Comparative study to evaluate three different techniques to attenuate haemodynamic response to propofol in patients with end stage renal disease [ESRD]

ABSTRACT

Propofol is the most common induction agent used in anaesthesia practice. However, it has some properties that limit its usefulness when used in critically ill patients. The aim of the present study is to compare the efficacy of pre-induction administration of ephedrine 200 mcg.kg-1, phenylephrine 1 mcg.kg-1 or ketamine 500 mcg.kg-1 against the anticipated hypotensive effect of propofol in patients with end stage renal disease [ESRD]. Eighty patients ASA physical status III -IV scheduled for creation of Arterio-Venous fistula [A-V Fistula] under general anesthesia with laryngeal mask airway [LMA] were included in the study. Patients were randomly allocated to one of four groups of 20 patients each to receive 2 ml of normal saline [Control group], 200 mcg.kg-1 of ephedrine [Group E], phenylephrine 1mcg.kg-1 [Group P], or ketamine 500 mcg.kg-1 [Group K] IV diluted in 2ml of normal saline one min before the induction of anesthesia. After haemodynamic baseline measurements, fentanyl 0.5 1.0 mcg.Kg-1 was given IV as a bolus. Anesthesia was induced 2 min later by using propofol 1.5 mg/kg over 30 s. If required, further increments of propofol 0.5 mg.kg-1 were given at 1 min and repeated every 30 s until loss of consciousness. Rescue medications with ephedrine 100 mcg.kg-1 was given if the SAP decreased to <80 mm Hg. Atropine 0.5 mg was given if the HR decreased to <45 bpm. Systolic Blood Pressure [SBP], Mean Arterial Pressure [MAP], and Diastolic Blood Pressure [DBP] at 3, 1, and 0 min before and 2, 5, and 10 min after induction of anaesthesia. Total fentanyl consumption in Post Anesthesia Care Unit [PACU] was recorded. There were no differences among studied groups in the distribution of age, sex; body weight; duration of surgery and duration of anesthesia .There were significant decrease in MBP in Control Group [C] 2 min after propofol induction and significant increase in MBP in Ephedrine Group [E] 10 min after induction. There were short-lived changes in HR 2min after induction in groups [E] and [P], with significant increase and decrease receptively. While, there was short-lived increase in HR 5min after induction in Control group [C] .Number of patients required rescue ephedrine was 16, 5, 2, and 1 in group C, E, P and K respectively with significant statistical increase in Control Group [Group C] [P<0.01]. Fentanyl consumption in PACU was significantly decreased in Ketamine group [K] in comparison to other groups. In conclusion, our study shows that Pre-induction IV injection of ephedrine, phenylephrine or ketamine are equally effective in maintaining haemodynamic during propofol induction in ESRD patients undergoing Arterio-Venous Fistula Creation. In addition ketamine not only has stable haemodynamic effect but also, has analgesic effect and reducing the post operative analgesia requirement