Ketamine-propofol (ketofol) in procedural sedation: a narrative review

Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.

Dexmedetomidine and LPS co-treatment attenuates inflammatory response on WISH cells via inhibition of p38/NF-kB signaling pathway

Background@#Inflammatory dental diseases that occur during pregnancy can cause preterm labor and/or intrauterine growth restriction. Therefore, proactive treatment of dental diseases is necessary during pregnancy. Dexmedetomidine (DEX) is a widely used sedative in the dental field, but research on the effect of DEX on pregnancy is currently insufficient. In this study, we investigated the effects of co-treatment with DEX and lipopolysaccharide (LPS) on inflammatory responses in human amnion-derived WISH cells. @*Methods@#Human amnion-derived WISH cells were treated with 0.001, 0.01, 0.1, and 1 μg/mL DEX with 1 μg/mL LPS for 24 h. Cytotoxicity of WISH cells was evaluated by 3-(4,5-)-2,5-diphenyltetrazolium bromide (MTT) assay. The protein expression of cyclooxygenase-2 (COX-2), prostaglandin E 2 (PGE 2 ), p38, and nuclear factor kappa B (NF-κB) was examined by western blot analysis. The mRNA expression of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α was analyzed by real-time quantitative polymerase chain reaction. @*Results@#Co-treatment with DEX and LPS showed no cytotoxicity in the WISH cells. The mRNA expression of IL-1β and TNF-α decreased after co-treatment with DEX and LPS. DEX and LPS co-treatment decreased the protein expression of COX-2, PGE 2 , phospho-p38, and phospho-NF-κB in WISH cells. @*Conclusion@#Co-treatment with DEX and LPS suppressed the expression of COX-2 and PGE 2 , as well as pro-inflammatory cytokines such as IL-1β and TNF-α in WISH cells. In addition, the anti-inflammatory effect of DEX and LPS co-treatment was mediated by the inhibition of p38/NF-κB activation.

Anti-inflammatory effect of remifentanil in lipopolysaccharide–stimulated amniotic epithelial cells

BACKGROUND: Sometimes general anesthesia is required for dental surgery in pregnant women. Facial bone fractures or neck abscess should be treated immediately. Dental surgery, however, creates a stressful situation that can cause inflammation. Inflammatory responses are a well-known major cause of preterm labor and preterm birth. Here we demonstrate the effects of remifentanil on the factors related to preterm labor and its mechanism of action on amniotic-derived epithelial cells (WISH cells). METHODS: WISH cells were exposed to lipopolysaccharide (LPS) for 24 h and co-treated with various concentrations of remifentanil. MTT assays were performed to measure cell viability. To explain the effects of remifentanil on the factors related to inflammation in WISH cells, activation of nuclear factor kappa B (NF-κB) and p38 and the expression of interleukin (IL)-1β, tumor necrosis factor (TNF)-α, cyclooxygenase (COX)2, and prostaglandin E (PGE)2 were quantified using western blotting and RT-PCR, respectively. RESULTS: Remifentanil did not affect WISH cell viability. In western blot analysis, co-treatment with remifentanil resulted in decreased phosphorylation of NF-κB, and expression of COX2 and PGE2 in LPS-induced inflammation, but the results were statistically significant only at low concentrations. Reduction of IL-1β and TNF-α expression was also observed with RT-PCR. CONCLUSION: Co-treatment with remifentanil does not affect the viability of WISH cells, but reduces the expression of the factors related to inflammation, which can induce uterine contraction and preterm labor. These findings provide evidence that remifentanil may inhibit uterine contraction and preterm labor in clinical settings.

Effects of remifentanil preconditioning on factors related to uterine contraction in WISH cells

BACKGROUND: Preterm labor and miscarriage may occur in stressful situations, such as a surgical operation or infection during pregnancy. Pharyngeal and buccal abscess and facial bone fractures are inevitable dental surgeries in pregnant patients. Remifentanil is an opioid analgesic that is commonly used for general anesthesia and sedation. Nonetheless, no study has investigated the effects of remifentanil on amniotic epithelial cells. This study evaluated the effects of remifentanil on the factors related to uterine contraction and its mechanism of action on amniotic epithelial cells.METHODS: Amniotic epithelial cells were preconditioned at various concentrations of remifentanil for 1 h, followed by 24-h lipopolysaccharide (LPS) exposure. MTT assays were performed to assess the cell viability in each group. The effects of remifentanil on factors related to uterine contractions in amniotic epithelial cells were assessed using a nitric oxide (NO) assay, western blot examinations of the expression of nuclear factor-kappa B (NF-κB), cyclooxygenase 2 (COX2), and prostaglandin E2 (PGE₂), and RT-PCR examinations of the expression of the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNF-α).RESULTS: Remifentanil did not affect viability and nitric oxide production of amniotic epithelial cells. Western blot analysis revealed that remifentanil preconditioning resulted in decreased expressions of NF-κB and PGE2 in the cells in LPS-induced inflammation, and a tendency of decreased COX2 expression. The results were statistically significant only at high concentration. RT-PCR revealed reduced expressions of IL-1β and TNF-α.CONCLUSION: Preconditioning with remifentanil does not affect the viability of amniotic epithelial cells but reduces the expression of factors related to uterine contractions in situations where cell inflammation is induced by LPS, which is an important inducer of preterm labor. These findings provide evidence that remifentanil may inhibit preterm labor in clinical settings.

Propofol promotes osteoclastic bone resorption by increasing DC-STAMP expression

BACKGROUND: Propofol is an intravenous anesthetic which has antioxidant effects due to its similarity in molecular structure to α-tocopherol. It has been reported that α-tocopherol increases osteoclast fusion and bone resorption. Here, we investigated the effects of propofol on signaling pathways of osteoclastogenic gene expression, as well as osteoclastogenesis and bone resorption using bone marrow-derived macrophages (BMMs). METHODS: BMMs were cultured with macrophage colony-stimulating factor (M-CSF) alone or M-CSF plus receptor activator of nuclear factor kappa B ligand (RANKL) in the presence of propofol (0–50 µM) for 4 days. Mature osteoclasts were stained for tartrate-resistant acid phosphatase (TRAP) and the numbers of TRAP-positive multinucleated osteoclasts were counted. To examine the resorption activities of osteoclasts, a bone resorption assay was performed. To identify the mechanism of action of propofol on the formation of multinucleated osteoclasts, we focused on dendritic cell-specific transmembrane protein (DC-STAMP), a protein essential for pre-osteoclastic cell fusion. RESULTS: Propofol increased the formation of TRAP-positive multinucleated osteoclasts. In addition, the bone resorption assay revealed that propofol increased the bone resorption area on dentin discs. The mRNA expression of DC-STAMP was upregulated most strongly in the presence of both RANKL and propofol. However, SB203580, a p38 inhibitor, significantly suppressed the propofol/RANKL-induced increase in mRNA expression of DC-STAMP. CONCLUSION: We have demonstrated that propofol enhances osteoclast differentiation and maturation, and subsequently increases bone resorption. Additionally, we identified the regulatory pathway underlying osteoclast cell-cell fusion, which was enhanced by propofol through p38-mediated DC-STAMP expression.

Medical adhesive related skin injury after dental surgery

An 87-year-old woman was referred for the extraction of residual teeth and removal of tori prior to prosthetic treatment. After surgery under general anesthesia, the surgical tape was removed to detach the bispectral index sensor and the hair cover. After the surgical tape was removed, skin injury occurred on the left side of her face. After epidermis repositioning and ointment application, a dressing was placed over the injury. Her wound was found to have healed completely on follow-up examination. Medical adhesive related skin injury (MARSI) is a complication that can occur after surgery and subjects at the extremes of age with fragile skin are at a higher risk for such injuries. Careful assessment of the risk factors associated with MARSI is an absolute necessity.

Effect of remifentanil on pre-osteoclast cell differentiation in vitro

BACKGROUND: The structure and function of bone tissue is maintained through a constant remodeling process, which is maintained by the balance between osteoblasts and osteoclasts. The failure of bone remodeling can lead to pathological conditions of bone structure and function. Remifentanil is currently used as a narcotic analgesic agent in general anesthesia and sedation. However, the effect of remifentanil on osteoclasts has not been studied. Therefore, we investigated the effect of remifentanil on pre-osteoclast (pre-OCs) differentiation and the mechanism of osteoclast differentiation in the absence of specific stimulus. METHODS: Pre-OCs were obtained by culturing bone marrow-derived macrophages (BMMs) in osteoclastogenic medium for 2 days and then treated with various concentration of remifentanil. The mRNA expression of NFATc1 and c-fos was examined by using real-time PCR. We also examined the effect of remifentanil on the osteoclast-specific genes TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. Finally, we examined the influence of remifentanil on the migration of pre-OCs by using the Boyden chamber assay. RESULTS: Remifentanil increased pre-OC differentiation and osteoclast size, but did not affect the mRNA expression of NFATc1 and c-fos or significantly affect the expression of TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. However, remifentanil increased the migration of pre-OCs. CONCLUSIONS: This study suggested that remifentanil promotes the differentiation of pre-OCs and induces maturation, such as increasing osteoclast size. In addition, the increase in osteoclast size was mediated by the enhancement of pre-OC migration and cell fusion.

The effect of tulobuterol patches on the respiratory system after endotracheal intubation

BACKGROUND: Endotracheal intubation during anesthesia induction may increase airway resistance (R(aw)) and decrease dynamic lung compliance (Cdyn). We hypothesized that prophylactic treatment with a transdermal β2-agonist tulobuterol patch (TP) would help to reduce the risk of bronchospasm after placement of the endotracheal tube. METHODS: Eighty-two American Society of Anesthesiologists (ASA) category I or II adult patients showing obstructive patterns were divided randomly into a control and a TP group (n = 41 each). The night before surgery, a 2-mg TP was applied to patients in the TP group. Standard monitors were recorded, and target controlled infusion (TCI) with propofol and remifentanil was used for anesthesia induction and maintenance. Simultaneously, end-tidal carbon dioxide, R(aw), and Cdyn were determined at 5, 10, and 15 min intervals after endotracheal intubation. RESULTS: There was no significant difference in demographic data between the two groups. The TP group was associated with a lower R(aw) and a higher Cdyn, as compared to the control group. R(aw) was significantly lower at 10 min (P < 0.05) and 15 min (P < 0.01), and Cdyn was significantly higher at 5 min (P < 0.05) and 15 min (P < 0.01) in the TP group. A trend towards a lower R(aw) was observed showing a statistically significant difference 5 min after endotracheal intubation (P < 0.01) in each group. CONCLUSIONS: Prophylactic treatment with TP showed a bronchodilatory effect through suppressing an increase in R(aw) and a decrease in C(dyn) after anesthesia induction without severe adverse effects.

Awake intubation in a patient with huge orocutaneous fistula: a case report

Mask ventilation, the first step in airway management, is a rescue technique when endotracheal intubation fails. Therefore, ordinary airway management for the induction of general anesthesia cannot be conducted in the situation of difficult mask ventilation (DMV). Here, we report a case of awake intubation in a patient with a huge orocutaneous fistula. A 58-year-old woman was scheduled to undergo a wide excision, reconstruction with a reconstruction plate, and supraomohyoid neck dissection on the left side and an anterolateral thigh flap due to a huge orocutaneous fistula that occurred after a previous mandibulectomy and flap surgery. During induction, DMV was predicted, and we planned an awake intubation. The patient was sedated with dexmedetomidine and remifentanil. She was intubated with a nasotracheal tube using a video laryngoscope, and spontaneous ventilation was maintained. This case demonstrates that awake intubation using a video laryngoscope can be as good as a fiberoptic scope.

Propofol protects human keratinocytes from oxidative stress via autophagy expression

BACKGROUND: The skin consists of tightly connected keratinocytes, and prevents extensive water loss while simultaneously protecting against the entry of microbial pathogens. Excessive cellular levels of reactive oxygen species can induce cell apoptosis and also damage skin integrity. Propofol (2,6-diisopropylphenol) has antioxidant properties. In this study, we investigated how propofol influences intracellular autophagy and apoptotic cell death induced by oxidative stress in human keratinocytes. METHOD: The following groups were used for experimentation: control, cells were incubated under normoxia (5% CO₂, 21% O₂, and 74% N₂) without propofol; hydrogen peroxide (H₂O₂), cells were exposed to H₂O₂ (300 µM) for 2 h; propofol preconditioning (PPC)/H₂O₂, cells pretreated with propofol (100 µM) for 2 h were exposed to H₂O₂; and 3-methyladenine (3-MA)/PPC/H₂O₂, cells pretreated with 3-MA (1 mM) for 1 h and propofol were exposed to H₂O₂. Cell viability, apoptosis, and migration capability were evaluated. Relation to autophagy was detected by western blot analysis. RESULTS: Cell viability decreased significantly in the H₂O₂ group compared to that in the control group and was improved by propofol preconditioning. Propofol preconditioning effectively decreased H₂O₂-induced cell apoptosis and increased cell migration. However, pretreatment with 3-MA inhibited the protective effect of propofol on cell apoptosis. Autophagy was activated in the PPC/H₂O₂ group compared to that in the H₂O₂ group as demonstrated by western blot analysis and autophagosome staining. CONCLUSION: The results suggest that propofol preconditioning induces an endogenous cellular protective effect in human keratinocytes against oxidative stress through the activation of signaling pathways related to autophagy.

Effects of propofol-induced autophagy against oxidative stress in human osteoblasts

BACKGROUND: Oxidative stress occurs during the aging process and other conditions such as bone fracture, bone diseases, and osteoporosis, but the role of oxidative stress in bone remodeling is unknown. Propofol exerts antioxidant effects, but the mechanisms of propofol preconditioning on oxidative stress have not been fully explained. Therefore, the aim of this study was to evaluate the protective effects of propofol against H2O2-induced oxidative stress on a human fetal osteoblast (hFOB) cell line via activation of autophagy. METHODS: Cells were randomly divided into the following groups: control cells were incubated in normoxia (5% CO2, 21% O2, and 74% N2) without propofol. Hydrogen peroxide (H2O2) group cells were exposed to H2O2 (200 µM) for 2 h, propofol preconditioning (PPC)/H2O2 group cells were pretreated with propofol then exposed to H2O2, 3-methyladenine (3-MA)/PPC/H2O2 cells were pretreated with 3-MA (1 mM) and propofol, then were exposed to H2O2. Cell viability and apoptosis were evaluated. Osteoblast maturation was determined by assaying bone nodular mineralization. Expression levels of bone related proteins were determined by western blot. RESULTS: Cell viability and bone nodular mineralization were decreased significantly by H2O2, and this effect was rescued by propofol preconditioning. Propofol preconditioning effectively decreased H2O2-induced hFOB cell apoptosis. However, pretreatment with 3-MA inhibited the protective effect of propofol. In western blot analysis, propofol preconditioning increased protein levels of collagen type I, BMP-2, osterix, and TGF-β1. CONCLUSIONS: This study suggests that propofol preconditioning has a protective effect on H2O2-induced hFOB cell death, which is mediated by autophagy activation.

Pharyngeal flap damage caused by nasotracheal intubation in a patient who underwent palatoplasty and pharyngoplasty

Patients with cleft lip and palate (CLP) must undergo corrective surgeries during infancy and early childhood. Many patients with CLP undergo orthognathic surgery during their childhood for correction of skeletal asymmetries or pharyngoplasty with a pharyngeal flap to improve the quality of speech and velopharyngeal function. During orthognathic surgeries, nasotracheal intubation is performed under general anesthesia. In our case report, the patient had undergone palatoplasty and pharygoplasty previously. During the orthognathic surgery, a flexible fiberoptic bronchoscope-guided nasotracheal tube was inserted through the pharyngeal flap ostium; however, active bleeding occurred in the nasopharynx. Bleeding occurred because the flap was torn. After achieving hemostasis, the surgery was completed successfully. Thus, if a patient may show the potential for velopharyngeal port obstruction, nasotracheal intubation should be performed with utmost care.

Difficult airway management in a patient with a thin mandible

A 47-year-old woman was referred for surgical treatment of osteomyelitis of the mandible. She had already undergone three previous surgeries. Pre-anesthetic airway evaluation predicted a difficult airway, due to the thin, retro-positioned mandible, tongue, and atrophic changes in the lips and soft tissue. We inserted packing gauzes in the buccal mucosa for easier mask fitting and ventilation. During direct laryngoscopic intubation with a nasotracheal tube (NTT), fracture of a thin mandible can easily occur. Therefore, we used a fiberoptic bronchoscope to insert the NTT. After surgery, we performed a tongue-tie to protect against airway obstruction caused by the backward movement of the tongue during recovery. The patient recovered without any complications. We determined the status of the patient precisely and consequently performed thorough preparations for the surgery, allowing the patient to be anesthetized safely and recover after surgery. Careful assessment of the patient and airway prior to surgery is necessary.

Acute mediastinitis secondary to delayed vascular injury by a central venous catheter and total parenteral nutrition

Vascular injury caused by a central venous catheter (CVC) has been reported to be a rare complication, especially delayed vascular injury due to CVC has a few cases and it can be fatal because of delayed recognition and more serious complications. A 59-year-old woman with no available medical history was admitted for treatment of ovarian cancer. For the surgery, a triple-lumen CVC was placed through the left subclavian vein. Parenteral nutrition through the CVC was used for postoperative nutritional management in the first postoperative day. On the sixth postoperative day (POD), the patient suddenly complained of dyspnea. The CT revealed bilateral pleural effusion and irregular soft tissue density and air bubble in anterior mediastinum suggesting migration of the distal portion of the CVC into the anterior mediastium. In the intensive care unit (ICU) bilateral thoracentesis and percutaneous drainage were performed. She was discharged from the ICU in 3 days later and transferred to the general ward. This case emphasizes the possibility of the delayed vascular injury related to CVC and some strategies for prevention of vascular injury.

Damage to the pilot balloon of the nasotracheal tube during orthognathic double-jaw surgery: A case report

In oral and maxillofacial surgery, many complications associated with nasotracheal tube can be caused. In this case, we reported ballooning tube damage of nasotracheal tube during orthognathic double-jaw surgery and replacement of tube through cut down of tube and tube exchange using airway exchange catheter. The patient scheduled for high Le Fort I osteotomy and bilateral sagittal split osteotomy was intubated nasotracheally with nasal endotracheal tube. During maxilla osteotomy, air bubble was detected in the oral blood. In spite of our repeated ballooning, the results were the same so we changed damaged tube using airway exchange catheter aseptically. Tiny and superficial cutting site was detected in the middle of pilot tube. As we know in our case, tiny injury impeded a normal airway management and prevention is important.

Protective Effect of Propofol against Hypoxia-reoxygenation Injury in HaCaT Human Keratinocytes

The aim of this study was to determine the beneficial effect of propofol on human keratinocytes that have undergone hypoxia reoxygenation (H/R) injury and to investigate whether autophagy is associated with the protective mechanism. Thus, we evaluated how propofol influences the intracellular autophagy and apoptosis during the H/R process in the HaCaT cells. The cultured human keratinocyte cells were exposed to 24 h of hypoxia (5% CO2, 1% O2, 94% N2) followed by 12 h of reoxygenation (5% CO2, 21% O2, 74% N2). The experiment was divided into 4 groups: (1) Control=Normoxia ; (2) H/R=Hypoxia Reoxygenation ; (3) PPC+H/R=Propofol Preconditioning+Hypoxia Reoxygenation; (4) 3-MA+PPC+H/R=3-MA-Methyladenine+Propofol Preconditioning+Hypoxia Reoxygenation. In addition, Western blot analysis was performed to identify the expression of apoptotic pathway parameters, including Bcl-2, Bax, and caspase 3 involved in mitochondrial-dependent pathway. Autophagy was determined by fluorescence microscopy, MDC staining, AO staining, and western blot. The H/R produced dramatic injuries in keratinocyte cells. In our study, the viability of Propofol in H/R induced HaCaT cells was first studied by MTT assay. The treatment with 25, 50, and 100 microM Propofol in H/R induced HaCaT cells enhanced cell viability in a dose-dependent manner and 100 microM was the most effective dose. The Atg5, Becline-1, LC3-II, and p62 were elevated in PPC group cells, but H/R-induced group showed significant reduction in HaCaT cells. The Atg5 were increased when autophagy was induced by Propofol, and they were decreased when autophagy was suppressed by 3-MA. These data provided evidence that propofol preconditioning induced autophagy and reduced apoptotic cell death in an H/R model of HaCaT cells, which was in agreement with autophagy playing a very important role in cell protection.

Administration of four different doses of gabapentin reduces awakening from breakthrough pain and adverse effects in outpatients with neuropathic pain during the initial titration / 대한마취과학회지

BACKGROUND: Gabapentin is a safe and well-tolerated anticonvulsant with a wide therapeutic index, and it is used for neuropathic pain. The aim of this study was to compare previous dosing methods with the administration of four different doses of gabapentin while maintaining the same maximum daily dose for the safe administration of high doses of the medication. METHODS: The subjects were outpatients with various neuropathic pain syndromes, with at least two of the following symptoms: allodynia, burning pain, shooting pain, or hyperalgesia. The TID group received equal doses of gabapentin 3 times per day, while the QID group received 4 different doses of gabapentin per day. The pain score, frequency of breakthrough pain (BTP), severity and the duration of pain, sleep disturbance due to nocturnal pain, and adverse effects were recorded each day. RESULTS: The average daily pain score and sleep disturbance were significantly reduced in the QID group between days 3 and 10 of the experiment. The adverse effects of the medication were also reduced in the QID group. However, the frequency of BTP and severity and duration of pain were not significantly different between two groups. CONCLUSIONS: Administration of 4 different doses of gabapentin during the initial titration in outpatients with neuropathic pain resulted in a significant reduction in awakening from breakthrough pain and a reduction in the adverse effects of the medication.

The EC50 of remifentanil to minimize the cardiovascular changes during head holder pinning in neurosurgery / 대한마취과학회지

BACKGROUND: During neuroanesthesia, head holder pinning commonly results in sympathetic stimulation manifested by hemodynamic changes, such as increased heart rate and arterial blood pressure. Remifentanil has been used successfully to control acute autonomic responses during neurosurgical procedures. The objective of this study was to determine effect-site concentration of remifentanil for suppressing the hemodynamic response to head holder pinning with the probability of 50% (EC50). METHODS: Forty-one ASA physical status I or II patients, between the ages of 20-70, who were scheduled for neurosurgery were recruited into this study. After arrival in the operating room, standard monitoring was applied throughout the study, which included a bispectral index monitor. Both propofol and remifentanil were administered by Target-control infusion device. The Dixon "up-and-down" sequential allocation method was used to determine the EC50 of remifentanil. RESULTS: The EC50 of remifentanil was 2.19 +/- 0.76 ng/ml by the turning point estimate (TPE). In probit analysis, EC50 was 2.42 ng/ml (95% CI : -0.62-4.66) and EC95 was 5.70 ng/ml (95% CI : 4.02-67.53). The EC50 estimator comes from isotonic regression is 2.90 ng/ml (95% CI : 1.78-3.65). The EC95 estimator comes from isotonic regression is 4.28 ng/ml (95% CI : 3.85-4.41). CONCLUSIONS: This study showed that EC50 of remifentanil was 2.19 +/- 0.76 ng/ml by TPE. EC50 was 2.42 ng/ml (95% CI -0.62-4.66) in probit analysis, as back up analysis. The EC50 estimator comes from isotonic regression is 2.90 ng/ml (95% CI : 1.78-3.65).

Intraoperative low dose ketamine reduce postoperative pain after combined anesthesia with propofol and remifentanil in mastectomy patients / 대한마취과학회지

BACKGROUND: Remifentanil is a useful opioid, but it induces postoperative hyperalgesia and acute tolerance associated N-methyl-D-aspartate (NMDA) receptor. This study was aimed to investigate whether small dose ketamine, NMDA receptor antagonist, prevent remifentanil induced postoperative hyperalgesia or acute tolerance after combined anesthesia with propofol and remifentanil using target controlled infusion (TCI) in patients undergoing mastectomy. METHODS: Fourty ASA physical status 1 or 2 women, undergoing mastectomy were randomly assigned to two groups to receive intraoperative infusion of ketamine at 3microgram/kg/min rate after injection of ketamine 0.3 mg/kg as a loading dose (Group K) or saline infusion after saline loading at the same rate and dose (Group C). All the patients were anesthetized with propofol and remifentanil to maintain bispectral index (BIS) 40-60, mean arterial pressure within 20% of basal values. Remifentanil was infused with target controlled infusion (TCI) to the effect site (concentration: 2.0 ng/ml). Postoperative paine scores (visual analog scale: VAS), morphine requirements, and sedation scores were recorded for 48 hours postoperatively. RESULTS: The VAS scores and morphine requirements of the Group K were significantly lower than those of the Group C at the postanesthetic care unit and at the ward for 24 hours postoperatively. The extubation time was delayed in Group K compared with Group C. CONCLUSIONS: Intraoperative infusion of small dose ketamine reduced postoperative pain and morphine requirements after combined anesthesia with propofol and remifentanil in patients undergoing mastectomy.

Effects of sevoflurane and propofol on wound healing in rats: comparison of blood flow and wound size / 대한마취과학회지

BACKGROUND: As the wound healing is a multi-factorial process, the anesthetic agent and the duration of its exposure may influence the healing process after surgery. This study investigated the effect of anesthetic agents and duration of its exposure on the wound healing process after operation. METHODS: Total 32 rats weighing 200-300 g were randomly allocated to one of eight groups according to the exposure time (1, 2, 4, 8 hours) of sevoflurane or propofol (n = 4 each). After wounding under the each anesthetic, anesthesia was maintained for 1, 2, 4 and 8 hours in each group. We compared the skin blood flow around the wound and the wound size at baseline, 3 days, and 7 days postoperatively. RESULTS: In sevoflurane group, short exposure group (1, 2 hours) showed higher wound blood flow than long exposure (4, 8 hours) at 3 days after wounding (P < 0.05), but not at 7 days after wounding. For the wound size, there was no difference at 3 days after wounding in sevoflurane group, but 8 hours exposure group had the largest wound at 7 days after wounding. In propofol group, wound blood flow showed no difference at 3 days after wounding, but that of 4, 8 hours exposure group was higher than 2 hours exposure group at 7 days after wounding. There was no difference in wound size in propofol group. CONCLUSIONS: This study implicates that sevoflurane might influence the wound healing process more prominently than propofol according to the duration of exposure time.