioid-sparing regimens and improve pain control post-operatively. Inadequate control of surgical pain can lead to development of chronic pain. Furthermore, studies have linked acute surgical opioid use to increased risk of long-term use. Long-term opioid use has undesirable, life-altering consequences, including physical dependence and addiction which may lead to overdose or death. Use of a variety of medications in the operative setting can lead to synergistic or additive effects on pain control, thus decreasing post-operative opioid consumption. Methods: A literature review was conducted to answer the question of whether multimodal analgesic regimens decrease acute post-operative opioid consumption among opioid naive patients when compared to standard therapy. Discussion: Review of literature on single opioid-sparing as well as multimodal opioid-sparing medication techniques in short-stay surgery suggest methods for decreasing post-operative opioid consumption. Limitations include smaller study groups and varying multimodal analgesic protocols and surgical procedures evaluated aside from barriers on implementing such protocols. Conclusion: More consistent research is needed to evaluate specific multimodal analgesic protocols and use within specific types of surgeries. Review of the literature suggests that multimodal analgesic regimens have the capability to reduce acute post-operative opioid use in ambulatory surgical settings among opioid naive patients It will be key to identify individuals that are at higher risk for long-term opioid use in the preoperative stage in order to ensure implementation of multimodal analgesia at time of surgery. Research regarding the impact of multimodal analgesia on frequency of long term opioid use would be of benefit

Preventivne metode za smanjivanje boli izazvane intravenskom primjenom propofola

Propofol is the most widely used intra-venous (IV) anesthetic for induction and maintenance of anesthesia. Its pharmacokinetics and pharmacodynamics properties make it an almost ideal anesthetic agent, but paradoxically it is painful on injection. Pain on propofol injection (POPI) is mostly a minor problem but its high incidence and its potentially high intensity of pain makes it important to solve in order to improve the practice of anesthesiology. This review article highlights the causes and solutions to POPI with a chronological approach, from the discovery of propofol to the latest remedies of the current practice. The mechanism of pain is still under investigation even though recent researches have achieved a huge step toward its understanding. It is probable that its comprehension will result in better preventive methods. As for now, IV lidocaine seems to be the best pharmacological option in the prevention of POPI considering its availability, price and rare adverse effects. On the other hand, recommended non-pharmacological measure to prevent POPI is rapid injection of propofol into a large vein. Latest recommendation on the subject promote usage of a combination of local anesthetic with a central sedative and rapid injection into large vein.Propofol je najčešće korišten intra-venski (IV) anestetik za indukciju i održavanje anestezije. Njegova farmakokinetička i farmakodinamična svojstva čine ga gotovo idealnim sredstvom za anesteziju, ali paradoksalno, bolno je kod injekcije. Bol na injekciji propofola (POPI) je uglavnom manji problem, ali njegova visoka učestalost i njezin potencijalno visok intenzitet boli čine važnim pronaći rješenje kako bismo poboljšali praksu anesteziologije. Ovaj pregledni članak ističe uzroke i rješenja POPI-a kronološkim pristupom, od otkrića propofola do najnovijih lijekova u praksi. Mehanizam boli još je pod istragom, iako su nedavna istraživanja postigla veliki korak prema njenom razumijevanju. Vjerojatno će njegovo razumijevanje rezultirati boljim preventivnim metodama. Kao i za sada, lidokain IV čini se najboljom farmakološkom opcijom u sprječavanju POPI-a s obzirom na njegovu dostupnost, cijenu i rijetke nuspojave. S druge strane, preporučena nefarmakološka mjera za sprječavanje POPI je brzo injektiranje propofola u veliku venu. Najnovija preporuka na temu promovira korištenje kombinacije lokalnog anestetika sa središnjim sedativom i brzo ubrizgavanje u veliku venu

INFLUENCE OF DIFFERENT TYPES OF ANESTHESIA FOR LAPAROSCOPIC HYSTERECTOMY ON THE DYNAMICS OF STRESS HORMONES

The aim of the study – to evaluate the influence of different variants of anesthesia, including low-opioid (LOA) and opioid-free anesthesia (OFA), on the dynamics of the stress response during laparoscopic hysterectomy. Materials and methods:&nbsp;102 patients were randomly allocated into 3 groups: 37 women assigned to receive a standard opioid-based anesthesia (OBA group), 33 women – LOA group and 32 patients OFA group. Results: The patients of OFA group after induction and intubation of the trachea showed a significant (p&lt;0.05) increase in cortisol level by 155.4 % and 160.9 % compared with the OBA group and LOA group. After completion of the hysterectomy, regardless of the variant of anesthesia, the level of cortisol exceeded the preoperative one (pOBA=0.116, pLOA=0.049, pOFA=0.043). Two hours after surgery with standard anesthesia (OBA group) there was a further increase in the concentration of cortisol in the blood, exceeding the initial values by 142.9 % (p=0.043). Patients in the LOA group and OFA group tended to decrease cortisolemia. The changes in adrenaline &amp; glucose levels were somewhat similar. Conclusion: Use of OFA is accompanied by an aggravation of the stress response at the stage of hysterectomy, which is manifested by an increase in the level of adrenaline and cortisol. The most adequate perioperative protection is inherent in low-opioid anesthesia, which is accompanied by a lower release of stress hormones during hysterectomy and in the postoperative period. Opioid-based anesthesia provides adequate intraoperative protection, but is accompanied by insufficient postoperative analgesia