الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Procedural sedation and analgesia (PSA) describes a state produced by the proper administration of sedative agents with analgesics to induce a state that allows the patient to tolerate unpleasant painful and anxiety-provoking procedures.
An ideal procedural sedation analgesia agent would have a rapid onset, a short duration of action and a smooth recovery, maintain hemodynamic stability, preserves protective reflexes, also provide sufficient analgesia, sedation, amnesia, and motor control through out the procedure, reversible and it must not cause major side effects. Several medications are commonly used and no single drug is ideal for all situations because their own drawbacks. The provision of PSA with ketamine–propofol combination is theoretically attenuating the negative effects of each other and providing better potentially synergism with complementary effects at decreased dosages.
The aim of this work was to evaluate the mixture of intravenous 1:1 ketamine–propofol in one syringe for adult procedural sedation and analgesia (PSA) for emergency procedures as regards changes in hemodynamics, adverse effect profile, effectiveness, the dose and recovery.This study was carried out on seventy adult patients of both sexes and ASA physical status classification I or II with age more than 20 years old. The Exclusion criteria were known allergy to either study medication (ketamine or propofol), age younger than 20 years, Patients with CNS problems especially epilepsy, hemodynamically unstable patients and major procedures that require proper anesthetic techniques
All patients were monitored and placed on oxygen 2-3L per minute .The mixture was prepared as a 1:1 mixture of 10 mg⁄mL ketamine to be diluted in normal saline and 10 mg⁄mL propofol into a single 20 mL syringe. PSA with the mixture were performed using titrated aliquots of 0.025mL⁄ kg of solution at 30-seconds intervals, constituting 0.125mg⁄ kg each of ketamine and propofol. Each bolus constituted 10 mg of each ketamine and propofol. The level of sedation was assessed before each aliquot until achievement of Modified Ramsey Sedation Scale of 5 before starting the procedure and increments of aliquots were given to keep level of sedation at this level through the procedure.
Mean arterial blood pressure, pulse rate and oxygen saturation were monitored and recorded Just before starting the sedation mixture, five minutes after giving the sedation mixture and Just after the procedure. The following adverse events were observed during and after the procedure “Apnea, hypoxia, tachycardia, bradycardia, hypertension, hypotension, nausea, vomiting, and agitation”. Dose of the mixture, recovery time were recorded, Procedural sedation and analgesia were considered effective if: The required procedure was completed without the need for adjunctive procedural medications to achieve acceptable sedation or there was no adverse event causing termination of the procedure related to the used mixture.
The majority of procedures for patients received ketamine-propofol mixture were orthopedic as reduction of fractures and dislocation procedures performed in 30 (42.8%) patients. Other procedures also were done like dilatation and curettage (D and C) ten (14.3%) patients, upper and lower gastro-intestinal endoscopy for eleven (15.7%) patients, incision and drainage for ten (14.3%) patients, laceration repair for five (7.2%) patients, imaging (CT and MRI) for four (5.7%) patients.
There were no cases of apnea reported while there were three cases of hypoxia (4.3), while one case (1.4%) was major. No patients required endotracheal intubation. No patients encountered hypotension, hypertension or bradycardia, while just one case(1.4%) of premature atrial contractions was reported resolved spontaneous without any intervention. No patients experienced seizers while three patients (4.3%) reported post procedural agitation and hallucination. No patients encountered nausea or vomiting.
The median recovery time from propofol-ketamine mixture was 14 minutes ranged from 3 to 37 minutes with mean of 14.66 ± 5.78 minutes. The median dose of the mixture was 0.8 mg/kg ranged from 0.2-2.6 mg/kg with mean 0.90 ± 0.49 mg/kg.
Ketamine-Propofol mixture was effective in 66 patients (94.3%).The four patients in whom the mixture was not effective, the procedures were successfully completed with the provision of adjunctive sedation till complete recovery and no procedures were terminated due to occurrence of adverse events.
from this study the following can be concluded that the combination of ketamine and propofol at 1:1 ratio is a safe and an effective PSA regimen and can be used for a wide variety of painful procedures and minor surgeries as it provides analgesia and promotes hemodynamic stability as regards changes in heart rate and mean arterial blood pressure. Also the mixture preserves respiratory function and lowers the incidence of apnea and hypoxia. Moreover, the mixture blunts recovery agitation, nausea and vomiting and shortens the expected recovery time of ketamine.