Dexmedetomidine and ketamine: an effective alternative for procedural sedation?

Opioid sparing anesthesia in patients with liver cirrhosis undergoing liver resection: a controlled randomized double-blind study

OBJECTIVE

Opioid metabolism and pharmacodynamics may be affected in hepatic patients. Ketamine and dexmedetomidine are conventional anesthetics used in our daily practice. The opioid-sparing effects of this combination have not been evaluated in patients with liver cirrhosis undergoing liver resection. We aimed to investigate the potential peri-operative opioid-sparing effects of intra-operative dexmedetomidine and ketamine infusions in patients with Child A liver cirrhosis undergoing liver resection.

METHODS

This study was a randomized controlled double-blind trial. 92 adult patients of both sex with Child class (A) liver cirrhosis aged 18 to 65 years entering and completing the study. We excluded patients with renal or cardiac dysfunction or contraindications from study medications.46 patients in the opioid-sparing group (OS) receiving ketamine and dexmedetomidine infusions and 46 patients in the opioid-based (OB) group as controls. The main outcome measures: were intra-operative fentanyl requirements, postoperative fentanyl requirements, visual analogue pain scores, postoperative nausea, vomiting, ileus, desaturation, intra-operative hemodynamic events, and ICU stay were recorded.

RESULTS

The total intra-operative fentanyl consumption was significantly lower in the OS group compared with the OB group, 183.2 ± 35.61 µg and 313.5 ± 75.06 µg, respectively, P < 0.001. The postoperative 1st 48 h fentanyl consumption was significantly lower in the OS group compared with the OB group, 354.5 ± 112.62 µg and 779.1 ± 294.97 ± µg, respectively, P < 0.001. Visual analogue scores were significantly better in the OS group at the early 2-hour assessment point postoperatively. The postoperative adverse events were significantly more frequent in the opioid-based group. ICU stay was significantly shorter in the OS group.

CONCLUSIONS

Administering dexmedetomidine and ketamine infusions intra-operatively to patients with Child A liver cirrhosis undergoing liver resection resulted in notable opioid-sparing effects, with reductions of approximately 40% intra-operatively and 55% postoperatively. The opioid-sparing group exhibited improved postoperative outcomes, including reduced pain, decreased incidence of opioid-related side effects and shorter ICU stays.

Ketamine Infusion as an Adjunct to Opioid Analgesia in Pediatric Patients with High-Risk Neuroblastoma Undergoing Treatment with Dinutuximab: Adverse Effects and Safety in a Non-ICU Setting

Introduction

Anti-GD2 immunotherapy has improved outcomes for children with high-risk neuroblastoma (HRNBL). Dinutuximab promotes complement-mediated reaction against disialoganglioside GD2, which is expressed in peripheral nerves and over-expressed in neuroblastoma. Dinutuximab is associated with ≥grade 3 neuropathic pain. Targeting GD2 stimulates the NMDA receptor, which makes ketamine useful in treatment of associated pain. The objective of this retrospective study is to describe the use of ketamine for pain uncontrolled by opioids, and ketamine's impact on total opioid usage for patients receiving dinutuximab. In addition, the secondary objective is to describe the toxicities of pain management with opioids versus opioid plus ketamine.

Methods

A retrospective chart review of 40 hRNBL patients receiving dinutuximab at Nationwide Children's Hospital, from 2010 to 2022, was conducted. Demographics, pain scores, medication records, and total daily IV morphine milligram equivalents (IVMME) with and without a ketamine adjunct were collected. Linear mixed effect regression was used to model IVMME use for pain management across dinutuximab cycles and explore the effect of ketamine.

Results

The study cohort included 187 dinutuximab hospitalizations from 40 patients. Age at diagnosis ranged from 1.2 to 11.4 years. 66/187 hospitalizations included ketamine. The average daily IVMME during post-consolidation dinutuximab infusions was greater in admissions with ketamine (median 11.67 mg/day vs 6.09 mg/day; p = 0.0005). Ketamine was not significantly associated (p = 0.77) with daily IVMME when examining opioid use longitudinally over dinutuximab cycles and controlling for patient age. Fever/chills was more frequent in admissions that utilized ketamine (79% vs 63%; p = 0.0297). No other significant statistical differences in adverse effects were observed in patients' receiving opioids versus opioids plus ketamine.

Conclusion

Findings suggest ketamine is safe in a non-ICU setting for treatment of complex pain during anti-GD2 immunotherapy. Additional prospective studies are needed to quantify the effect of reducing opioid side effects by including ketamine in pain management plans.

Awake fiberoptic intubation in a pediatric patient with Tessier's cleft: Navigating the challenges

Awake fibreoptic intubation is the gold standard of airway management in anticipated difficult airways. Paediatric patients with orofacial defects pose unique challenges to the anaesthetist as management requires meticulous planning and preparation as well as titration of drugs to maintain spontaneous ventilation without losing the airway. We report a case of an 11-year-old patient with Tessier cleft type 4,6 posted for orbital reconstruction and discuss the management with awake fibreoptic intubation.

Ketodex: A Game-Changer in Pediatric Sedation for Challenging Airway

Managing sedation in pediatric patients with complex facial anomalies and airway challenges requires careful consideration of safety and efficacy. This case report presents the use of the Ketodex sedation protocol, combining ketamine (NMDA receptor antagonist) and dexmedetomidine (alpha-2-agonist), for a child with a large cervical/facial mass undergoing a diagnostic magnetic resonance imaging (MRI). Ketodex provides effective sedation with minimal need for manipulation of the airway and side effects, making it ideal for cases involving difficult airways. Our protocol allows spontaneous ventilation without compromising airway reflexes and reduces airway hyperreactivity, ensuring safety in high-risk pediatric cases. Initiating sedation in a controlled environment enhances safety before moving to remote locations. The Ketodex protocol is a safe and effective choice for managing pediatric patients with challenging airways. Its use should be prioritized in controlled settings, with adaptations for individual patient needs.

Trends in analgesia-sedation of pediatric patients receiving I-131 MIBG in the pediatric intensive care unit: A report from the Pediatric Health Information System database

BACKGROUND

Children with neuroblastoma receiving I-131 metaiodobenzylguanidine (MIBG) therapy require sedation-analgesia for strict radiation safety precautions during MIBG infusion and clearance. We evaluated the sedation-analgesia trends of patients undergoing MIBG therapy using the Pediatric Health Information System (PHIS) database.

MATERIALS AND METHODS

Retrospective data from 476 patient encounters from the PHIS from 2010 to 2019.

RESULTS

Total 240/476 (50.45%) children evaluated were under 6 years of age. Compared to 2010, in 2018 there was a decrease in benzodiazepine infusion use (60% vs. 40%, p < .04), as well as a decrease in use of opiate infusion (35% vs. 25%, p < .001). Compared to 2010, in 2018 we report an increase in the use of ketamine (from 5% to 10%, p < .002), as well as an increase in dexmedetomidine use (0% vs. 30%, p < .001). Dexmedetomidine was the most used medication in the 0-3 years age group compared to children older than 3 years of age (14.19% vs. 5.80%, p < .001). Opiate was the most used medication in children greater than 3 years compared to the 0-3-year age group (36.23 vs. 23.87, p < .05).

CONCLUSION

Using PHIS data, we discovered considerable variability in the medications used for sedation in patients undergoing MIBG therapy. Although benzodiazepines and opioids were the most used agents, there was a trend toward decreasing use of benzodiazepines and opioids in these patients. Furthermore, there has been an increasing trend in the use of dexmedetomidine and ketamine.

Dexmedetomidine-ketamine combination versus fentanyl-midazolam for patient sedation during flexible bronchoscopy: a prospective, single-blind, randomized controlled trial

BACKGROUND

Sedation during flexible bronchoscopy (FB) should maintain an adequate respiratory drive, ensure maximum comfort for the patient, and warrant that the objectives of the procedure are achieved. Nevertheless, the optimal sedation method for FB has yet to be established. This study aimed to compare the standard recommended combination of midazolam-fentanyl (MF) with that of dexmedetomidine-ketamine (DK) for patient sedation during FB.

METHODS

Patients subjected to FB were randomly assigned to a DK (n = 25) and an MF group (n = 25). The primary outcome was the rate of critical desaturation events (arterial oxygen saturation < 80% with nasal oxygen supply 2 L/min). Secondary outcomes included sedation depth, hemodynamic complications, adverse events, and patient and bronchoscopist satisfaction.

RESULTS

The incidence rates of critical desaturation events were similar between the two groups (DK: 12% vs. MF: 28%, p = 0.289). DK achieved deeper maximum sedation levels (higher Ramsay - lower Riker scale; p < 0.001) and was associated with longer recovery times (p < 0.001). Both groups had comparable rates of hemodynamic and other complications. Patient satisfaction was similar between the two groups, but bronchoscopist satisfaction was higher with the DK combination (p = 0.033).

CONCLUSION

DK demonstrated a good safety profile in patients subjected to FB and achieved more profound sedation and better bronchoscopist satisfaction than the standard MF combination without increasing the rate of adverse events.

Esketamine Combined with Dexmedetomidine to reduce Visceral Pain During elective Cesarean Section Under Combined Spinal-Epidural Anesthesia: A double-Blind Randomized Controlled Study

Purpose

We aimed to evaluate the effect of intravenous esketamine combined with dexmedetomidine as supplemental analgesia in reducing intraoperative visceral pain during elective cesarean section under combined spinal-epidural anesthesia (CSEA).

Patients and Methods

A total of 269 parturients scheduled for elective cesarean section under CSEA between May 2023 and August 2023 were assessed. The parturients were randomly allocated to receiving either intravenous infusion of 0.3-mg/kg esketamine combined with 0.5-μg/kg dexmedetomidine (group ED, n=76), 0.5-μg/kg dexmedetomidine (group D, n=76), or normal saline (group C, n=76) after umbilical cord clamping. The primary outcome was intraoperative visceral pain. Secondary outcomes included the visual analog scale (VAS) score for pain evaluation and other intraoperative complications.

Results

The incidence of visceral pain was lower in group ED [9 (12.7%)] than in group D [32 (43.8%)] and group C [36 (48.6%), P <0.0001]. The VAS score was also lower in group ED when exploring abdominal cavity [0 (0), P <0.0001] and suturing the muscle layer [0 (0), P =0.036]. The mean arterial pressure was higher in group D [83 (9) mmHg] and group ED [81 (11) mmHg] than in group C [75 (10) mmHg, P <0.0001] after solution infusion. The heart rate after infusion of the solution was lower in group D [80 (12) bpm] than in group C [86 (14) bpm] and group ED [85 (12) bpm, P = 0.016]. The incidence of transient neurologic or mental symptoms was higher in group ED compared to group C and group D (76.1% vs 18.9% vs 23.3%, P<0.0001).

Conclusion

During cesarean section, 0.3-mg/kg esketamine combined with 0.5-μg/kg dexmedetomidine can alleviate visceral traction pain and provide stable hemodynamics. Parturients receiving this regimen may experience transient neurologic or mental symptoms that can spontaneously resolve at the end of the surgery.

Trends in sedation-analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database

BACKGROUND

Children admitted to the pediatric intensive care unit (PICU), after liver transplantation, frequently require analgesia and sedation in the immediate postoperative period. Our objective was to assess trends and variations in sedation and analgesia used in this cohort.

METHODS

Multicenter retrospective cohort study using the Pediatric Health Information System from 2012 to 2022.

RESULTS

During the study period, 3963 patients with liver transplantation were admitted to the PICU from 32 US children's hospitals with a median age of 2 years [IQR: 0.00, 10.00]. 54 percent of patients received mechanical ventilation (MV). Compared with patients without MV, those with MV were more likely to receive morphine (57% vs 49%, p < .001), fentanyl (57% vs 44%), midazolam (45% vs 31%), lorazepam (39% vs. 24%), dexmedetomidine (38% vs 30%), and ketamine (25% vs 12%), all p < .001. Vasopressor usage was also higher in MV patients (22% vs. 35%, p < .001). During the study period, there was an increasing trend in the utilization of dexmedetomidine and ketamine, but the use of benzodiazepine decreased (p < .001).

CONCLUSION

About 50% of patients who undergo liver transplant are placed on MV in the PICU postoperatively and receive a greater amount of benzodiazepines in comparison with those without MV. The overall utilization of dexmedetomidine and ketamine was more frequent, whereas the administration of benzodiazepines was less during the study period. Pediatric intensivists have a distinctive opportunity to collaborate with the liver transplant team to develop comprehensive guidelines for sedation and analgesia, aimed at enhancing the quality of care provided to these patients.

A comparative study of esketamine-dexmedetomidine and sufentanil-dexmedetomidine for sedation and analgesia in lung tumor percutaneous radiofrequency ablation (PRFA): a randomized double-blind clinical trial

OBJECTIVE

To observe and evaluate the effectiveness and safety of Esketamine or Sufentanil combined with Dexmedetomidine for sedation and analgesia in lung tumor percutaneous radiofrequency ablation (PRFA) to provide a clinical basis for the optimization of sedation and analgesia in lung tumor PRFA protocols outside the operating room.

METHODS

In this trial, 44 patients aged 37 to 84 undergoing lung tumor PRFA were enrolled and assigned to Group E (n = 22, Esketamine 0.2 mg/kg) or Group S (n = 22,Sufentanil 0.1 μg/kg ). Dexmedetomidine was infused intravenously as a sedative in both groups. The modified observer's assessment of alertness and sedation scale (MOAAS), physical movement pain scale, intraoperative vital signs, anesthesia recovery time, radiologist and patient satisfaction rates, incidence of respiratory depression, and incidence of postoperative nausea and vomiting were recorded.

RESULTS

Although there was no significant difference in the physical movement pain scale, blood oxygen saturation or incidence of perioperative adverse events between the two groups during ablation, the MOAAS, mean arterial pressure (MAP) and heart rate (HR) were higher in Group E than in Group S. The anesthesia recovery time was shorter in Group E than in Group S, and radiologist satisfaction was better in Group E than in Group S, but there was no significant difference between the two groups in terms of patient satisfaction.

CONCLUSION

Esketamine or Sufentanil combined with Dexmedetomidine is safe for lung tumor PRFA. However, in elderly patients with multiple underlying diseases, low-dose Esketamine combined with Dexmedetomidine has fewer hemodynamic effects on patients, milder respiratory depression, shorter recovery time, and better radiologist satisfaction because of its better controllability of sedation depth.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration number#ChiCTR ChiCTR21000500 21); Date of Registration: 16/08/2021.

Narrative Review: Low-Dose Ketamine for Pain Management

Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.

Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.

A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center

Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table. A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention. To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.

Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”

This supplementary material was provided by the authors to give readers additional information and resources to replicate their work.

Ketamine and dexmedetomidine (Keto-dex) or ketamine and propofol (Keto-fol) for procedural sedation during endoscopic retrograde cholangiopancreatography: Which is safer? A randomized clinical trial

BACKGROUND

Optimum procedural sedation is very essential for conducting non-operating room procedures such as endoscopic retrograde cholangiopancreatography (ERCP). The combination of ketamine and dexmedetomidine (KD) is expected to balance out the undesirable effects of either drug and provide smooth sedation. Together ketamine and propofol (KP) also provide synergistic sedation with stable hemodynamics. This prospective, single-blinded randomized study aimed to compare the effect of both the combinations during ERCP in terms of oxygen desaturation, respiratory depression, hemodynamic parameters, analgesia, recovery time, and ease with which the endoscopist could perform the endoscopy.

METHODS

This prospective, single-blinded randomized study (CTRI/2019/08/020625) was conducted on 84, ASA (American Society of Anesthesiologists) physical status I or II patients, of age 18-65 years presenting for ERCP in a tertiary care center. They were randomized to receive either KD (n=42) or KP (n=42) combination during ERCP. Mean SPO₂ at the end of the procedure was compared between the groups. Apart from these periprocedural hemodynamic and respiratory parameters, pain scores on arrival in the recovery room (t0), 15 minutes (t15), and 30 minutes (t30), recovery time, and endoscopist's satisfaction as per a Likert's scale were recorded.

RESULTS

The mean SpO₂ (SpO₂ recorded every minute during the procedure and averaged over procedure time in minutes) in group KP (97.7 [96.1-98.6]) was significantly lower than group KD (98.5 [98.1-98.8]) (p=0.005). The post-procedure pain scores measured at t0 and t15 were higher in group KP (p<0.001 and p=0.043), and comparable at t30 in both the groups (p=0.711). The time to achieve Modified Aldrete score (MAS) ≥ 9 was significantly more in group KD (p<0.001). The lowest mean arterial pressure and heart rate in group KD were significantly lower than in group KP (p<0.001, p=0.006, respectively). The overall endoscopist satisfaction was better in group KP compared to group KD (p= 0.011).

CONCLUSIONS

The combination of ketamine-dexmedetomidine for procedural sedation during ERCP is a safe alternative to ketamine-propofol with a better respiratory profile.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CTRI/2019/08/020625 ( www.ctri.nic.in ).

Effect of esketamine vs dexmedetomidine adjunct to propofol sedation for pediatric 3Tesla magnetic resonance imaging: a randomized, double-blind, controlled trial

BACKGROUND

Adequate sedation is essential for pediatric patients undergoing 3Tesla (T) magnetic resonance imaging (MRI). Using propofol alone is associated with patient arousing and adverse airway events. This study aimed to assess esketamine vs dexmedetomidine adjunct to propofol sedation for pediatric 3 T MRI.

METHODS

In this randomized, double-blind, controlled trial, 114 pediatric patients aged between 6 months and 8 years were randomly assigned, in a 1:1 ratio, to the esketamine-propofol group or the dexmedetomidine-propofol group. Sedation was provided with esketamine or dexmedetomidine in combination with propofol titration. The primary outcome was the total dose of propofol. Secondary outcomes included propofol infusion dose, adverse events, time to emergence from sedation, and time to discharge from recovery room.

RESULTS

A total of 111 patients completed this study (56 in the esketamine-propofol group and 55 in the dexmedetomidine-propofol group). All MRI procedures were successfully performed under sedation. The total median (IQR) dose of propofol was significantly lower in the esketamine-propofol group (159.8 [121.7, 245.2] μg/kg/min) than that in the dexmedetomidine-propofol group (219.3 [188.6, 314.8] μg/kg/min) (difference in medians [95% CI] =  - 66.9 [- 87.8 to - 43.0] μg/kg/min, P < 0.0001). The use of esketamine resulted in a lower dose of propofol for titration (difference in medians [95% CI] =  - 64.3 [- 75.9 to - 51.9] μg/kg/min), a shorter time to emergence (difference in means [95% CI] =  - 9.4 [- 11.4 to - 7.4] min), and a reduced time to recovery room discharge (difference in means [95% CI] =  - 10.1 [- 12.1 to - 8.2] min). In the dexmedetomidine-propofol group, 2 patients experienced upper airway obstruction and 6 patients had bradycardia. No episodes of oxygen desaturation or other adverse events were observed.

CONCLUSIONS

Although both regimens provided effective sedation for pediatric 3 T MRI, the esketamine-propofol sedation reduced propofol requirement and facilitated recovery, without detection of increased adverse effects in the studied population. Trial registration Chinese Clinical Trial Registry (identifier: ChiCTR2100048477).

Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department

BACKGROUND

Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic.

OBJECTIVE

Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department.

METHODS

This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale.

RESULTS

Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment.

CONCLUSIONS

The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine-ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.

Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis

OBJECTIVE

To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication.

METHODS

Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events.

RESULTS

15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia.

CONCLUSIONS

DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.

Near ideal anesthetic technique for tracheal stenting in central airway obstruction with dexmedetomidine-ketamine infusion: a case report

Central airway obstruction presents as an emergency with dyspnea and stridor. Anesthetic management of rigid bronchoscopy-guided tracheal stenting is highly stimulating procedure requiring general anesthesia. But it may lead to life threatening airway obstruction and cardiovascular collapse after induction. Total intravenous anesthesia based on propofol-remifentanil is an optimal anesthetic technique, but remifentanil is not available in many countries. Although dexmedetomidine-ketamine has been used for procedural sedation, its use for rigid bronchoscopy in the setting of central airway obstruction has not been described in literature. We describe near ideal anesthetic technique for management of central airway obstruction using dexmedetomidine-ketamine combination.

Intranasal Dexmedetomidine Compared to a Combination of Intranasal Dexmedetomidine with Ketamine for Sedation of Children Requiring Dental Treatment: A Randomized Clinical Trial

Outpatient pediatric sedation is challenging. This study aimed to test intranasal dexmedetomidine efficacy as a single drug or combined with ketamine (DK) to sedate children undergoing dental treatment. Children < 7 years were randomized into dexmedetomidine 2 mcg/kg and ketamine 1 mg/kg (DK) or dexmedetomidine 2.5 mcg/kg (D) groups. Videos from the dental sedation allowed the systematic assessment of children's behavior (primary outcome) according to the Ohio State University Behavioral Rating Scale (OSUBRS). Secondary outcomes were parental and dentist satisfaction, adverse events, and recovery time. The data were analyzed descriptively and through regression models. Participants were 88 children (44 per group; 50 boys). The duration of quiet behavior (OSUBRS) was higher than 50% (DK mean 58.4 [standard deviation 38.1]; D 55.2 [39.1]; p = 0.225). Parents (DK 78.0 [32.2]; D 72.7 [35.1]; p = 0.203) and dentists (KD 62.7 [41.0]; D 62.8 [40.1]; p = 0.339) were overall satisfied. Adverse events occurred in 16 cases (DK n = 10, 62.5%; D n= 6, 37.5%; p = 0.104) and were minor. The median recovery time in the DK group was 1.3 times greater than in group D (p < 0.05). Intranasal sedation with dexmedetomidine alone is equally efficacious and satisfactory for pediatric sedation with fewer adverse events and faster recovery than the DK combination.

Gastrointestinal endoscopy in children and adults: How do they differ?

Gastrointestinal endoscopy has grown dramatically over the past century, and with subsequent improvements in technology and anaesthesia, it has become a safe and useful tool for evaluation of GI pathology in children. There are substantial differences between paediatric and adult endoscopy beyond size, including: age-related patho-physiology and the different spectrum of diseases in children. Literature on endoscopic procedures in children is sparse but significant. The present review aims at describing the current knowledges on paediatric endoscopy practice and highlights the main areas of differences between paediatric and adult practice.

Comeback of ketamine: resurfacing facts and dispelling myths

Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.

Comparison of the effects of dexmedetomidine and propofol in reducing recovery agitation in pediatric patients after ketamine procedural sedation in emergency department

Background:

Ketamine has been a safe and effective sedative agent commonly used for painful pediatric procedures in the emergency department (ED). This study aimed to compare the effect of dexmedetomidine (Dex) and propofol when used as co-administration with ketamine on recovery agitation in children who underwent procedural sedation.

Materials and Methods:

In this prospective, randomized, and double-blind clinical trial, 93 children aged between 3 and 17 years with American Society of Anesthesiologists Class I and II undergoing short procedures in the ED were enrolled and assigned into three equal groups to receive either ketadex (Dex 0.7 μg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg), or ketamine alone (ketamine1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between the groups.

Results:

There was no statistically significant difference between the three groups with respect to age, gender, and weight (P > 0.05). The incidence of recovery agitation was 3.2% in the ketadex group, 22.6% in the ketofol group, and 22.6% in the ketamine group (P = 0.002, children undergoing short procedures were recruited). There was a less unpleasant recovery reaction (hallucination, crying, and nightmares) in the ketadex group compared with the ketofol and ketamine groups (P < 0.05). There was no difference in the incidence of oxygen desaturation between the groups (P = 0.30).

Conclusion:

The co-administering of Dex to ketamine could significantly reduce the incidence and severity of recovery agitation in children sedated in the ED.

Comparison of pectoralis plane blocks with ketamine-dexmedetomidine adjuncts and opioid-based general anaesthesia in patients undergoing modified radical mastectomy

Background and Aims:

Regional anaesthesia attenuates surgical stress-response, provides superior analgesia, reduces recovery time with early mobilisation and is opioid-sparing [addresses post-operative nausea vomiting (PONV), constipation, immunosuppression and cancer-progression concerns with opioids]. Hence, we studied pectoralis (PECS) blocks for modified radical mastectomy (MRM).

Methods:

A prospective, interventional, double-blind, randomised, parallel-arm, active-controlled study comparing two anaesthetic techniques for post-operative pain relief in70 adult American Society of Anesthesiologists grade I/II carcinoma breast patients undergoing MRM was conducted. Patients were randomised to Group-O (opioids, sevoflurane) and Group-P (PECS-block, pre-incisional intravenous (IV) ketamine (0.5 mg/kg), pre-incisional IVdexmedetomidine (1 μg/kg over 10 min, then 0.6 μg/kg/h). Data were subjected to statistical analysis using the Statistical Package for Social Sciences, version-23 and independent sample t-test/Welch test for equality of means and expressed as dotted box-whisker plots. Nominal categorical intergroup data was compared using Chi-squared test/Fisher's exact test. P<0.05 was considered statistically significant. Clinical significance was calculated.

Results:

Higher Visual Analogue Scale (VAS)-scores were recorded in Group-O versus Group-P, immediately post-extubation [mean (SD) 3.6 ± 1.5 and 0.76 ± 0.6] and at 1h (3.1 ± 1.2 and1.4 ± 0.5), 2h (2.5 ± 0.9 and 1.2 ± 0.6) and 4h (2.2 ± 0.5 and 1.7 ± 0.9) respectively. At 8h and 24h post-surgery VAS was comparable. Cumulative-VAS was lower in Group-P. Intraoperative haemodynamics were comparable. Incidence of PONV and constipation was higher in Group-O where each patient received average 27.46 mg morphine-equivalents of opioids. Time to discharge from surgical intensive care unit was 2h shorter in Group-P.

Conclusion:

Pre-emptive PECS-blocks supplemented with low-dose ketamine and dexmedetomidine comprise a practical and useful alternative technique to the standard opioid-based general anaesthetic technique for MRM.

Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia

Systemic sclerosis (SSc) is an autoimmune disease that can cause fibrosis in vital organs, often resulting in damage to the skin, blood vessels, gastrointestinal system, lungs, heart, and/or kidneys. Patients with SSc are also likely to develop microstomia, which can render dental treatment difficult and painful, thereby necessitating advanced anesthetic management. This is a case report of a 61-year-old woman with a history of SSc with microstomia, interstitial pneumonia, and gastroesophageal reflux disease in whom intravenous moderate sedation was performed using a combination of dexmedetomidine and ketamine for dental extractions. Both anesthetic agents are known to have analgesic effects while minimizing respiratory depression. Consequently, the increased discomfort caused by opening the patient's mouth and stretching the buccal mucosa was sufficiently managed, permitting an increase in maximum interincisal opening and completion of treatment without complications. Patients with SSc present with serious comorbidities that can negatively impact anesthetic management, so the implementation of an anesthetic plan that takes such risks into account is required. Furthermore, emergency airway management is likely to be difficult in patients with microstomia. For intravenous moderate sedation, combined use of dexmedetomidine and ketamine, which have analgesic effects while minimizing respiratory depression, may be particularly effective in patients with SSc and microstomia.

Analgesia for spinal anesthesia positioning in elderly patients with proximal femoral fractures: Dexmedetomidine-ketamine versus dexmedetomidine-fentanyl

Elderly patients with femoral fractures are anticipated to endure the most pain caused by positional changes required for spinal anesthesia. To improve pain relief, we compared the analgesic effects of intravenous dexmedetomidine-ketamine and dexmedetomidine-fentanyl combinations to facilitate patient positioning for spinal anesthesia in elderly patients with proximal femoral fractures. Forty-six patients were randomly assigned to two groups and received either 1 mg/kg of intravenous ketamine (group K) or 1 μg/kg of intravenous fentanyl (group F) concomitant with a loading dose of dexmedetomidine 1 μg/kg over 10 minutes, then dexmedetomidine infusion only was continued at 0.6 μg/kg/h for following 20 minutes, and titrated at a rate of 0.2 to 0.6 μg/kg/h until the end of surgery. After completion of the infusion of either ketamine or fentanyl, the patients were placed in the lateral position with the fracture site up. The pain score (0 = calm, 1 = facial grimacing, 2 = moaning, 3 = screaming, and 4 = unable to proceed because of restlessness or agitation) was used to describe the pain intensity in each step during the procedure (lateral positioning, hip flexion, and lumbar puncture), and quality score (0 = poor hip flexion, 1 = satisfactory hip flexion, 2 = good hip flexion, and 3 = optimal hip flexion) was used to describe the quality of posture. Group K showed a median pain score of 0 (0-1), 0 (0-0) and 0 (0-0) in lateral positioning, hip flexion and lumbar puncture, respectively, while group F showed a score of 3 (2.75-3), 3 (2-3) and 0 (0-1), respectively. The pain score in lateral positioning (P < .0001) and hip flexion (P < .0001) was significantly lower in group K than group F. Group K showed the significantly higher quality scores of spinal anesthesia positioning (P = .0044) than group F. Hemodynamic adverse effects, such as bradycardia, hypotension, and desaturation, were not significantly different between the groups. The administration of dexmedetomidine-ketamine showed a greater advantage in reducing pain intensity and increasing the quality with patient positioning during spinal anesthesia in elderly patients with proximal femoral fractures, without any serious adverse effects.

Continuous Rate Infusion of Ketamine Hydrochloride and Dexmedetomidine for Maintenance of Anesthesia during Laryngotracheal Surgery in New Zealand White Rabbits (Oryctolagus cuniculus)

New Zealand white rabbits (Oryctolagus cuniculus) are an established in vivo model for the study of structural and functional consequences of vocal-fold vibration. Research design requires invasive laryngotracheal procedures, and the presence of laryngospasms or pain responses (or both) hinder phonation-related data collection. Published anesthesia regimens report respiratory depression and muscle tone changes and have been unsuccessful in mitigating autonomic laryngeal responses in our protocol. Infusion of ketamine hydrochloride and dexmedetomidine hydrochloride in pediatric medicine provides effective analgesia and sedation for laryngotracheal procedures including intubation and bronchoscopy; however, data evaluating the use of ketamine-dexmedetomidine infusion in rabbits are unavailable. This study reports a new infusion regimen, which was used in 58 male New Zealand white rabbits that underwent a nonsurvival laryngotracheal procedure to induce phonotraumatic vocal-fold injury. Animals were sedated by using ketamine hydrochloride (20 mg/kg IM) and dexmedetomidine (0.125 mg/kg IM). Maintenance anesthesia was provided by using continuous rate intravenous infusion of ketamine hydrochloride (343 μg/kg/min) and dexmedetomidine (1.60 μg/kg/min). A stable plane of anesthesia with no autonomic laryngeal response (laryngospasm) was achieved in 32 of the 58 rabbits (55%). Laryngospasms occurred in 25 of 58 animals (43%) and were controlled in 20 cases (80%) by providing 0.33 mL 2% topical lidocaine, incremental increase in infusion rate, or both. Continuous rate infusion of ketamine hydrochloride-dexmedetomidine with prophylactic topical lidocaine provides a predictable and adjustable surgical plane of anesthesia, with minimal confounding respiratory and autonomic laryngeal responses, during extended-duration laryngotracheal surgery in rabbits. This regimen should be considered as an alternative to injection maintenance for prolonged, invasive procedures.

Driving Simulator Performance After Administration of Analgesic Doses of Ketamine With Dexmedetomidine or Fentanyl

PURPOSE/BACKGROUND

As a sole agent, ketamine acutely compromises driving ability; however, performance after coadministration with the adjuvant sedating agents dexmedetomidine or fentanyl is unclear.

METHODS/PROCEDURES

Using a randomized within-subject design, 39 participants (mean ± SD age, 28.4 ± 5.8 years) received 0.3 mg/kg bolus followed by 0.15 mg kg h infusion of ketamine (3-hour duration), in addition to either (i) 0.7 μg kg h infusion of dexmedetomidine for 1.5 hours (n = 19; KET/DEX) or (ii) three 25 μg fentanyl injections for 1.5 hours (n = 20; KET/FENT). Whole blood drug concentrations were determined during ketamine only, at coadministration (KET/DEX or KET/FENT) and at 2 hours after treatment. Subjective effects were determined using a standardized visual analog scale. Driving performance was assessed at baseline and at posttreatment using a validated computerized driving simulator. Primary outcomes included SD of lateral position (SDLP) and steering variability (SV).

FINDINGS/RESULTS

Administration of ketamine with dexmedetomidine but not fentanyl significantly increased SDLP (F1,18 = 22.60, P < 0.001) and reduced SV (F1,18 = 164.42, P < 0.001) 2 hours after treatment. These deficits were comparatively greater for the KET/DEX group than for the KET/FENT group (t37 = -5.21 [P < 0.001] and t37 = 5.22 [P < 0.001], (respectively). For the KET/DEX group, vehicle control (SV) and self-rated performance (visual analog scale), but not SDLP, was inversely associated with ketamine and norketamine blood concentrations (in nanograms per milliliter). Greater subjective effects were moderately associated with driving deficits.

IMPLICATIONS/CONCLUSIONS

Driving simulator performance is significantly compromised after coadministration of analgesic range doses of ketamine with dexmedetomidine but not fentanyl. An extended period of supervised driver abstinence is recommended after treatment, with completion of additional assessments to evaluate home readiness.

Pharmacokinetics, absolute bioavailability and tolerability of ketamine after intranasal administration to dexmedetomidine sedated dogs

Intranasal ketamine has recently gained interest in human medicine, not only for its sedative, anaesthetic or analgesic properties, but also in the management of treatment resistant depression, where it has been shown to be an effective, fast acting alternative treatment. Since several similarities are reported between human psychiatric disorders and canine anxiety disorders, intranasal ketamine could serve as an alternative treatment for anxiety disordered dogs. However, to the authors knowledge, intranasal administration of ketamine and its pharmacokinetics have never been described in dogs. Therefore, this study aimed to examine the pharmacokinetics, absolute bioavailability and tolerability of intranasal ketamine administration compared with intravenous administration. Seven healthy, adult laboratory Beagle dogs were included in this randomized crossover study. The dogs received 2 mg/kg body weight ketamine intravenously (IV) or intranasally (IN), with a two-week wash-out period. Prior to ketamine administration, dogs were sedated intramuscularly with dexmedetomidine. Venous blood samples were collected at fixed times until 480 min post-administration and ketamine plasma concentrations were determined by liquid chromatography-tandem mass spectrometry. Cardiovascular parameters and sedation scores were recorded at the same time points. Non-compartmental pharmacokinetic analysis revealed a rapid (Tmax = 0.25 ± 0.14 h) and complete IN bioavailability (F = 147.65 ± 49.97%). Elimination half-life was similar between both administration routes (T1/2el IV = 1.47 ± 0.24 h, T1/2el IN = 1.50 ± 0.97 h). Heart rate and sedation scores were significantly higher at 5 and 10 min following IV administration compared to IN administration, but not at the later time-points.

Neurocognitive performance under combined regimens of ketamine-dexmedetomidine and ketamine-fentanyl in healthy adults: A randomised trial

Analgesic doses of ketamine affects neurocognition; however, deficits under co-administration regimens are unknown. This study evaluated the effects of ketamine, alone and in combination with dexmedetomidine or fentanyl on neurocognition. Using a randomised, within-subjects gender stratified design, 39 participants (mean age = 28.4, SD ± 5.8) received a ketamine bolus of 0.3 mg/kg followed by 0.15 mg/kg/h infusion of ketamine (3 h duration). At 1.5 h post-ketamine infusion commencement, participants received either: i) 0.7 μg/kg/h infusion of dexmedetomidine (n = 19) (KET/DEX) or (ii) three 25 μg fentanyl injections over 1.5 h (n = 20) (KET/FENT). Reaction and Movement time (RTI, Simple and 5Choice), Visuospatial Working Memory (SWM) and Verbal Recognition Memory (VRM) were assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB). Whole blood drug concentrations were determined during ketamine-only infusion, at co-administration (KET/DEX or KET/FENT) and at 2-h post-treatment. Ketamine-only administration impaired psychomotor response speed (Simple and 5Choice) and impaired memory (all p < .001), however did not alter executive function abilities. Independent of sedation, co-administration of dexmedetomidine produced synergistic performance and memory deficits which persisted at post-treatment (KET/DEX) (all p < .001), and were comparatively greater than for KET/FENT (all p < .05). Ketamine, norketamine and dexmedetomidine concentrations were modestly associated with reduced psychomotor speed and accuracy (all p < .05), and an inverse relationship was found between blood concentrations of ketamine, norketamine and dexmedetomidine and performance on memory tasks. Co-administration of ketamine with dexmedetomidine but not with fentanyl exerts synergistic effects on psychomotor performance and memory without executive dysfunction. Assessment of these effects in clinical groups is warranted.

Safety of Pediatric Peripheral Blood Stem Cell Harvest in Daycare Setting: An Institutional Experience

Introduction

Children serving as a donor for their siblings will require anesthesia or sedation. In view of shortage of time and space in operating room setting, peripheral blood stem cell (PBSC) harvest is performed as a daycare procedure.

Aim

This study aims to find out whether performing PBSC harvest in hematology blood collection area as a daycare procedure is safe or not.

Settings and Design

This secondary analysis included 164 pediatric PBSC harvest (154 pediatric donors, of which 10 had repeat harvesting done) donors, performed under anesthesia, in the Department of Hematology, between January 2009 and June 2017.

Materials and Methods

Donors were examined, informed consent was obtained, and adequate premedications were ensured. Induction was intravenous for cooperative donors or inhalational sevoflurane followed by intravenous maintenance infusion using either face mask or a laryngeal mask airway (LMA). During the procedure, vitals are monitored with a noninvasive monitor. Normal hemodynamics were ensured before transferring the children to the ward.

Statistical Analysis

Statistical analysis was performed using SPSS 16.0 statistical software. Descriptive statistics and frequencies were used for the data description.

Results

A total of 137 donors (median age of 5 years) were induced with sevoflurane and LMA was used in 84 children and face mask in 53. Twenty-seven children cooperated for intravenous induction. Various combinations of propofol, dexmedetomidine, and ketamine were used with respiratory and hemodynamic stability. The median duration of anesthesia was 250 (165-375) min. The recovery from anesthesia was smooth with a median wake-up time of 20 (5-60) min.

Conclusion

This retrospective analysis demonstrates that nonoperating room anesthesia for pediatric age group for PBSC harvest can be safely and successfully accomplished outside the operation room setting by a consultant anesthesiologist.

Analysis of 17 948 pediatric patients undergoing procedural sedation with a combination of intranasal dexmedetomidine and ketamine

BACKGROUND

Intranasal procedural sedation using dexmedetomidine is well described in the literature. The combination of intranasal dexmedetomidine and ketamine is a novel approach for which there are little data on the rate of successful sedation or adverse events.

OBJECTIVES

The aim of this study is to evaluate the rate of successful sedation and adverse events of intranasal procedural sedation using a combination of dexmedetomidine and ketamine for diagnostic examination in children.

METHODS

This was a retrospective study and data were collected after ethics approval. A total of 17 948 pediatric patients (7718 females, 10 230 males) in a tertiary hospital in China were evaluated. Patients received a combination of 2 μg kg^-1 of dexmedetomidine and 1 mg kg^-1 of ketamine intranasally for procedural sedation. The level of sedation and recovery was assessed by the Modified Observer Assessment of Alertness/Sedation scale and the Modified Aldrete Score.

RESULTS

The rate of intranasal sedation success was 93% (16691/17948), intranasal sedation rescue was 1.8% (322/17948), and intranasal sedation failure was 5.2% (935/17948). Sedation success was defined as successful completed the diagnostic examination and obtained adequate diagnostic-quality images and reports. Intranasal sedation success, rescue and failure were respectively defined as sedation success with intranasal a single dose, additional bolus dose and the need for intravenous (IV) medications/inhalation agents. Median sedation time was 62 min (interquartile range: 55-70 min), median time for onset of sedation was 15 min (interquartile range: 15-20 min), and median sedation recovery time was 45 min (interquartile range: 38-53 min). Incidence of adverse events was low (0.58%; 105/17948), with major and minor adverse event being reported in 0.02% (4/17948) and 0.56% (101/17948) patients, respectively. Postoperative nausea and vomiting was the most common (0.3%; 53/17948) minor adverse event.

CONCLUSION

Procedural sedation using a combination of intranasal dexmedetomidine and ketamine is associated with acceptable effectiveness and low rates of adverse events.

Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions

Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.

Comparison of dexmedetomidine and ketamine versus propofol and ketamine for procedural sedation in children undergoing minor cardiac procedures in cardiac catheterization laboratory

BACKGROUND

The ideal anaesthetic technique for management of paediatric patients scheduled to undergo cardiac catheterisation is still not standardised.

AIM

To compare the effects of ketamine-propofol and ketamine-dexmedetomidine combinations on hemodynamic parameters and recovery time in paediatric patients undergoing minor procedures and cardiac catheterisation under sedation for various congenital heart diseases.

MATERIAL AND METHODS

60 children of either sex undergoing cardiac catheterisation were randomly assigned into two groups Dexmedetomidine-ketamine group (DK) and Propofol-ketamine (PK) of 30 patients each. All patients were premedicated with glycopyrrolate and midazolam (0.05mg/kg) intravenously 5-10 min before anaesthetic induction. Group 'DK'received dexmedetomidineiv infusion 1 μg/kg over 10 min + ketamine1mg/kg bolus, followed by iv infusion of dexmedetomidine 0.5μg/kg/hr and of ketamine1 mg/kg/hr. Group 'PK' received propofol 1mg/kg and ketamine 1mg/kg/hr for induction followed by iv infusion of propofol 100 μg/kg/hr and ketamine 1 mg/kg/hr for maintenance. Haemodynamic parameters and recovery time was recorded postoperatively.

STATISTICAL ANALYSIS

Independent sample t test was used to compare the statistical significance of continuous variables of both the groups.Chi square test was used for numerical data like gender.Fischer exact test was applied for non parametric data like ketamine consumption.

RESULTS

We observed that heart rate in dexmedetomidine (DK) group was significantly lower during the initial 25 mins after induction compared to the propofol (PK) group. Recovery was prolonged in the DK group compared to the PK group (40.88 vs. 22.28 min). Even ketamine boluses consumption was higher in DK group.

CONCLUSION

Use of dexmedetomidine-ketamine combination is a safe alternative, without any hemodynamic orrespiratory effects during the cardiac catheterization procedure but with some delayed recovery.

Non-intubated thoracoscopic bullectomy under sedation is safe and comfortable in the perioperative period

Background

Non-intubated thoracoscopic surgery can be performed under sedation using adjuvant regional anesthesia, however, the benefits of non-intubated thoracoscopic surgery under sedation have not yet been completely verified. In this study, we compare the perioperative safety and pain complaints of sedation without intubation in thoracoscopic bullectomy with that of conventional general anesthesia with double-lumen intubation and mechanical ventilation.

Methods

Forty-one patients with primary spontaneous pneumothorax who were scheduled for thoracoscopic bullectomy were enrolled in this study. Twenty-one patients were under sedation anesthesia (SA group) and 20 patients were under general anesthesia (GA group). In SA group, sedation was done with dexmedetomidine (a loading dose of 1 µg/kg for 10 min and then maintained in dosages of 0.3-1 µg/kg/h) and ketamine (2-4 mg/kg/h intraoperatively). Meanwhile, in GA group, induction with propofol and rocuronium, intubation with double lumen endotracheal tube and maintenance with 1.0-2.5% sevoflurane was done. In both groups, thoracoscopic bullectomy was performed in the same manner and all operations were conducted by single surgeon. Time for anesthesia [including emergence time and post-anesthesia care unit (PACU) recovery time] and operation, postoperative pain, sore throat, hoarseness, adverse events (nausea, vomiting, hypotension and bradycardia), dose of rescue analgesic drug used for 24 hours post-operatively and perioperative arterial blood gas analysis were recorded.

Results

The times for anesthesia, operation and emergence were significantly shorter in SA than GA. Incidence of sore throat were significantly lower in SA. The difference of other adverse events in the two groups was not significant.

Conclusions

Our study demonstrated that compared to double-lumen intubation with general anesthesia, non-intubation with sedation for bullectomy for primary spontaneous pneumothorax was safe and efficient to reduce perioperative time.

The Use of Continuous Ketamine for Analgesia and Sedation in Critically Ill Patients with Opioid Abuse: A Case Series

Managing pain and agitation in patients with opioid abuse is becoming more common in intensive care units. Tolerance to commonly used agents is often observed, leading to inadequate pain control and increased agitation. Ketamine's unique mechanism of action and opioid-sparing effects make it an ideal agent for patients with suboptimal response to opioid therapy. This report describes our experience using continuous ketamine infusions for analgesia and sedation in four mechanically ventilated patients with histories of opioid abuse that had suboptimal response to standard therapy. Ketamine was successful in improving analgesia and sedation in three patients while reducing the need for other analgesics and sedatives with minimal adverse effects. Continuous ketamine infusions may be useful to facilitate mechanical ventilation in patients with histories of opioid abuse with minimal toxicity. More information is needed on the optimal dose and titration parameters.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

Myocardial protective effects of dexmedetomidine in patients undergoing cardiac surgery: A meta-analysis and systematic review

Arrhythmias are the common complications following cardiac surgery and contribute to hemodynamic instability, cognitive impairment, thromboembolic events, and congestive heart failure. Prevention of atrial fibrillation following cardiac surgery reduces morbidity and among the many available preventive approaches dexmedetomidine shows many positive effects on cardiovascular stability. Even though many studies indicated the beneficial effects of dexmedetomidine, the power of the analysis and conclusion of these studies is rather weak due to relatively smaller number of patients in these studies. In the present meta-analysis, we included a large number of patients, both children and adults, undergoing cardiac surgery, to address the efficacy of dexmedetomidine. Several databases were searched to identify clinical studies comparing the efficacy of dexmedetomidine in myocardial protection in patients undergoing cardiac surgery. Cardiac function related parameters including heart rate, blood pressure, tachycardia, arrhthmias, and bradycardia were measured. In accordance with the selection criteria, a total of 18 studies published between 2003 and 2016, with a total of 19,225 patients were included in the present meta-analysis. Dosage of dexmedetomidine was in the range of 0.5-1 µg/kg body weight loading followed by continuous infusion at a rate of 0.2-0.7 µg/kg/h. Dexmedetomidine treatment was found to lower heart rate, systolic blood pressure, incidence of tachycardia and arrhythmias in both adult and pediatric patients, but elevated the risk of bradycardia. In conclusion, results of this meta-analysis indicate that dexmedetomidine is an efficacious cardioprotective drug in adults and children undergoing cardiac surgery.

Dexmedetomidine-ketamine versus Dexmedetomidine-midazolam-fentanyl for monitored anesthesia care during chemoport insertion: a Prospective Randomized Study

Background

Dexmedetomidine as a sole agent showed limited use for painful procedures due to its insufficient sedative/analgesic effect, pronounced hemodynamic instability and prolonged recovery. The aim of this study was to compare the effects of dexmedetomidine-ketamine (DK) versus dexmedetomidine-midazolam-fentanyl (DMF) combination on the quality of sedation/analgesia and recovery profiles for monitored anesthesia care (MAC).

Methods

Fifty six patients undergoing chemoport insertion were randomly assigned to group DK or DMF. All patients received 1 μg.kg⁻¹ dexmedetomidine over 10 min followed by 0.2–1.0 μg.kg⁻¹h⁻¹ in order to maintain 3 or 4 of modified Observer's Assessment of Analgesia and Sedation score checked every 3 min. At the start of dexmedetomidine infusion, patients in group DK or DMF received 0.5 mg.kg⁻¹ ketamine or 0.05 mg.kg⁻¹ midazolam + 0.5 μg.kg⁻¹ fentanyl intravenously, respectively. When required, rescue sedatives (0.5 mg.kg-1 of ketamine or 0.05 mg.kg-1 of midazolam) and analgesics (0.5 mg.kg-1 of ketamine or 0.5 μg.kg-1 of fentanyl) were given to the patients in DK or DMF group, respectively. The primary outcome of this study was the recovery parameters (time to spontaneous eye opening and the length of the recovery room stay). The secondary outcomes were parameters indicating quality of sedation/analgesia, cardiorespiratory variables, and satisfaction scores.

Results

There were no significant differences in the onset time, time to spontaneous eye opening, recovery room stay, the incidences of inadequate analgesia, hypotension and bradycardia between the two groups. Despite lower infusion rate of dexmedetomidine, more patients in the DMF group had bispectral index (BIS) < 60 than in the DK group and vice versa for need of rescue sedatives. The satisfaction scores of patients, surgeon, and anesthesiologist in the DMF group were significantly better than the DK group.

Conclusions

The DK and DMF groups showed comparable recovery time, onset time, cardiorespiratory variables, and analgesia. However, the DMF group showed a better sedation quality and satisfaction scores despite the lower infusion rate of dexmedetomidine, and a higher incidence of BIS < 60 than the DK group.

Trial registration

Clinical Trial Registry of Korea KCT0000951, registered 12/12/2013

Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children

AIM

Examination of dynamic airway collapse in patients with obstructive sleep apnea (OSA) during drug-induced sleep endoscopy (DISE) can help identify the anatomic causes of airway obstruction. We hypothesized that a combination of dexmedetomidine and ketamine (Group DK) would result in fewer oxygen desaturations and a higher successful completion rate during DISE in children with OSA when compared to propofol (Group P) or sevoflurane/propofol (Group SP).

METHODS

In this retrospective study, we reviewed the records of 59 children who presented for DISE between October 2013 and March 2015. Data analyzed included demographics, OSA severity, and hemodynamics (heart rate and blood pressure). The primary outcomes were airway desaturation during DISE to <85% and successful completion of DISE; these were compared between the three groups: DK, P, and SP.

RESULTS

Preoperative polysomnography was available for 49 patients. There were significantly more patients with severe OSA in Group P as compared to the other two groups. The mean (±sd) bolus dose for ketamine, dexmedetomidine, and propofol were 2.0 ± 0.6 mg·kg(-1) , 1.9 ± 0.9 mcg·kg(-1) , and 1.8 ± 1.1 mg·kg(-1) , respectively. The mean (±sd) infusion rate for dexmedetomidine was 1.6 ± 0.7 mcg·kg(-1) ·h(-1) and for propofol was 248 ± 68 mcg·kg(-1) ·min(-1) in Group P and 192 ± 48 mcg·kg(-1) ·min(-1) in Group SP. Patients in Group DK had significantly fewer desaturations to <85% during DISE compared to Group P. Patients in Group DK had significantly more successful completion of DISE (100% Group DK, 92% Group P, and 79% Group SP) as compared to Group SP.

CONCLUSIONS

These results suggest that the described dose regimen of propofol used alone or in combination with sevoflurane appears to be associated with more oxygen desaturations and a lower rate of successful completion than a combination of dexmedetomidine and ketamine during DISE in children with OSA.

A randomized, controlled trial to compare the efficacy and safety profile of a dexmedetomidine-ketamine combination with a propofol-fentanyl combination for ERCP

BACKGROUND AND AIMS

Moderate to deep levels of sedation and analgesia are required for ERCP. Propofol-based sedation is simple, easy to use, and effective, but is not without cardiovascular and respiratory adverse effects. The combination of dexmedetomidine and ketamine (DK) has shown promising results for sedation in other similar scenarios. The aim of this study was to compare the efficacy and safety of a standard propofol-fentanyl (PF) regimen with a DK combination.

METHODS

After approval of the hospital ethics committee, 83 patients (18-75 years of age) were randomized and divided into 2 groups. Forty-two patients received a PF combination (group PF) and 41 patients received DK combination (group DK) for total intravenous anesthesia for ERCP as initial boluses followed by an infusion of PF and DK, respectively. The sedation-related adverse effects and recovery time were noted.

RESULTS

The mean values of the hemodynamic and respiratory parameters were in clinically acceptable ranges, but there were more episodes of hypotension (19%), bradycardia (4.7%), and decrease in oxygen saturation (Spo(2) <80% in 11.9% and Spo(2) <90% for >10 s in 42.8%) in group PF. The procedure could be completed in all of the patients but was interrupted in 6 patients in group PF because of desaturation (5) or sudden patient movement (1). The recovery time was longer in group DK than in group PF.

CONCLUSION

There were significantly fewer sedation-related adverse effects, but the recovery time was longer with DK.