Comparison of Ketamine-Dexmedetomidine Combination with Fentanyl-Dexmedetomidine Combination for Procedural Sedoanalgesia during CT-Guided Interventional Radiology Procedures: A Randomized Controlled Study
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Shagun Bhatia Shah
,
Akhilesh Pahade
,
Namrata Gupta
,
Deepti Gupta
,
Rajiv Chawla
,
Ajay Kumar Bhargava
Abstract
Background: The quest for an ideal sedoanalgesic-combination exhibiting the triad of efficacy, safety and patient comfort has led to administration of several permutations and combinations of drugs (midazolam, fentanyl, remifentanil, dexmedetomidine, propofol, ketamine, pethidine, pentazocine). The ideal sedoanalgesic for CT-guided core-biopsy of spine, radiofrequency/microwave ablation of hepatic/pulmonary lesions, has hitherto been elusive. In the absence of any guidelines, we compared a ketamine-dexmedetomidine combination (Group-K) with fentanyl-dexmedetomidine (Group-F).
Methods: This prospective, interventional, single-centric, parallel-armed, randomized controlled study included 60 patients (ASA physical state I-II, either gender, aged 18-75y, weighing 35-85kg), undergoing CT-guided core biopsy/radiofrequency/microwave ablation in remote location, allocated to Group-K and Group-F. Independent/paired-sample t-tests were utilized and data expressed as box-whisker plots and trendlines, p-value<0.05 being statistically significant.
Results: There was a significant difference in intraprocedural pain-scores between both groups (p-values 0.0001, 0.0011, 0.0092 and 0.0201 at 0-10mins, 10-20mins, 20-30mins and 30-40mins respectively). More patients in Group-F required rescue-analgesic with reduced interventionist-satisfaction score versus Group-K. In Group-K, mean arterial pressure and heart rate (95.1mmHg;79.6/min) increased after initial ketamine bolus, but were maintained/decreased at intervention-initiation (93.2mmHg;79.4/min) and at 10min and 30min thereafter. In Group-F, MAP and HR decreased after initial fentanyl bolus (83.5mHg;71.9/min), increased with intervention-initiation (90.1mmHg;77/min), progressively decreasing at every time-point thereafter. VAS-scores (resting; on coughing) were lower in Group-K.
Conclusion: A ketamine-dexmedetomidine combination technique demonstrated a superior sedoanalgesic effect with reduced intra-procedural bradypnea, bradycardia, rescue-drug requirement and post-procedural complications with enhanced interventionist-satisfaction and may emerge as the ideal procedural sedoanalgesic for patients undergoing CT-guided core-biopsy, radiofrequency/microwave ablation.
[2] Amornyotin S, Jirachaipitak S, Wangnatip S. Anesthetic management for radiofrequency ablation in patients with hepatocellular carcinoma in a developing country. J Anesth Crit Care. 2015; 3:86-90.
[3] Tobias JD, Leder M. Procedural sedation: A review of sedative agents, monitoring, and management of complications. Saudi J Anaesth. 2011; 5:395-410.
[4] Jennings PA, Cameron P, Bernard S. Ketamine as an analgesic in the pre‐hospital setting: a systematic review. Acta Anaesthesiol Scand. 2011; 55:638-43.
[5] Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Pediatr Crit Care Med. 2012; 13:423-7.
[6] Salmore R. Development of a new pain scale: Colorado Behavioral Numerical Pain Scale for sedated adult patients undergoing gastrointestinal procedures. Gastroenterol Nurs. 2002; 25:257–62.
[7] Oh C, Kim Y, Eom H. Procedural Sedation Using a Propofol-Ketamine Combination (Ketofol) vs. Propofol Alone in the Loop Electrosurgical Excision Procedure (LEEP): A Randomized Controlled Trial. J Clin Med 2019; 8:943-8.
[8] Chen F, Wang C, Lu Y, Huang M, Fu Z. Efficacy of different doses of dexmedetomidine as a rapid bolus for children: a double-blind, prospective, randomized study. BMC Anesthesiol. 2018; 18(1):1-7.
[9] Williams MR, McKeown A, Dexter F, Miner JR, Sessler DI, Vargo J, Turk DC, Dworkin RH. Efficacy outcome measures for procedural sedation clinical trials in adults: an ACTTION systematic review. Anesthesia & Analgesia. 2016; 122(1):152-70.
[10] David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med. 2011; 57:435–41
[11] Romero TR, Galdino GS, Silva GC, Resende LC, Perez AC, Côrtes SF, Duarte ID. Ketamine activates the L-arginine/Nitric oxide/cyclic guanosine monophosphate pathway to induce peripheral antinociception in rats. Anesth Analg. 2011; 113:1254-9.
[12] Gupta A, Devi LA, Gomes I. Potentiation of mu-opioid receptor-mediated signaling by ketamine. J Neurochem. 2011; 119:294–302.
[13] De Kock M, Loix S, Lavand'homme P. Ketamine and peripheral inflammation. CNS Neurosci Ther. 2013; 19:403–10.
[14] Taheri R, Seyedhejazi M, Ghojazadeh M, Ghabili K, Shayeghi S. Comparison of ketamine and fentanyl for postoperative pain relief in children following adenotonsillectomy. Pak J Bio Sci. 2011; 14:572-7.
[15] Messenger DW, Murray HE, Dungey PE, van Vlymen J, Sivilotti ML. Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: A randomized clinical trial. Acad Emerg Med. 2008; 15:877–86
[16] Majidinejad S, Esmailian M, Emadi M. Comparison of intravenous ketamine with morphine in pain relief of long bones fractures: a double blind randomized clinical trial. Emerg. 2014; 2:77-80.
[17] Motov S, Rockoff B. Intravenous sub-dissociative dose ketamine versus morphine for analgesia in the emergency department: A randomized controlled trial. Ann Emerg Med. 2015; 66:222-9.
[18] Miller JP, Schauer SG, Ganem VJ, Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: A randomized controlled trial. Am J Emerg Med. 2015; 33:402–8.
[19] Balzer N, McLeod SL, Walsh C, Grewal K. Low-dose ketamine for acute pain control in the Emergency Department: A systematic review and meta-analysis. Acad Emerg Med. 2021; 28:444-54.
[20] Lee EN, Lee JH. The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis. PLoS ONE. 2016; 11(10): e0165461.
[21] Yuan F, Fu H, Yang P. Dexmedetomidine-fentanyl versus propofol-fentanyl in flexible bronchoscopy: A randomized study. Exp Ther Med. 2016; 12:506-12.
[22] Lahti AC, Weiler MA, Michaelidis BT, Parwani A, Tamminga CA. Effects of ketamine in normal and schizophrenic volunteers. Neuropsychopharmacol. 2001; 25:455-67.
[23] Mauermann E, Clamer D, Ruppen W, Bandschapp O. Association between intra-operative fentanyl dosing and postoperative nausea/vomiting and pain: A prospective cohort study. Eur J Anaesthesiol. 2019; 36:871-80.
[24] Gunduz M, Sakalh S, Gunes Y, Kesiktas E, Ozcengiz D. Comparison of effects of ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. J Anesthesiol Clin Pharmacol. 2011; 27: 220-4.
[25] Kayyal TA, Wolfswinkel EM, Weathers WM, Capehart SJ, Monson LA. Treatment effects of dexmedetomidine and ketamine on postoperative analgesia after cleft palate repair. Cranio Maxillofac Trauma Recon. 2014; 7:131-8.
[26] Kako H, Corridore M, Kean J, Mendell JR, Flanigan KM. Dexmedetomidine and ketamine sedation for muscle biopsies in patients with Duchenne muscular dystrophy. Pediatr Anesth. 2014; 24:851-6.
[27] Nama S, Meenan DR, Fritz WT. The use of sub-anesthetic intravenous ketamine and adjuvant dexmedetomidine when treating acute pain from CRPS. Pain Physician. 2010; 13:365-8.
[28] Tosun Z, Akin A, Guler G, Esmaoglu A, Boyaci A. Dexmedetomidine-ketamine and propofol-ketamine combinations for anesthesia in spontaneously breathing pediatric patients undergoing cardiac catheterization. J Cardiothorac Vasc Anesth. 2006; 20:515-9.
| Files | ||
| Issue | Vol 9 No Supp. 1 (2023): Supplement 1 |
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| Section | Research Article(s) | |
| DOI | https://doi.org/10.18502/aacc.v9i5.13963 | |
| Keywords | ||
| Dexmedetomidine Fentanyl Interventional radiology Ketamine Procedural sedation Remote location | ||
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