Abstract
Objective
Anesthetic agents are often combined to enhance their therapeutic effects while minimizing adverse events. The aim of this study was to evaluate the effects of two different sedation regimens of ketamine and propofol combination via infusion on perioperative variables in patients who underwent plastic and reconstructive surgery.
Methods
This randomized double-blind clinical trial was done on 80 patients who were randomized to two groups; group 1 (n = 40) received a 2:1 mixture of 9 mg/ml propofol and 4.5 mg/ml ketamine, and group 2 (n = 40) received a 4:1 mixture of 9 mg/ml propofol and 2.25 mg/ml ketamine. After premedication and before local anesthetic injection, the infusion of mixtures was adjusted to attain the Ramsay sedation scores of 5 in both groups. We recorded induction time, sedation efficacy, cardiovascular and respiratory events, recovery time, and incidence of adverse events during and after the procedure.
Results
The mean of volume infusion of mixtures in the beginning of the procedure was higher in group 2 (3.2 ± 1. 2 ml) than in group 1 (2.4 ± 0.8 ml) (p < 0.001). The induction time for sedation was 2.8 ± 0.8 min and 2.6 ± 0.4 min in group 1 and group 2, respectively (p = 0. 92). The number of oversedated patients was greater in group 2 compared to group 1 but not statistically significant (p = 0. 80). The sedation efficacy was similar between the two groups. The hemodynamic changes during the procedure were greater in group 2 compared to group 1 (p = 0. 001). The recovery time was not significantly different between the two groups (p = 0.43). The mean pain score in the recovery room was lower in group 1 than group 2 (1.2 ± 0.8 vs 2.8 ± 1.8, p = 0. 01). Moreover, 4 (10 %) patients in group 1 and 10 (25 %) patients in group 2 needed opioid administration (p = 0. 02). Other postoperative adverse events were similar between the two groups.
Conclusion
We recommend the use of a 2:1 combination of propofol–ketamine, because it reduced the rescue propofol requirement and consequently produced lower cardiovascular and respiratory depression effects and also less postoperative pain.
Level of Evidence I
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Similar content being viewed by others
References
Hug CC Jr, McLeskey CH, Nahrwold ML, Roizen MF, Stanley TH, Thisted RA, Walawander CA, White PF, Apfelbaum JL, Grasela TH et al (1993) Hemodynamic effects of propofol: data from over 25,000 patients. Anesth Analg 77(4 Suppl):S21–S29
Bowdle TA, Radant AD, Cowley DS, Kharasch ED, Strassman RJ (1998) Roy-Byrne PP. Psychedelic effects of ketamine in healthy volunteers: relationship to steady-state plasma concentrations. Anesthesiology 88(1):82–88
Suzuki M, Tsueda K, Lansing PS, Tolan MM, Fuhrman TM, Ignacio CI, Sheppard RA (1999) Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery. Anesth Analg 89(1):98–103
Mortero RF, Clark LD, Tolan MM, Metz RJ, Tsueda K, Sheppard RA (2001) The effects of small-dose ketamine on propofol sedation: respiration, postoperative mood, perception, cognition, and pain. Anesth Analg 92(6):1465–1469
Badrinath S, Avramov MN, Shadrick M, Witt TR, Ivankovich AD (2000) The use of a ketamine-propofol combination during monitored anesthesia care. Anesth Analg 90(4):858–862
Erden IA, Pamuk AG, Akinci SB, Koseoglu A, Aypar U (2010) Comparison of two ketamine-propofol dosing regimens for sedation during interventional radiology procedures. Minerva Anestesiol 76(4):260–265
Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. Br Med J 2(5920):656–659
Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, Willman E (2012) Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med 59(6):504-12.e1-2
David H, Shipp J (2011) A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 57(5):435–441
Erden IA, Pamuk AG, Akinci SB, Koseoglu A, Aypar U (2009) Comparison of propofol-fentanyl with propofol-fentanyl-ketamine combination in pediatric patients undergoing interventional radiology procedures. Paediatr Anaesth 19(5):500–506
Chiaretti A, Ruggiero A, Barone G, Antonelli A, Lazzareschi I, Genovese O, Paiano S, Sammartino M, Maurizi P, Riccardi R (2010) Propofol/alfentanil and propofol/ketamine procedural sedation in children with acute lymphoblastic leukaemia: safety, efficacy and their correlation with pain neuromediator expression. Eur J Cancer Care (Engl) 19(2):212–220
Claeys MA, Gepts E, Camu F (1988) Hemodynamic changes during anaesthesia induced and maintained with propofol. Br J Anaesth 60(1):3–9
Frazee BW1, Park RS, Lowery D, Baire M (2005) Propofol for deep procedural sedation in the ED. Am J Emerg Med. 23(2):190-5
Kim G, Green SM, Denmark TK, Krauss B (2003) Ventilatory response during dissociative sedation in children-a pilot study. Acad Emerg Med 10(2):140–145
Green SM, Andolfatto G, Krauss B (2011) Ketofol for procedural sedation? Pro and con. Ann Emerg Med. 57(5):444–448
Aouad MT, Moussa AR, Dagher CM, Muwakkit SA, Jabbour-Khoury SI, Zbeidy RA, Abboud MR, Kanazi GE (2008) Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability. Acta Anaesthesiol Scand 52(4):561–565
Willman EV, Andolfatto G (2007) A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med 49(1):23–30
Idvall J, Ahlgren I, Aronsen KR, Stenberg P (1979) Ketamine infusions: pharmacokinetics and clinical effects. Br J Anaesth 51(12):1167–1173
Ghadami Yazdi A, Ayatollahi V, Hashemi A, Behdad Sh, Ghadami Yazdi E (2013) Effect of two Different Concentrations of Propofol and Ketamine Combinations (Ketofol) in Pediatric Patients under Lumbar Puncture or Bone Marrow Aspiration. Iran J Ped Hematol Oncol. 3(1):187–192
Taylor DM, O’Brien D, Ritchie P, Pasco J, Cameron PA (2005) Propofol versus midazolam/fentanyl for reduction of anterior shoulder dislocation. Acad Emerg Med 12(1):13–19
Vardi A, Salem Y, Padeh S, Paret G, Barzilay Z (2002) Is propofol safe for procedural sedation in children? A prospective evaluation of propofol versus ketamine in pediatric critical care. Crit Care Med 30(6):1231–1236
Dachs RJ, Innes GM (1997) Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med 29(1):146–150
Strayer RJ, Nelson LS (2008) Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med 26(9):985–1028
Langston WT, Wathen JE, Roback MG, Bajaj L (2008) Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial. Ann Emerg Med 52(1):30–34
Behdad A, Hosseinpour M, Khorasani P (2011) Preemptive use of ketamine on post operative pain of appendectomy. Korean J Pain. 24(3):137–140
Nesek-Adam V, Grizelj-Stojčić E, Mršić V, Rašić Z, Schwarz D (2012) Preemptive use of diclofenac in combination with ketamine in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study. Surg Laparosc Endosc Percutan Tech. 22(3):232–238
Singh H, Kundra S, Singh RM, Grewal A, Kaul TK, Sood D (2013) Preemptive analgesia with ketamine for laparoscopic cholecystectomy. J Anaesthesiol Clin Pharmacol 29(4):478–484
Naghibi K, Kashefi P, Abtahi AM (2013) The comparison of preemptive effects of propofol, remifentanil and ketamine on post-operative pain scores and analgesic requirements in elective lower abdominal surgery under general anesthesia: a randomized, double-blinded study. J Res Med Sci. 18(7):567–572
Acknowledgments
The authors thank Zahra Mokhtari, Nahid Jafarkhan, Fatemeh Daroughezadeh, Hooriyeh Naeimi, and Faezeh Keshavarz for their assistance in data collection and Zohreh Shahabi for her assistance in statistical analysis.
Conflicts of interest
The authors declare that they have no conflicts of interest to disclose
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sanatkar, M., Abianeh, S.H., Ghazizadeh, S. et al. The Comparison of Infusion of Two Different Sedation Regimens with Propofol and Ketamine Combination During Plastic and Reconstructive Surgery. Aesth Plast Surg 39, 141–146 (2015). https://doi.org/10.1007/s00266-014-0419-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00266-014-0419-y