Dexmedetomidine-ketamine versus Dexmedetomidine-midazolam-fentanyl for monitored anesthesia care during chemoport insertion: a Prospective Randomized Study

Abstract

BackgroundDexmedetomidine as a sole agent showed limited use for painful procedures due to its insufficient sedative/analgesic effect, pronounced hemodynamic instability and prolonged recovery. The aim of this study was to compare the effects of dexmedetomidine-ketamine (DK) versus dexmedetomidine-midazolam-fentanyl (DMF) combination on the quality of sedation/analgesia and recovery profiles for monitored anesthesia care (MAC).MethodsFifty six patients undergoing chemoport insertion were randomly assigned to group DK or DMF. All patients received 1 μg.kg−1 dexmedetomidine over 10 min followed by 0.2–1.0 μg.kg−1h−1 in order to maintain 3 or 4 of modified Observer's Assessment of Analgesia and Sedation score checked every 3 min. At the start of dexmedetomidine infusion, patients in group DK or DMF received 0.5 mg.kg−1 ketamine or 0.05 mg.kg−1 midazolam + 0.5 μg.kg−1 fentanyl intravenously, respectively. When required, rescue sedatives (0.5 mg.kg-1 of ketamine or 0.05 mg.kg-1 of midazolam) and analgesics (0.5 mg.kg-1 of ketamine or 0.5 μg.kg-1 of fentanyl) were given to the patients in DK or DMF group, respectively. The primary outcome of this study was the recovery parameters (time to spontaneous eye opening and the length of the recovery room stay). The secondary outcomes were parameters indicating quality of sedation/analgesia, cardiorespiratory variables, and satisfaction scores.ResultsThere were no significant differences in the onset time, time to spontaneous eye opening, recovery room stay, the incidences of inadequate analgesia, hypotension and bradycardia between the two groups. Despite lower infusion rate of dexmedetomidine, more patients in the DMF group had bispectral index (BIS) < 60 than in the DK group and vice versa for need of rescue sedatives. The satisfaction scores of patients, surgeon, and anesthesiologist in the DMF group were significantly better than the DK group.ConclusionsThe DK and DMF groups showed comparable recovery time, onset time, cardiorespiratory variables, and analgesia. However, the DMF group showed a better sedation quality and satisfaction scores despite the lower infusion rate of dexmedetomidine, and a higher incidence of BIS < 60 than the DK group.Trial registrationClinical Trial Registry of Korea KCT0000951, registered 12/12/2013

Midazolam–ketamine versus dexmedetomidine–ketamine combinations for anesthesia of pediatric patients undergoing cardiac catheterization

“…Our observation is that the sedation was satisfactory in both study groups, but this was at the expense of the significantly higher ketamine consumption in group M when compared with group D (P < 0.05). The anesthetic sparing effect of intravenous dexmedetomidine was better when compared with intravenous midazolam which was proved in multiple previous studies (Feng et al 2017;Kumari et al 2018), and this was attributed to that dexmedetomidine not only has sedative anixolytic properties but also has also analgesic one (Tosun et al 2006) while midazolam has sedative anixolytic amnesic properties (Koruk et al 2010) and lacks the analgesic one (Chun et al 2016).…”

“…Ketamine is an N-methyl-D-aspartate receptor (NMDA) antagonist with sedative, analgesic, and sympathomimetic effects (Miller et al 2011). Among its benefits is the ability to protect airway reflexes with minimal effect on ventilatory drive (Bernard et al 2011), but there are potential problems concerning its use in pediatrics such as emergence delirium (Chun et al 2016). Midazolam is another commonly used intravenous sedative agent with a rapid onset and relatively rapid recovery compared to other benzodiazepines (Chun et al 2016).…”

“…Among its benefits is the ability to protect airway reflexes with minimal effect on ventilatory drive (Bernard et al 2011), but there are potential problems concerning its use in pediatrics such as emergence delirium (Chun et al 2016). Midazolam is another commonly used intravenous sedative agent with a rapid onset and relatively rapid recovery compared to other benzodiazepines (Chun et al 2016). It possesses a sedative, anxiolytic, and amnesic properties (Koruk et al 2010) and minimal hemodynamic effects in clinically recommended doses for sedation (Frölich et al 2011).…”

“…It possesses a sedative, anxiolytic, and amnesic properties (Koruk et al 2010) and minimal hemodynamic effects in clinically recommended doses for sedation (Frölich et al 2011). However, the lack of analgesic action is a major concern (Abbas et al 2012;Chun et al 2016). Both midazolam and ketamine have been used for sedation in pediatric patients for a variety of procedures.…”

The Effectiveness of Low-dose Dexmedetomidine Infusion in Sedative Flexible Bronchoscopy: A Retrospective Analysis

“…One systemic review study suggested dexmedetomidine exerts potential benefits over midazolam in procedural sedation [10]. However, these sedatives alone often provide insufficient sedative or analgesic effects as well as delayed recovery [11][12][13], for which previous studies suggest a combined sedative/analgesic regimen improve efficacy and safety during endoscopic examination [14][15][16].…”