Dexmedetomidine–ketamine and midazolam–ketamine combinations for sedation in pediatric patients undergoing extracorporeal shock wave lithotripsy: a randomized prospective study

Purpose

Extracorporeal shock wave lithotripsy (ESWL) requires sedation in pediatric patients. Dexmedetomidine is a relatively new agent used for sedation. The aim of this randomized prospective study was to compare the effects of dexmedetomidine–ketamine and midazolam–ketamine combinations on the recovery time, hemodynamic and respiratory variables, and side effects in pediatric patients undergoing ESWL.

Methods

Fifty pediatric patients aged between 2 and 15 years who were scheduled for elective ESWL were randomized into two groups. In Group D we applied dexmedetomidine at1 μg/kg, given over 10 min, and a bolus of 1 mg/kg ketamine for sedation. In Group M we applied midazolam at a 0.05 mg/kg bolus dose 10 min before the procedure and a 1 mg/kg bolus of ketamine. We measured and monitored the hemodynamic variables, oxygen saturation, and recovery time, and we also monitored the side effects.

Results

Four patients in group D refused to complete the study; 21 patients in group D and 25 patients in group M completed the study. We found the recovery time [eye-opening time (9.3 ± 4.5 vs. 16.2 ± 6.5 min; p < 0.001), verbal response time (12.8 ± 4.9 vs. 19.2 ± 7.2 min; p < 0.001), and the cooperation time (17.1 ± 5.0 vs. 23.3 ± 7.7 min; p < 0.001)] to be shorter in the dexmedetomidine group. Also, the heart rate values were lower in the dexmedetomidine group at the 20th minute of the procedure (99.1 ± 19.0 vs. 118.7 ± 7.3 beats/min; p = 0.016).

Conclusion

In this study we found the recovery time to be shorter, with hemodynamic stability, in the dexmedetomidine group, compared with the midazolam group. So we can conclude that dexmedetomidine may be a good and safe alternative agent for sedation, with a shorter recovery period than midazolam, in the pediatric population.

     

Comparative study between novel sedative drug (dexmedetomidine) versus midazolam–propofol for conscious sedation in pediatric patients undergoing oro-dental procedures

ObjectiveA comparative study to evaluate the effect of dexmedetomidine as a sedative in pediatric dental patients in comparison to the currently used combination of midazolam and propofol.MethodsSixty ASA I children (4–10 years old) referred from the outpatient clinic of the pediatric dentistry department for sedation for dental procedures. They were randomly classified into two groups, group I (dexmedetomidine group) was given as 2 μg/kg loading dose over 5 min followed by 0.4 μg/kg/h continuous infusion. Group II (midazolam–propofol group) midazolam was given as 0.05 mg/kg and propofol was given loading dose as 1 mg/kg over 5 min followed by 5 mg/kg/h continuous infusion. Heart rate, mean arterial blood pressure, oxygen saturation, respiratory rate were recorded every 5 min till discharge. The onset of sedation, procedure time, recovery time, discharge time and the need of analgesia were recorded. The incidence of occurrence of adverse effects was observed.ResultsIn group I, the mean onset of sedation was significantly longer than in group II, but recovery time was significantly shorter in group I than group II, there are significantly hemodynamics effects in the first 15 min and more incidence of occurrence of side effects in group II than group I. There are more analgesic effects of dexmedetomidine in group I than group II postoperatively.ConclusionDexmedetomidine is safe and effective when used for sedation in pediatric patients undergoing dental procedures.     

IV paracetamol effect on propofol–ketamine consumption in paediatric patients undergoing ESWL

Purpose

Electroshock wave lithotripsy (ESWL) is a painful procedure performed with sedoanalgesia in paediatric patients. The propofol?Cketamine combination may be the preferable anaesthesia for this procedure, and propofol?Cketamine consumption may be decreased with the administration of intravenous (IV) paracetamol. In this study we investigated the effect of IV paracetamol administration on propofol?Cketamine consumption, recovery time and frequency of adverse events in paediatric patients undergoing ESWL.

Methods

Sixty children, ranging in age from 1 to 10?years and with American Society of Anesthesiologists Physical Status 1?C2, were included in this prospective, randomized, double-blinded study. Thirty minutes prior to the procedure children randomly assigned to Group I received IV 15?mg/kg paracetamol, and those randomly assigned to Group II received 1.5?mL/kg IV saline infusion 30?min. The propofol?Cketamine combination was prepared by mixing 25?mg propofol and 25?mg ketamine in a total 10?mL solution in the same syringe. After the administration of 0.1?mg/kg midazolam and 10???g/kg atropine to both groups and during the procedure, the propofol?Cketamine combination was administered at 0.5?mg/kg doses to achieve a Wisconsin sedation score of 1 or 2. Oxygen saturation and heart rate were recorded at 5-min intervals. Propofol?Cketamine consumption, recovery times and adverse events were also recorded.

Results

Demographic data were similar between groups. Propofol?Cketamine consumption (Group I, 25.2?±?17.7?mg; Group II, 35.4?±?20.1?mg; p?=?0.04) and recovery times (Group I, 19.4?±?7.9?min; Group II, 29.6?±?11.4?min; p?Conclusion Our data suggest that the administration of IV paracetamol decreases propofol?Cketamine consumption for adequate sedation during ESWL procedures in paediatric patients and shortens recovery time.     

Prevention of rocuronium injection pain in paediatrics: Ketamine versus midazolam? A prospective randomized double blind study

Introduction

Rocuronium bromide is a non-depolarizing muscle relaxant related to mono-quaternary steroid group which is used commonly in general anaesthesia for the facilitation of endotracheal intubation and for maintenance of muscle relaxation. Rocuronium injection pain is a significant drawback with an incidence ranging from 50% to 80% [1] and [2]. Separation of children from their parents and shifting them to the OT is an everyday problem to paediatric anaesthetists, in our centre; majority of anaesthetists use IV midazolam to solve this problem, some anaesthetists use IV ketamine hydrochloride instead. This randomized, double-blind study was designed to compare the effect of IV ketamine versus IV midazolam in reducing rocuronium injection-related withdrawal movements in paediatric patients.

Methods

Hundred and twenty paediatric patients aged 2–10 years subjected to urologic procedures under general anaesthesia were randomly classified into two groups: the ketamine group in which IV ketamine 1 mg kg⁻¹ was given and the midazolam group in which IV midazolam 0.05 mg kg⁻¹ was given before shifting the child to the operation room.

Results

Ketamine showed a highly significant reduction in the incidence of rocuronium injection-related withdrawal movements in paediatric patients (P-value 0.000) compared to midazolam which was ineffective.

Conclusion

This study demonstrated that ketamine effectively reduced pain after injection of rocuronium in paediatric patients compared to midazolam which was ineffective, and both ketamine and midazolam resolved peacefully the problem of child-parent separation before shifting to the OR.     

Cerebral state index versus bispectral index during propofol–fentanyl–nitrous oxide anesthesia

Purpose  

The aim of this study was to compare the cerebral state index (CSI) and bispectral index (BIS) during propofol–fentanyl–nitrous oxide anesthesia.     

Which anesthetic agent alters the hemodynamic status during pediatric catheterization? Comparison of propofol versus ketamine

OBJECTIVE: To compare the effects of propofol and ketamine on systemic and pulmonary circulations in pediatric patients scheduled for elective cardiac catheterization. DESIGN: Prospective, randomized, and blinded. SETTING: University hospital. PARTICIPANTS: Children (n = 41) undergoing cardiac catheterization. INTERVENTIONS: All children were premedicated with oral midazolam 60 minutes before the procedure. Patients were separated into 3 groups according to shunts diagnosed by transthoracic echocardiography before the catheterization procedure: patients without cardiac shunt (Group I, n = 11), left-to-right shunt (Group II, n = 12), and right-to-left shunt (Group III, n = 18). A continuous infusion of propofol (100-200 microg/kg/min) or ketamine (50-75 microg/kg/min) was randomly started in all groups to obtain immobility during the procedure. Hemodynamic data, including systemic venous, pulmonary artery and vein, aortic saturations and pressures, were recorded; Qp/Qs were calculated. The same set of data was recorded before discontinuation of infusions at the end of the procedure. MEASUREMENTS AND MAIN RESULTS: After the propofol administration, in all 3 patient groups propofol infusion was associated with significant decreases in systemic mean arterial pressure. In groups with cardiac shunts (Group II and III), propofol infusion significantly decreased systemic vascular resistance and increased systemic blood flow, whereas pulmonary vascular resistance and pulmonary blood flow did not change significantly. These changes resulted in decreased left-to-right shunting and increased right-to-left shunting; the pulmonary-to-systemic flow ratio decreased significantly. On the other hand, after ketamine infusion, systemic mean arterial pressure increased significantly in all patient groups, but pulmonary mean arterial pressure, systemic vascular resistance, and pulmonary vascular resistance were unchanged. CONCLUSION: In children with cardiac shunting, the principal hemodynamic effect of propofol is a decrease in systemic vascular resistance. In children with intracardiac shunting, this results in an increase in right-to-left shunting and a decrease in the ratio of pulmonary to systemic blood flow, which may lead to arterial desaturation. Ketamine did not produce these changes. The authors suggested that during cardiac catheterization in children, both the anesthesiologists and cardiologists need to know that anesthetic agents can significantly alter the hemodynamic status in children with complex congenital heart defects and affect the results of hemodynamic calculations that are important for decision-making and treatment of these patients.     

Does propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial

BACKGROUND: Intravenous propofol (2,6-diisopropylphenol) infusion is used commonly for sedation/anesthesia during operations. Several authors have reported that propofol can interfere with intact parathyroid hormone (PTH) testing in vitro. Therefore, many surgeons avoid propofol during parathyroidectomy. METHODS: To determine whether propofol affects intraoperative PTH levels in vivo, we randomly assigned 34 patients (80% power; alpha < .05) with secondary hyperparathyroidism to undergo surgery for dialysis access. Patients were assigned randomly to local anesthesia with either propofol (n = 17 patients) or midazolam (n = 17 patients) sedation. PTH values were obtained before the procedure and at 10 minutes and 30 minutes after the start of the propofol or midazolam. RESULTS: Median preoperative serum PTH and calcium levels were 175 pg/mL (range, 27-2646 pg/mL) and 9.2 mg/dL (range, 8.1-10.8 mg/dL), respectively. There was no statistically significant difference between the PTH levels in the 2 groups at each of our time points. There was also no difference in the percentage of change from baseline in the PTH values between our 2 groups. No patient in either group had a sustained drop in their PTH level of greater than 50%. CONCLUSIONS: Intravenous propofol infusion does not alter PTH levels significantly during the operation. Therefore, we believe the intraoperative PTH assay can be used safely during propofol sedation when parathyroid surgical procedures are being performed.     

Comparison between ketamine and fentanyl–droperidol for rectal premedication in children: a randomized placebo controlled trial

Purpose  

A common concern of anesthesiologists is the management of children involved in stressful scenarios, and premedication is considered, in most situations, as useful to reduce the stress responses. This randomized placebo-controlled study was designed to evaluate two premedicants, ketamine versus a combination of fentanyl–droperidol, rectally administered, in pediatric surgical outpatients.     

Middle-sized posterior malleolus fractures: Fixed versus non-fixed – A prospective randomized study

PurposeThis study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome.MethodsA prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10–25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years.ResultsDemographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001).ConclusionAlthough there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor.Level of evidenceLevel I; prospective randomized controlled study.     

Could ephedrine replace meperidine for prevention of shivering in women undergoing Cesarean Section under spinal anesthesia? A randomized study

PurposeTo compare possible unlabeled effect of ephedrine, as shivering prophylaxis, with meperidine during spinal anesthesia for Cesarean Section.MethodsAfter institutional ethical committee approval, 96 parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated according to shivering prophylaxis to receive either 15 mg meperidine (group M, n = 48) or 6 mg ephedrine (group E, n = 48) intravenously before spinal block. Incidence and intensity of shivering as well as side effects of either drug were assessed.ResultsThe incidence shivering in meperidine and ephedrine groups in women undergoing Cesarean Section under spinal anesthesia was comparable (27%, 29% respectively, P = 0.06). Also, intensity of shivering was not different between two groups. Moreover, phenylephrine requirement and incidence of nausea and vomiting were significantly less in ephedrine group (121 ± 2.2% and 4.1% respectively) relative to meperidine group (168 ± 3.2% and 16.6% respectively).ConclusionThe prophylactic use of a low dose ephedrine is effective as meperidine for shivering prophylaxis in women undergoing Cesarean Section under spinal anesthesia as meperidine. Moreover, it is associated with less hypotension, nausea and vomiting.     

Comparison of effects of propofol and ketamine–propofol mixture (ketofol) on laryngeal mask airway insertion conditions and hemodynamics in elderly patients: a randomized, prospective, double-blind trial

Purpose

The objective of this study was to compare the effects of ketamine–propofol mixture (ketofol) and propofol on ProSeal laryngeal mask airway (PLMA) insertion conditions and hemodynamics in elderly patients.

Methods

Eighty elderly patients, American Society of Anesthesiologists (ASA) physical status I and II, were randomly divided into two groups to receive either propofol 0.15 ml/kg (n = 40), or ketofol (using a 1:1 single-syringe mixture of 5 mg/ml ketamine and 5 mg/ml propofol) (n = 40) before induction of anesthesia. Sixty seconds after induction, the PLMA was inserted. Heart rate and arterial blood pressure (systolic [S] BP) were recorded prior to the induction of anesthesia, immediately following induction, immediately after PLMA insertion, and 5 and 10 min after PLMA insertion. PLMA insertion conditions were scored according to mouth opening, swallowing, coughing, head and body motion, laryngospasm, and ease of PLMA insertion by the same experienced anesthesiologist, who did not know which agents were used.

Results

There were no differences in PLMA insertion conditions between the groups. The number of patients in need of ephedrine (P = 0.043) and the total dose of ephedrine (P = 0.022) were significantly lower, and apnea duration (P < 0.001) was significantly higher in the ketofol group compared with the propofol group. SBP was significantly higher in the ketofol group than in the propofol group immediately after PLMA insertion and 5 min after PLMA insertion.

Conclusions

The same PLMA insertion conditions were found with ketofol and propofol. The number of patients in need of ephedrine and the total ephedrine dose were lower and apnea duration was increased in the ketofol group.     

Caudal anesthesia in pediatric cardiac surgery: does it affect outcome?

OBJECTIVE: The purpose of this study was to examine the influence of caudal anesthesia on outcomes (pediatric intensive care unit [PICU] length of stay, hospital length of stay, ventilatory time, early extubation rate) in pediatric patients undergoing congenital heart disease repair requiring cardiopulmonary bypass (CPB). DESIGN: Retrospective. SETTING: University teaching hospital. PARTICIPANTS: Pediatric patients undergoing surgery to treat congenital heart disease between 1999 and 2002. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients with atrial septal defect (ASD), 37 with ventricular septal defect, and 46 with tetralogy of Fallot (TOF) were included in the analysis. No differences were found in preoperative and intraoperative data between caudal and noncaudal group for each disorder. There was no difference between caudal and noncaudal groups in PICU and hospital stay. A statistically significant difference was found in the postoperative ventilatory time in patients with ASD and TOF between caudal and noncaudal groups. The early extubation rate was higher in the TOF caudal group compared with the noncaudal group. CONCLUSIONS: This retrospective study demonstrated that postinduction placement of caudal anesthesia does not affect PICU or hospital length of stay. A well-controlled prospective study is needed to confirm these findings.     

A comparative study of general anesthesia versus combined spinal–epidural anesthesia on the fetus in cesarean section

BackgroundObstetric anesthesia guidelines recommend regional over general anesthesia for most caesarean sections to decrease the risk for both fetus and mother.Aim of the workTo determine the effects of combined spinal epidural anesthesia and general anesthesia on the newborns and the mother undergoing elective cesarean section.SubjectsA total of 60 consecutive women with uncomplicated singleton pregnancies at term and scheduled to undergo elective cesarean section at Kasr Al-Aini obstetric hospital participated in this prospective study. The women were divided into 2 groups (each 30), a general anesthesia group (A) and combined spinal–epidural anesthesia group (B).MethodsUmbilical artery blood gas analysis and Apgar scores were assessed at 1 and 5 min after delivery in the newborn while systolic and diastolic blood pressure, heart rate, oxygen saturation and (capnography in general anesthesia) were measured preoperative and after 5, 10 and 15 min of induction of anesthesia in the mothers. In addition, the time from induction of anesthesia till delivery of the fetus and duration in operative room were measured.ResultsApgar score recorded statistically significant differences between the 2 groups at 1 min and 5 min, where with combined spinal–epidural anesthesia the Apgar score readings were higher than with general anesthesia. HCO₃ readings showed a statistically significant difference between the 2 groups after 1 and 5 min, where the newborns in general anesthesia group had a statistically significant lower HCO₃ compared to the newborns in combined spinal–epidural group. Patients in general anesthesia group were significantly more tachycardic compared to patients in combined spinal–epidural group.ConclusionCombined spinal–epidural anesthesia is safer on the newborn than general anesthesia regarding the APGAR scores and acid–base balance.     

Effects of intrathecal bupivacaine–fentanyl versus bupivacaine–dexmedetomidine in diabetic surgical patients

BackgroundDiabetes mellitus is the most common endocrine disorder encountered during anesthesia. Experimental researches showed that the functional μ opioid receptors in the dorsal horn of spinal cord in diabetics are either reduced or impaired in their function. This prospective study was postulated to differentiate between the effects of either opioid like fentanyl versus nonopioid like dexmedetomidine agents added to spinal bupivacaine in diabetic patients.MethodsSixty diabetic patients of either sex were submitted for elective lower limb orthopedic surgery. Patients were randomly allocated into three equal groups (each group 20 patient): bupivacaine group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5% plus 0.5 mL of normal saline, bupivacaine–fentanyl group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5% plus 25 μg fentanyl in 0.5 mL of normal saline and bupivacaine–dexmedetomidine group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5%, plus 10 μg dexmedetomidine in 0.5 mL of normal saline. Duration and quality of sensory and motor block were assessed.ResultsThe duration of sensory and motor block as well as duration of effective analgesia was significantly longer in the bupivacaine–dexmedetomidine group as compared with both bupivacaine–fentanyl and control bupivacaine groups.ConclusionAddition of intrathecal dexmedetomidine to heavy bupivacaine 0.5% was more advantageous than fentanyl with special regard to its analgesic properties in diabetic surgical patients.