Comparison of ketofol (combination of ketamine and propofol) and propofol anesthesia in aneurysmal clipping surgery: A prospective randomized control trial

Ajit Bhardwaj; Nidhi Panda; Rajeev Chauhan; Summit Bloria; Neerja Bharti; Hemant Bhagat; Vishwanath Bhaire; Ankur Luthra; Rajesh Chhabra; Shalvi Mahajan

doi:10.4103/ajns.AJNS_346_19

Asian Journal of Neurosurgery, Table of Contents

CC BY-NC-ND 4.0 · Asian J Neurosurg 2020; 15(03): 608-613
DOI: 10.4103/ajns.AJNS_346_19

Original Article

Comparison of ketofol (combination of ketamine and propofol) and propofol anesthesia in aneurysmal clipping surgery: A prospective randomized control trial

Ajit Bhardwaj

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Nidhi Panda

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Rajeev Chauhan

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Summit Bloria

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Neerja Bharti

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Hemant Bhagat

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Vishwanath Bhaire

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Ankur Luthra

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

,

Rajesh Chhabra

¹Department of Neurosurgery, PGIMER, Chandigarh

,

Shalvi Mahajan

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh

› Author Affiliations

Abstract

Background: The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms. Materials and Methods: Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups. Results: The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone (P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference (P > 0.05). Conclusion: Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

Key-words:

Aneurysmal clipping - brain relaxation - hemodynamic stability - intracranial pressure - ketofol

Full Text

References

References
1 Priebe HJ. Aneurysmal subarachnoid haemorrhage and the anaesthetist. Br J Anaesth 2007;99:102-18.
2 Trapani G, Altomare C, Liso G, Sanna E, Biggio G. Propofol in anesthesia. Mechanism of action, structure-activity relationships, and drug delivery. Curr Med Chem 2000;7:249-71.
3 Kotani Y, Shimazawa M, Yoshimura S, Iwama T, Hara H. The experimental and clinical pharmacology of propofol, an anesthetic agent with neuroprotective properties. CNS Neurosci Ther 2008;14:95-106.
4 Jones GM, Doepker BA, Erdman MJ, Kimmons LA, Elijovich L. Predictors of severe hypotension in neurocritical care patients sedated with propofol. Neurocrit Care 2014;20:270-6.
5 Bryson HM, Fulton BR, Faulds D. Propofol. An update of its use in anaesthesia and conscious sedation. Drugs 1995;50:513-59.
6 AstraZeneca. Diprivan (propofol) Injectable Emulsion for IV Administration Prescribing Information. Wilmington, DE: AstraZeneca; 2001.
7 Zanos P, Moaddel R, Morris PJ, Riggs LM, Highland JN, Georgiou P, et al. Ketamine and ketamine metabolite pharmacology: Insights into therapeutic mechanisms. Pharmacol Rev 2018;70:621-60.
8 Takeshita H, Okuda Y, Sari A. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology 1972;36:69-75.
9 Shapiro HM, Wyte SR, Harris AB. Ketamine anesthesia in patients with intracranial pathology. Br J Anaesth 1972;44:1200-4.
10 Mayberg TS, Lam AM, Matta BF, Domino KB, Winn HR. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy. Anesth Analg 1995;81:84-9.
11 Strebel S, Kaufmann M, Maître L, Schaefer HG. Effects of ketamine on cerebral blood flow velocity in humans. Influence of pretreatment with midazolam or esmolol. Anaesthesia 1995;50:223-8.
12 Albanèse J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997;87:1328-34.
13 Bourgoin A, Albanèse J, Wereszczynski N, Charbit M, Vialet R, Martin C. Safety of sedation with ketamine in severe head injury patients: Comparison with sufentanil. Crit Care Med 2003;31:711-7.
14 Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas 2006;18:37-44.
15 Weatherall A, Venclovas R. Experience with a propofol-ketamine mixture for sedation during pediatric orthopedic surgery. Paediatr Anaesth 2010;20:1009-16.
16 Erdogan Kayhan G, Yucel A, Colak YZ, Ozgul U, Yologlu S, Karlıdag R, et al. Ketofol (mixture of ketamine and propofol) administration in electroconvulsive therapy. Anaesth Intensive Care 2012;40:305-10.
17 Rapeport DA, Martyr JW, Wang LP. The use of “ketofol” (ketamine-propofol admixture) infusion in conjunction with regional anaesthesia. Anaesth Intensive Care 2009;37:121-3.
18 Samar A, Henry A, Enas M, Ehab M. Preliminary evaluation of ketofol based sedation for awake craniotomy procedures. Egypt J Anaesthesia 2010;26:293-7.
19 Gardner AE, Olson BE, Lichtiger M. Cerebrospinal-fluid pressure during dissociative anesthesia with ketamine. Anesthesiology 1971;35:226-8.
20 Wyte SR, Shapiro HM, Turner P, Harris AB. Ketamine-induced intracranial hypertension. Anesthesiology 1972;36:174-6.
21 Gibbs JM. The effect of intravenous ketamine on cerebrospinalfluid pressure. Br J Anaesth 1972;44:1298-302.
22 Hayes GJ, Slocum HC. The achievement of optimal brain relaxation by hyperventilation technics of anesthesia. J Neurosurg 1962;19:65-70.
23 Petersen KD, Landsfeldt U, Cold GE, Petersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: A randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology 2003;98:329-36.
24 Talke P, Caldwell JE, Richardson CA. Sevoflurane increases lumbar cerebrospinal fluid pressure in normocapnic patients undergoing trans-sphenoidal hypophysectomy. Anesthesiology 1999;91:127-30.
25 Talke P, Caldwell J, Dodsont B, Richardson CA. Desflurane and isoflurane increase lumbar cerebrospinal fluid pressure in normocapnic patients undergoing trans-sphenoidal hypophysectomy. Anesthesiology 1996;85:999-1004.
26 Chui J, Mariappan R, Mehta J, Manninen P, Venkatraghavan L. Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: Systematic review and meta-analysis. Can J Anaesth 2014;61:347-56.
27 Andolfatto G, Willman E. A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults. Acad Emerg Med 2011;18:237-45.