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

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.

Ketofol as an Anesthetic Agent in Patients With Isolated Moderate to Severe Traumatic Brain Injury: A Prospective, Randomized Double-blind Controlled Trial

“…In addition, the total propofol dose was lower in the ketofol group than in the propofol group, and this may have contributed to the lower incidence of intraoperative hypotension in patients receiving ketofol. Similar to our findings, 2 recently published studies reported superior hemodynamic stability and decreased vasopressor requirement in good grade aneurysmal subarachnoid hemorrhage patients receiving ketofol (ketamine/propofol ratio 1:5) compared with those receiving propofol during craniotomy for aneurysmal clipping 12,13. In another study, ketofol provided superior hemodynamic stability compared with propofol during induction of anesthesia; propofol was more likely than ketofol to be associated with a ≥20% reduction in systolic blood pressure from baseline at 5 minutes (48.8% vs. 12%) and at 10 minutes (67.4% vs. 39%) after induction 14…”

“…Similar to our findings, 2 recently published studies reported superior hemodynamic stability and decreased vasopressor requirement in good grade aneurysmal subarachnoid hemorrhage patients receiving ketofol (ketamine/propofol ratio 1:5) compared with those receiving propofol during craniotomy for aneurysmal clipping. 12,13 In another study, ketofol provided superior hemodynamic stability compared with propofol during induction of anesthesia; propofol was more likely than ketofol to be associated with a ≥ 20% reduction in systolic blood pressure from baseline at 5 minutes (48.8% vs. 12%) and at 10 minutes (67.4% vs. 39%) after induction. 14 A tight brain during craniotomy can further aggravate brain injury because of the greater force required by the surgeon's retractor to achieve an adequate surgical field.…”

“…Thus, the addition of ketamine to propofol in 1:5 ratio did not worsen brain relaxation compared with propofol alone, a finding similar to those reported in previous studies. 13,14 Historically, ketamine was reported to be associated with increases in intracranial pressure, 15,16 but more recent data do not support these findings. In one study, a bolus dose of ketamine (1 mg/kg) during isoflurane anesthesia in neurosurgical patients resulted in a decrease in intracranial pressure and middle cerebral artery blood flow velocity in the absence of changes in MAP.…”

“…In this study, there was no difference in the quality of brain relaxation in patients receiving ketofol or propofol, and most patients had moderate brain swelling that did not require intervention (Grade III brain relaxation). Thus, the addition of ketamine to propofol in 1:5 ratio did not worsen brain relaxation compared with propofol alone, a finding similar to those reported in previous studies 13,14. Historically, ketamine was reported to be associated with increases in intracranial pressure,15,16 but more recent data do not support these findings.…”

Comparison of the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) on postoperative analgesia and intraoperative hemodynamics in patients undergoing spine surgery: A prospective randomized double-blind controlled trial

“…For Group OFA [ 13 14 ] : Around 10 ml syringe (labeled as an analgesic agent) contains ketamine (in a dose of 1 mg/kg) diluted with saline to a total volume of 10 ml. Around 50 ml syringe (labeled as an anesthetic agent) contains ketofol (ketamine and propofol in a ratio of 1:5), which contains 8 ml of ketamine (10 mg/ml) and 40 ml of propofol (10 mg/ml) [1 ml of ketofol contains 1.67 mg of ketamine and 8.33 mg of propofol.]…”