Effects of adding ketamine to dexmedetomidine on smooth recovery from isoflurane anesthesia in adults undergoing endoscopic sinus surgery

Abstract

Background: Recovery from general anesthesia after endoscopic sinus surgery can abruptly become dangerous and having serious complications leading to lost intravenous cannulas, disconnected cables, self extubation, physical injury, increased pain and hemorrhage. This study aimed to evaluate the effects of adding ketamine to dexmedetomidine on smooth recovery from isoflurane anesthesia in adults undergoing endoscopic sinus surgery. Methods: A prospective double-blind randomized controlled study. Ten minutes before ending of surgery, 94 patients were randomly divided into two equal groups: Group (KD) (n = 47): received ketamine 0.5 mg/kg and dexmedetomidine 0.5ug/kg completed to 10 ml 0.9% normal saline and Group (C) (n = 47): received 10 ml 0.9% normal saline. Result: The extubation, recovery and discharge times were statistically significant prolonged in KD group (6.82 ± 0.76, 8.68 ± 0.81 and17.63 ± 4.8) min compared to C group (4.34 ± 0.61, 6.3 ± 0.72 and14.8 ± 2.7) min respectively. The median Ricker Sedation-Agitation scale (RSAS) score at the recovery time, at admission to PACU, at PACU and at discharge from PACU was statistically significant lower in KD group compared to C group (p < 0.0001). The mean Visual Analogue Scale (VAS) score on arrival to PACU, discharge from PACU, one hour, 2hs, 4hs, 8hs, 12hs and 24hs postoperative and pethidine requirements were statistically significant lower in KD group compared to C group (p < 0.0001). No statistically significant difference in side-effects between groups. Conclusion: Adding 0.5 mg ketamine to 0.5ug dexmedetomidine provides smooth recovery from isoflurane anesthesia in adults undergoing endoscopic sinus surgery.

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

“…25,29,79 Previous research on ketamine has reported conflicting findings, 66 with some indicating that it increases the likelihood of emergence delirium 67,68,77 and others suggesting that it can reduce the likelihood. 31,32,37,50,69,[73][74][75]78,80,81 Among the studies reporting an association between ketamine and an increased likelihood of emergence delirium, they administered ketamine under both of the following conditions: 1) administered a relatively higher dose (e.g., >0.5 mg/kg); 67,77 and 2) without an additional active anesthetic agent (e.g., propofol, volatile agent) or an active sedative adjunct (e.g., dexmedetomidine). 67,77 In contrast, in the studies that reported an association between use of ketamine and a decreased likelihood of emergence delirium, they administered ketamine under one or more of the following conditions: 1) administered a relatively low dose (e.g., <0.5 mg/kg); 74,75,78,81 and/or 2) paired with an active anesthetic agent (e.g., propofol, volatile agent) and/or an active sedative adjunct (e.g., dexmedetomidine).…”

“…67,77 In contrast, in the studies that reported an association between use of ketamine and a decreased likelihood of emergence delirium, they administered ketamine under one or more of the following conditions: 1) administered a relatively low dose (e.g., <0.5 mg/kg); 74,75,78,81 and/or 2) paired with an active anesthetic agent (e.g., propofol, volatile agent) and/or an active sedative adjunct (e.g., dexmedetomidine). 37,69,[73][74][75]78,80,81 For example, a double-blind study of pediatric cases with sevoflurane-based anesthesia found that patients who were administered 0.15 mg/kg of ketamine and 0.3 mcg/kg of dexmedetomidine, 10 minutes before the end of surgery, resulted in a significantly lower rate and severity of emergence delirium, relative to administration of saline (control condition). 81 Our review of literature indicates that when ketamine is administered as a low dose and/or when paired with an active anesthetic agent or sedative adjunct, there is a lower likelihood and severity of emergence delirium.…”

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

“…25,29,79 Previous research on ketamine has reported conflicting findings, 66 with some indicating that it increases the likelihood of emergence delirium 67,68,77 and others suggesting that it can reduce the likelihood. 31,32,37,50,69,[73][74][75]78,80,81 Among the studies reporting an association between ketamine and an increased likelihood of emergence delirium, they administered ketamine under both of the following conditions: 1) administered a relatively higher dose (e.g., >0.5 mg/kg); 67,77 and 2) without an additional active anesthetic agent (e.g., propofol, volatile agent) or an active sedative adjunct (e.g., dexmedetomidine). 67,77 In contrast, in the studies that reported an association between use of ketamine and a decreased likelihood of emergence delirium, they administered ketamine under one or more of the following conditions: 1) administered a relatively low dose (e.g., <0.5 mg/kg); 74,75,78,81 and/or 2) paired with an active anesthetic agent (e.g., propofol, volatile agent) and/or an active sedative adjunct (e.g., dexmedetomidine).…”

“…67,77 In contrast, in the studies that reported an association between use of ketamine and a decreased likelihood of emergence delirium, they administered ketamine under one or more of the following conditions: 1) administered a relatively low dose (e.g., <0.5 mg/kg); 74,75,78,81 and/or 2) paired with an active anesthetic agent (e.g., propofol, volatile agent) and/or an active sedative adjunct (e.g., dexmedetomidine). 37,69,[73][74][75]78,80,81 For example, a double-blind study of pediatric cases with sevoflurane-based anesthesia found that patients who were administered 0.15 mg/kg of ketamine and 0.3 mcg/kg of dexmedetomidine, 10 minutes before the end of surgery, resulted in a significantly lower rate and severity of emergence delirium, relative to administration of saline (control condition). 81 Our review of literature indicates that when ketamine is administered as a low dose and/or when paired with an active anesthetic agent or sedative adjunct, there is a lower likelihood and severity of emergence delirium.…”

Comeback of ketamine: resurfacing facts and dispelling myths

“…They observed a decrease in heart rate after dexmedetomidine administration, which returned to baseline after co-administration of ketamine (mean difference between baseline and after ketamine 6.5 bpm; 95% CI, 11.2 to 1.8; P = 0.005). In 2020, a double-blind randomized RCT concluded that adding ketamine to dexmedetomidine led to good postoperative analgesia, decreased postoperative opioid requirements, and led to smooth recovery after functional endoscopic sinus surgery [ 60 ]. Sinha et al [ 61 ] compared combination of dexmedetomidine and ketamine with dexmedetomidine alone for awake fiberoptic nasotracheal intubation and concluded that the addition of low-dose ketamine (15 mg as a bolus of 5 ml, followed by continuous infusion at 20 mg/h) further enhanced hemodynamic stability and provided better sedation than dexmedetomidine alone.…”