Exploring the Effects of Sub-Dissociative Doses of Ketamine on Sedation Quality in Bronchoscopy: A Double-Blind Clinical Study
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Abstract
Background: Sedation is recommended during flexible fiberoptic bronchoscopy (FFB) to aid in airway evaluation, minimize patient mobility, and enhance patient safety. This study was conducted to compare the impact of different sub-dissociative ketamine (SDK) doses on the quality of sedation within FFB.
Methods: This research utilized randomized clinical trial design involving three cohorts, each consisting of 30 participants. The cohorts were administered varying doses of ketamine: 0.2 mg/kg (SDK1), 0.4 mg/kg (SDK2), and 0.5 mg/kg (SDK3). After receiving ketamine, all participants received propofol in bolus dose 0.4 mg/kg followed by infusion 50-100 µg/kg.
FFB started when sedation level 4 was reached, according to Ramsey's sedation score.
Results: Regarding demographic variables revealed no statistically notable discrepancy among the cohorts (P>0.05). The SDK3 cohort exhibited a higher average sedation score and longer duration of sedation compared to the SDK2, with both metrics also surpassing those of the SDK1 cohort. (P>0.001). Furthermore, the satisfaction levels reported by the bronchoscopist (P=0.78) and the participants (P=0.019) were notably greater in the SDK3 cohort than in the other groups. Additionally, the amount of propofol administered to the SDK3 cohort was less than that given to the SDK2, and both cohort received lower doses than the SDK1 cohort (P>0.001).
Conclusion: Elevating the SDK from 0.2 mg/kg to 0.5 mg/kg when administered alongside propofol correlates with a rise in the score of sedation, increasing patient and bronchoscopist satisfaction, and decreasing propofol consumption in FFB in adults. A dosage of 0.5 mg/kg might be more advantageous compared to alternative dosages for FFB in adult patients.
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[11] Beaudrie-Nunn AN, Wieruszewski ED, Woods EJ, Bellolio F, Mara KC, Canterbury EA. Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department. Am J Emerg Med. 2023; 70:133-139.
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[13] Stanzel F. Bronchoalveolar Lavage. Principles and Practice of Interventional Pulmonology. 2012; 165–76.
[14] Banerjee S, McCormack S. Ketamine for Sedation During Bronchoscopy Procedures: A Review of Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health, Ottawa (ON); 2020.
[15] Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974; 2(5920):656-9.
[16] Reips UD, Funke F. Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator. Behav Res Methods. 2008; 40(3):699-704.
[17] Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995; 7(1):89-91.
[18] Wuensch KL. What is a likert scale? and how do you pronounce'likert?'. East Carolina University. 2005; 4.
[19] Belachew BG, Kasahun B, Demissie BW, Sintayhu A, Dendir G, Ali A, et al. Comparison of the hemodynamic changes between preeclamptic and normotensive parturients who underwent cesarean section under spinal anesthesia at North Showa zone public hospitals, Oromia region, Ethiopia, 2022: a prospective cohort study. BMC Anesthesiol. 2023; 23(1):387.
[20] Mitra M, Basu D, Ganguly T, Kar S, Chaterjee S. Comparison of the hemodynamic alterations in normotensive and Preeclamptic pregnant woman posted for cesarean section under subarachnoid block. J Cardiovasc Dis Diagn. 2016;4(242):2.
[21] Başaran B, Çelebioğlu B, Başaran A, Altınel S, Kutlucan L, Martin JN Jr. Anesthetic practices for patients with preeclampsia or HELLP syndrome: a survey. J Turk Ger Gynecol Assoc. 2016;17(3):128.
[22] Dennis A. Management of pre-eclampsia: issues for anaesthetists. Anaesthesia. 2012; 67(9):1009–20
[23] McCollum ED, King C, Ahmed S, Hanif AAM, Roy AD, Islam AA, et al. Defining hypoxaemia from pulse oximeter measurements of oxygen saturation in well children at low altitude in Bangladesh: an observational study. BMJ Open Respir Res. 2021; 8(1):e001023.
[24] Ali Chehrei. The book of sampling and calculation of sample size in medical studies. Pajhwok Alam Arya Publications: 2016.
[25] Hwang J, Jeon Y, Park HP, Lim YJ, Oh YS. Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy. Acta Anaesthesiol Scand. 2005; 49(9):1334-8.
[26] Huang X, Ai P, Wei C, Sun Y, Wu A. Comparison of the Effects of Esketamine/Propofol and Sufentanil/Propofol on the Incidence of Intraoperative Hypoxemia during Bronchoscopy: Protocol for a Randomized, Prospective, Parallel-Group Trial. J Clin Med. 2022; 11(15):4587.
[27] Sazak H, Tunç M, Alagöz A, Pehlivanoğlu P, Demirci NY, Alıcı İO, et al. Assessment of perianesthesic data in subjects undergoing endobronchial ultrasound-guided transbronchial needle aspiration. Respir Care. 2015; 60(4):567-76.
[28] Dal T, Sazak H, Tunç M, Sahin S, Yılmaz A. A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study. J Thorac Dis. 2014; 6(6):742-51.
[29] Gunathilaka PKG, Jat KR, Sankar J, Lodha R, Kabra SK. Propofol versus Fentanyl for Sedation in Pediatric Bronchoscopy: A Randomized Controlled Trial. Indian Pediatr. 2019; 56(12):1011-1016.
[30] Abulebda K, Abu-Sultaneh S, Ahmed SS, Moser EAS, McKinney RC, Lutfi R. Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy. World J Crit Care Med. 2017; 6(4):179–184.
[31] Yoon HI, Kim JH, Lee JH, Park S, Lee CT, Hwang JY, et al. Comparison of propofol and the combination of propofol and alfentanil during bronchoscopy: a randomized study. Acta Anaesthesiol Scand. 2011; 55(1):104-9.
[32] Pazoki Sh, Norouzi A, Shadman AH. Comparison effect of different doses of Ketamine with Pethedine in reducing postoperative shivering after cesarean section. Journal of Arak University of Medical Sciences, Summer 2009; 12(2): 9-16
[33] Yazdi B, Khalili M, Talebi H, Fotovat AR, Nikaeen A. Effect of adding ketamine to propofol infusion on hemodynamics and recovery time of patients under cataract surgery. Anesthesiology and Pain. 2011; 2(2):10-23.
[34] Mo H, Campbell MJ, Fertel BS, Lam SW, Wells EJ, Casserly E, et al. Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience. West J Emerg Med. 2020 Jan 27;21(2):272-281.
[35] Ali I, Alahdal M, Xia H, S El Moughrabi A, Shiqian H, Yao S. Ketofol performance to reduce postoperative emergence agitation in children undergoing adenotonsillectomy. Libyan J Med. 2020; 15(1):1688450.
[2] Fruchter O, Manevich Y, Carmi U, Rozengarten D, Kramer MR. Prospective Randomized Trial Evaluating Ketamine for Adult Bronchoscopy. J Bronchology Interv Pulmonol. 2017; 24(4):279-284.
[3] Joseph JM, Gori D, Curtin C, Hah J, Ho VT, Asch SM, et al. Gaps in standardized postoperative pain management quality measures: A systematic review. Surgery. 2022; 171(2):453-458.
[4] Meshkat S, Rodrigues NB, Di Vincenzo JD, Ceban F, Jaberi S, McIntyre RS, et al. Pharmacogenomics of ketamine: A systematic review. J Psychiatr Res. 2021; 145:27-34.
[5] Zhang Y, Ye F, Zhang T, Lv S, Zhou L, Du D, et al. Structural basis of ketamine action on human NMDA receptors. Nature. 2021; 596(7871):301-305.
[6] Sahinovic MM, Struys MM, Absalom AR. Clinical pharmacokinetics and pharmacodynamics of propofol. Clinical pharmacokinetics. 2018; 57(12):1539-58.
[7] Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med. 2019; 73(5):470-480.
[8] Folino TB, Muco E, Safadi AO, Parks LJ. Propofol. StatPearls [Internet]. 2020.
[9] Crichton N. Visual analogue scale (VAS). J Clin Nurs. 2001; 10(5):706-6.
[10] Prabhudev AM, Chogtu B, Magazine R. Comparison of midazolam with fentanyl-midazolam combination during flexible bronchoscopy: A randomized, double-blind, placebo-controlled study. Indian J Pharmacol. 2017; 49(4):304-311.
[11] Beaudrie-Nunn AN, Wieruszewski ED, Woods EJ, Bellolio F, Mara KC, Canterbury EA. Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department. Am J Emerg Med. 2023; 70:133-139.
[12] Optimizing the Treatment of Acute Pain in the Emergency Department. Ann Emerg Med. 2017; 70(3):446-448.
[13] Stanzel F. Bronchoalveolar Lavage. Principles and Practice of Interventional Pulmonology. 2012; 165–76.
[14] Banerjee S, McCormack S. Ketamine for Sedation During Bronchoscopy Procedures: A Review of Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health, Ottawa (ON); 2020.
[15] Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974; 2(5920):656-9.
[16] Reips UD, Funke F. Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator. Behav Res Methods. 2008; 40(3):699-704.
[17] Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995; 7(1):89-91.
[18] Wuensch KL. What is a likert scale? and how do you pronounce'likert?'. East Carolina University. 2005; 4.
[19] Belachew BG, Kasahun B, Demissie BW, Sintayhu A, Dendir G, Ali A, et al. Comparison of the hemodynamic changes between preeclamptic and normotensive parturients who underwent cesarean section under spinal anesthesia at North Showa zone public hospitals, Oromia region, Ethiopia, 2022: a prospective cohort study. BMC Anesthesiol. 2023; 23(1):387.
[20] Mitra M, Basu D, Ganguly T, Kar S, Chaterjee S. Comparison of the hemodynamic alterations in normotensive and Preeclamptic pregnant woman posted for cesarean section under subarachnoid block. J Cardiovasc Dis Diagn. 2016;4(242):2.
[21] Başaran B, Çelebioğlu B, Başaran A, Altınel S, Kutlucan L, Martin JN Jr. Anesthetic practices for patients with preeclampsia or HELLP syndrome: a survey. J Turk Ger Gynecol Assoc. 2016;17(3):128.
[22] Dennis A. Management of pre-eclampsia: issues for anaesthetists. Anaesthesia. 2012; 67(9):1009–20
[23] McCollum ED, King C, Ahmed S, Hanif AAM, Roy AD, Islam AA, et al. Defining hypoxaemia from pulse oximeter measurements of oxygen saturation in well children at low altitude in Bangladesh: an observational study. BMJ Open Respir Res. 2021; 8(1):e001023.
[24] Ali Chehrei. The book of sampling and calculation of sample size in medical studies. Pajhwok Alam Arya Publications: 2016.
[25] Hwang J, Jeon Y, Park HP, Lim YJ, Oh YS. Comparison of alfetanil and ketamine in combination with propofol for patient-controlled sedation during fiberoptic bronchoscopy. Acta Anaesthesiol Scand. 2005; 49(9):1334-8.
[26] Huang X, Ai P, Wei C, Sun Y, Wu A. Comparison of the Effects of Esketamine/Propofol and Sufentanil/Propofol on the Incidence of Intraoperative Hypoxemia during Bronchoscopy: Protocol for a Randomized, Prospective, Parallel-Group Trial. J Clin Med. 2022; 11(15):4587.
[27] Sazak H, Tunç M, Alagöz A, Pehlivanoğlu P, Demirci NY, Alıcı İO, et al. Assessment of perianesthesic data in subjects undergoing endobronchial ultrasound-guided transbronchial needle aspiration. Respir Care. 2015; 60(4):567-76.
[28] Dal T, Sazak H, Tunç M, Sahin S, Yılmaz A. A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study. J Thorac Dis. 2014; 6(6):742-51.
[29] Gunathilaka PKG, Jat KR, Sankar J, Lodha R, Kabra SK. Propofol versus Fentanyl for Sedation in Pediatric Bronchoscopy: A Randomized Controlled Trial. Indian Pediatr. 2019; 56(12):1011-1016.
[30] Abulebda K, Abu-Sultaneh S, Ahmed SS, Moser EAS, McKinney RC, Lutfi R. Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy. World J Crit Care Med. 2017; 6(4):179–184.
[31] Yoon HI, Kim JH, Lee JH, Park S, Lee CT, Hwang JY, et al. Comparison of propofol and the combination of propofol and alfentanil during bronchoscopy: a randomized study. Acta Anaesthesiol Scand. 2011; 55(1):104-9.
[32] Pazoki Sh, Norouzi A, Shadman AH. Comparison effect of different doses of Ketamine with Pethedine in reducing postoperative shivering after cesarean section. Journal of Arak University of Medical Sciences, Summer 2009; 12(2): 9-16
[33] Yazdi B, Khalili M, Talebi H, Fotovat AR, Nikaeen A. Effect of adding ketamine to propofol infusion on hemodynamics and recovery time of patients under cataract surgery. Anesthesiology and Pain. 2011; 2(2):10-23.
[34] Mo H, Campbell MJ, Fertel BS, Lam SW, Wells EJ, Casserly E, et al. Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience. West J Emerg Med. 2020 Jan 27;21(2):272-281.
[35] Ali I, Alahdal M, Xia H, S El Moughrabi A, Shiqian H, Yao S. Ketofol performance to reduce postoperative emergence agitation in children undergoing adenotonsillectomy. Libyan J Med. 2020; 15(1):1688450.
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How to Cite
1.
Shetabi H, Rostami S. Exploring the Effects of Sub-Dissociative Doses of Ketamine on Sedation Quality in Bronchoscopy: A Double-Blind Clinical Study. Arch Anesth & Crit Care. 2024;.
