Randomized clinical trial comparing the efficacy and safety of ketamine and fentanyl for analgesia in pediatric orthopedic procedures / Ensaio clínico randomizado comparando a eficácia e a segurança da cetamina e do fentanil para analgesia em procedimentos ortopédicos pediátricos

ABSTRACT BACKGROUND AND OBJECTIVES: Bone fractures constitute a frequent cause of emergency care in the pediatric population. Opioid drugs are routinely used for analgesia during the hospitalization of children victims of trauma. Few studies have evaluated the importance of a multimodal approach to analgesia in this context. The aim of this study was to compare the analgesic effect and possible side effects of fentanyl compared to those of ketamine. METHODS: The study analyzed 50 children and adolescents, aged between 24 and 192 months, submitted to surgical treatment of upper limb fractures in a tertiary trauma care hospital. The participants were randomized into two groups: one that received Ketamine and the other Fentanyl. In the post-anesthetic recovery room (PARR), pain intensity and the occurrence of delirium were measured for a period of 30 minutes. The incidence of respiratory depression, nausea, vomiting and other side effects during the surgical procedure were assessed. RESULTS: The sample consisted mostly of male individuals (76.0%). The mean age of the participants was 90.1 months. The use of a low-flow oxygen cannula was necessary in 30.0% of the participants. The incidence of vomiting and laryngospasm was 2.0% among the participants, and 6.0% presented increased salivary secretion. The occurrence of pain, delirium and respiratory depression was not different between the two assessed groups, as well as the occurrence of nausea and laryngospasm. CONCLUSION: Ketamine is not an effective and safe option to opioids for analgesia in children undergoing surgical procedures to treat upper limb fractures.

RESUMO JUSTIFICATIVA E OBJETIVOS: As fraturas ósseas constituem causa frequente de atendimento de emergência na população pediátrica. Fármacos opioides são rotineiramente utilizados para analgesia durante a hospitalização de crianças vítimas de trauma. Poucos estudos avaliaram a importância de uma abordagem multimodal para analgesia nesse contexto. O objetivo deste estudo foi comparar o efeito analgésico e possíveis efeitos adversos do fentanil em relação aos da cetamina. MÉTODOS: Foram analisados 50 crianças e adolescentes, com idade entre 24 e 192 meses, submetidos ao tratamento cirúrgico das fraturas de membros superiores em um hospital terciário de atendimento ao trauma. Os participantes foram aleatorizados em dois grupos: um recebeu cetamina e outro fentanil. Na sala de recuperação pós-anestésica (SRPA), a intensidade da dor e a ocorrência de delirium foram mensuradas por um período de 30 minutos. A incidência de depressão respiratória, náuseas, vômitos e outros efeitos adversos durante o procedimento cirúrgico foram avaliados. RESULTADOS: A amostra foi composta, em sua maioria, por indivíduos do sexo masculino (76,0%). A média de idade dos participantes foi de 90,1 meses. O uso de cânula de oxigênio de baixo fluxo foi necessário em 30,0% dos participantes. A incidência de vômitos e laringoespasmo foi de 2,0% entre os participantes, sendo que 6,0% apresentaram aumento da secreção salivar. A ocorrência de dor, delirium e depressão respiratória não foi diferente entre os dois grupos avaliados, assim como a ocorrência de náuseas e laringoespasmo. CONCLUSAO: Acetamina não se mostrou uma opção eficaz e segura aos opioides para analgesia em crianças submetidas a procedimentos cirúrgicos para tratamento de fraturas de membros superiores.

Intravascular ketamine infusion for the treatment of chronic pain and depression. Case report / Infusão intravascular de cetamina para o tratamento de dor crônica e depressão. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Chronic pain and depression are two comorbidities that correlate at the molecular level in the central nervous system and cause sufering to the patient, being dificult to be managed. In recent years, several studies have shown significant analgesic and antidepressant efects from intravascular infusion of ketamine, being a promising alternative option for refractory patients. Tus, the aim of the study was to report the case of a patient with refractory chronic pain and depression submitted to serial ketamine single dose infusions. CASE REPORT: Female patient, 33 years old, diagnosed with interstitial cystitis 13 years ago with refractory chronic pain and depression, submitted to serial infusions of intravascular ketamine. Tree serial infusions were performed, providing a significant improvement in pain and mood. However, the patient could not tolerate the adverse efects, particularly, the transient sensation of impending death and panic attack, and abandoned the treatment. CONCLUSION: Ketamine is a safe and promising treatment option for chronic pain and depression and can promote significant, albeit transient, pain and mood relief using subanesthetic dosage. However, its adverse efects can be an important limitation for therapeutic success. Standardized clinical studies are needed to better understand the relationship between chronic pain and depression and to establish the best therapeutic approach.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor crônica e a depressão são duas comorbidades que se correlacionam em nível molecular no sistema nervoso central e promovem sofrimento ao paciente, sendo de difícil manejo. Nos últimos anos, diversos estudos demonstraram efeitos analgésicos e antidepressivos significativos a partir da infusão intravascular de cetamina, sendo uma opção alternativa para pacientes refratários ao tratamento convencional. Assim, o objetivo do estudo foi relatar o caso de uma paciente com dor crônica e depressão refratária submetida a infusões seriadas de doses únicas de cetamina. RELATO DO CASO: Paciente do sexo feminino, 33 anos, diagnosticada com cistite intersticial há 13 anos com refratariedade no manejo da dor e da depressão, submetida a infusões seriadas de cetamina intravascular. Foram realizadas 3 infusões seriadas que proporcionaram uma melhora significativa na dor e no humor. Entretanto, a paciente não tolerou os efeitos adversos, particularmente, de sensação de morte iminente e ataque de pânico, e abandonou o tratamento. CONCLUSÃO: A cetamina é uma opção de tratamento promissora para dor crônica e depressão e pode promover alívio significativo, embora transitório, da dor e humor utilizando dose subanestésica. No entanto, seus efeitos adversos podem ser uma limitação para o sucesso terapêutico. Estudos clínicos padronizados são necessários para compreender melhor a relação entre dor crônica e depressão e para estabelecer a melhor abordagem terapêutica.

Uso da cetamina na depressão resistente ao tratamento: uma revisão sistemática / Use of ketamine in treatment-resistant depression: a systematic review

RESUMO Objetivo A cetamina apresenta-se como uma alternativa promissora contra a depressão resistente ao tratamento (DRT), no entanto o conhecimento de sua aplicação como antidepressivo ainda é restrito. Diante disso, objetivou-se investigar sua eficácia em pacientes com DRT. Métodos A busca da literatura foi efetuada na base de dados MedLine. Os critérios de inclusão foram: estudos clínicos controlados e randomizados dos últimos cinco anos e em inglês. Excluímos os artigos que não responderam à pergunta PICO e aqueles com tamanho de amostra e metodologia de estudo destoantes, quando comparados aos ensaios que basearam esta revisão. Resultados Considerando uma amostra final de seis artigos, observou-se uma melhor resposta à cetamina (principalmente em ganho de humor), quando comparada ao tratamento convencional contra a DRT. Já com sua primeira infusão, na dose de 0,5 mg/kg, foi possível perceber seus efeitos antidepressivos. A manutenção desses efeitos parece ser obtida com a administração de 0,5 mg/kg do medicamento, três vezes por semana. Por outro lado, a redução de tal dosagem pode diminuir ou anular os efeitos. Conclusões O uso da cetamina apresentou resultados efetivos na melhora do quadro de DRT, com efeitos adversos de pequena gravidade e de fácil controle. Entretanto, outros estudos, com amostras maiores e métodos diferentes, são necessários, para uma conclusão de maior consistência.

ABSTRACT Objective Ketamine presents itself as a promising alternative against treatment-resistant depression (TRD), however, the knowledge of its application as an antidepressant is still restricted. Therefore, the objective was to investigate its effectiveness in patients with TRD. Methods The literature search was carried out in the MedLine database. Inclusion criteria were: controlled and randomized clinical studies from the last five years and in English. We excluded articles that did not answer the PICO question and those with different sample size and study methodology, when compared to the tests that based this review. Results Considering a final sample of six articles, a better response to ketamine was observed (mainly in mood gain), when compared to conventional treatment against TRD. With its first infusion, at a dose of 0.5 mg/kg, it was possible to notice its antidepressant effects. The maintenance of these effects seems to be achieved with the administration of 0.5 mg/kg of the drug, three times a week. On the other hand, the reduction of such a dosage can diminish or cancel the effects. Conclusions The use of ketamine showed effective results improving the condition of TRD, with adverse effects of small severity and easy control. However, further studies, with larger samples and different methods, are needed, for a more consistent conclusion.

Infusão contínua de fentanil e cetamina para controle de dor no transcirurgico: relato de caso / Continuous infusion of fentanyl and ketamine for trans-surgical pain control: case report

O paciente da espécie canina, sem raça definida, com 5 anos, deu entrada a clínica veterinária particular apresentando quadro de dor aguda e intensa em cavidade abdominal associada a prostração. Foram realizados exames de sangue, ultrassonografia e radiografia de abdômen, cuja suspeita foi torção parcial do estômago, com esplenomegalia, além de gastrite e enterite. O paciente foi submetido imediatamente ao procedimento cirúrgico para alívio, reposicionamento do órgão e gastropexia. O animal foi medicado previamente com metadona, tramadol e dipirona duas horas antes do ato cirúrgico, portanto não foram utilizadas medicações pré-anestésicas e optou-se pelo propofol e cetamina para a indução anestésica, além da infusão contínua com cetamina e fentanil para se obter a analgesia multimodal. Os parâmetros de dor foram avaliados por meio das frequências cardíaca e respiratória, traçado eletrocardiográfico, pressão arterial sistólica e média, aferição da temperatura retal e coloração de mucosas, a cada 5 minutos. Os mesmos indicaram boa estabilidade hemodinâmica, segurança e analgesia, sem necessidade de alterar as doses estabelecidas durante o procedimento. Pode ser observada também redução do requerimento de isoflurano para manutenção do plano cirúrgico. O paciente acordou sem sinais de dor no pós-operatório imediato evitando estresse sistêmico, o que conferiu o bom resultado do protocolo analgésico instituído.

The patient (Caramel) canine, mixed breed, approximately 5 years old, weighing 26kg was seen at the Ame Vet veterinary clinic, with severe abdominal pain, apathy, anorexia, prostration. Blood tests, abdominal ultrasound and abdominal x-ray were performed according to the tests a suspicion of partial torsion of the stomach and splenomegaly with right displacement, in addition to gastritis and enteritis. It was decided by the clinic and surgeon to perform laparotomy and prophylactic gastropexy. The animal was previously medicated by the clinic that treated the animal for analgesia with methadone, tramadol and dipyrone two hours before the beginning of the surgical procedure, therefore, pre-anesthetic medications, anesthetic induction with propofol, and ketamine were not used, aiming to perform analgesia. Multimodal with continuous infusion of ketamine and fentanyl, that is, more than one different mechanism of action, acting synergistically and reducing dose-dependent adverse effects and monitoring hemostasis and patient parameters, presenting its efficacy and safety in intraoperative pain control. The parameters addressed were heart rate (HR), respiratory rate (RR), electrocardiographic tracing, Spo2, systolic blood pressure (SBP), mean arterial pressure (MAP), temperature and mucosal color, evaluated every 5 minutes. The parameters evaluated indicated good hemodynamic stability, safety and analgesia, with no need to change the doses established during the procedure. A reduction in the requirement of isoflurane to maintain the surgical plan can also be observed. The patient woke up without signs of pain in the immediate postoperative period, thus avoiding systemic stress. which conferred the good result of the analgesic protocol instituted.

Anestesia intravenosa contínua com cetamina racêmica ou dextrocetamina e detomidina em cadelas / [Continuous intravenous anesthesia with racemic ketamine or dextroketamine and detomidine in female dogs]

Objetivou-se com este estudo comparar a associação de detomidina e cetamina ou dextrocetamina, por via intravenosa contínua, em oito cadelas submetidas a dois protocolos: GCD - indução anestésica com 5mg/kg e infusão intravenosa contínua de 20mg/kg/h de cetamina; e GDD - indução com 3,5mg/kg e infusão de 14mg/kg/h de dextrocetamina. Associou-se detomidina, 30µg/kg/h, em ambos os grupos. Registraram-se frequência cardíaca (FC), pressão arterial (PA), frequência respiratória (f), temperatura (TC), miorrelaxamento, analgesia, hemogasometria e eletrocardiograma, antes e 15 minutos após a MPA (Mbasal e Mmpa); após o início da infusão (Mic); a cada 10 minutos até 90 minutos (M10, M20, M30, M40, M50, M60, M70, M80 e M90); e 30 minutos após o fim da infusão (M120). Foi observada bradicardia em Mmpa no GCD e de Mmpa a M10 no GDD. Ocorreu hipotensão em Mmpa e hipertensão a partir de Mic. A f diminuiu de M10 a M30. Foram observados: onda T de alta amplitude, bloqueios atrioventriculares e parada sinusal. Ocorreu acidose respiratória. O período de recuperação foi de 219,6±72,3 minutos no GCD e de 234,1±96,8 minutos no GDD. A cetamina e a dextrocetamina, associadas à detomidina por infusão contínua, causam efeitos cardiorrespiratórios e anestésicos similares.(AU)

The combination of detomidine and ketamine or dextrocetamine for continuous intravenous infusion was compared in eight female dogs submitted to two protocols: GCD - 5mg/kg of anesthetic induction and continuous intravenous infusion of ketamine 20mg/kg/h; and GDD - induction with 3.5mg/kg and infusion of 14mg/kg/h of dextrocetamine. Detomidine, 30µg/kg/h was associated in both groups. Heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (CT), myorelaxation, analgesia, blood gas analysis and electrocardiogram were recorded before and 15 minutes after MPA (Mbasal and Mmpa); after the start of infusion (Mic); every 10 minutes to 90 minutes (M10, M20, M30, M40, M50, M60, M70, M80 and M90); and 30 minutes after the end of infusion (M120). Bradycardia was observed in Mmpa in GCD and from Mmpa to M10 in GDD. There was hypotension in Mmpa and hypertension from Mic. The RR decreased from M10 to M30. High amplitude T wave, atrioventricular blocks and sinus arrest were observed. Respiratory acidosis occurred. The recovery period was 219.6±72.3 minutes in GCD and 234.1±96.8 minutes in GDD. Ketamine and S+ ketamine associated with detomidine for continuous infusion cause cardiorespiratory and similar anesthetic effects.(AU)

Anestesia geral em jabuti-piranga (Chelonoides carbonaria) para retirada de corpo estranho gástrico / General anesthesia in red-footed tortoise (Chelonoides carbonaria) for gastric foreign body removal

Background: The anatomical, physiological, and pharmacological characteristics of reptiles make anesthesia in chelonians particularly challenging. Specific literature regarding safe anesthetic protocols that provide immobilization, antinociception, amnesia, and unconsciousness are scarce. Thus, this paper aims to report the case of a red-footed tortoise submitted to long-duration general anesthesia to celiotomy for foreign body removal. Case: An adult red-footed tortoise (Chelonoides carbonaria), 5.9 kg, was admitted due to hyporexia after ingesting a metallic fishhook. Serial radiographs confirmed the diagnosis and location of the foreign body in the stomach. The animal was premedicated with 0.03 mg/kg dexmedetomidine, 6 mg/kg ketamine, and 0.4 mg/kg butorphanol intramuscularly. After 90 min we inserted a 22G jugular catheter and proceeded to anesthesia induction with 5 mg/kg propofol. We intubated the animal with a 2.5 mm uncuffed endotracheal and started fluid therapy at a rate of 5 mL/kg/h. Surgical anesthesia was maintained with isoflurane in 0.21 oxygen, in a non-rebreathing circuit (baraka), under spontaneous breathing. Expired isoflurane was maintained between 3 and 4.5%. Due to reduced respiratory rate and hypercapnia, we opted for implementing manually-assisted positive pressure ventilation. Morphine (0.5 mg/kg) was administered at 10 and 87 min after the beginning of the surgery for further analgesia when the isoflurane requirement increased significantly. We did not detect any alterations in heart and body temperature. Surgical anesthesia lasted 6 h. During anesthesia recovery, voluntary head retraction and coordinated movement of the limbs occurred at 240 and 540 min after the extubation, respectively. In 2 days, the patient returned to voluntary feeding, being very active and responsive to stimulus. The post-surgical hematologic evaluation was unremarkable. Discussion: Pre-anesthetic medication aimed to promote sedation and preemptive analgesia. Due to its minimal cardiorespiratory depression, we chose the combination of ketamine, dexmedetomidine, and butorphanol. Dexmedetomidine reduced the ketamine dose and caused sufficient muscle relaxation and immobilization to perform the jugular catheter placement. Butorphanol is an agonist-antagonist opioid; that is why we decided to add it to the protocol for antinociception. However, due to signs of nociceptive response (increased isoflurane requirements and heart rate), and considering the evidence of a predominance of µ receptors in reptiles, we administered low-dose morphine twice during the procedure. Propofol was chosen as an induction agent at a dose sufficient to allow endotracheal intubation. Since reptilians often show apnea in the presence of 100% oxygen, we used a 0.21 oxygen fraction. Despite this, the patient showed respiratory depression. Due to right to left cardiac shunt, sudden changes in the direction of the blood can lead to very rapid changes in the serum concentrations of isoflurane, which leads to frequent oscillations in the anesthetic depth and consequently the need for vaporizer adjustments, which may justify the high expired isoflurane fraction during the procedure. Despite that, physiological parameters were maintained within normal ranges for the species, with slight variations during the surgical procedure. We conclude that the proposed anesthetic protocol is safe for long-duration anesthesia in chelonians, ensuring cardiovascular and respiratory stability. Thus, this report may help veterinarians to perform safe anesthesia in tortoises submitted to invasive surgical procedures.

Anestesia multimodal em cachorro-do-mato (Cerdocyon thous) submetido à hemilaminectomia e estabilização sacrococcígea / Multimodal anaesthesia in a crab-eating fox (Cerdocyon thous) undergoing hemilaminectomy and sacrococcygeal stabilization

Background: Several researches have shown the impacts of roads more directly to wildlife in Brazil. The crab-eating fox(Cerdocyon thous) is a frequent run over victim. Dissociative drugs are commonly used, but inhalation anesthesia is indicatedin cases of extensive and prolonged surgeries. Despite their similarity with domestic dogs, the literature is scarce regarding theassociation of new anesthetic techniques and protocols in wild canids. The aim of this paper was to report the viability of multimodal anesthesia in a crab-eating fox, victim of running over, undergoing hemilaminectomy and sacrococcygeal stabilization.Case: An adult male specimen of crab-eating fox was rescued after being run over and taken to a wild animal screening center.Physical examination showed superficial and deep pain, lack of support for the pelvic limbs and proprioception, increasedreflexes, and reduced tail mobility. Chemical restraint with intramuscular (IM) tiletamine-zolazepam (6.0 mg/kg) and morphine (0.5 mg/kg) was performed. Meloxicam (0.2 mg/kg IM) and enrofloxacin (5.0 mg/kg IM) were also administered. Theanimal was sequentially admitted to the veterinary hospital. Radiographic images showed compaction of the spinal columnof the T10 and T11 thoracic vertebrae and the sacrococcygeal region. Sixty min after chemical restraint, the anesthesia wassupplemented with IM tiletamine-zolazepam (4.5 mg/kg), and fluid therapy with 0.9% NaCl (10 mL/kg/h) was started. Ten minlater, intravenous propofol dose-effect (2.5 mg/kg) was administered and general anesthesia was maintained with isoflurane(FiO2 = 1.0). Thirty min after the induction of anesthesia, the animal was urdergoing hemilaminectomy and sacrococcygealstabilization. Constant rate infusions (CRI) of dexmedetomidine (0.5 μg/kg/h) and ketamine (0.6 mg/kg/h) were started. Lidocaine (7.0 mg/kg) and bupivacaine (2.0 mg/kg) were administered into the surgical site on the T10 and T11 vertebrae at 35...(AU)

Anestesia multimodal em cachorro-do-mato (Cerdocyon thous) submetido à hemilaminectomia e estabilização sacrococcígea / Multimodal anaesthesia in a crab-eating fox (Cerdocyon thous) undergoing hemilaminectomy and sacrococcygeal stabilization

Background: Several researches have shown the impacts of roads more directly to wildlife in Brazil. The crab-eating fox(Cerdocyon thous) is a frequent run over victim. Dissociative drugs are commonly used, but inhalation anesthesia is indicatedin cases of extensive and prolonged surgeries. Despite their similarity with domestic dogs, the literature is scarce regarding theassociation of new anesthetic techniques and protocols in wild canids. The aim of this paper was to report the viability of multimodal anesthesia in a crab-eating fox, victim of running over, undergoing hemilaminectomy and sacrococcygeal stabilization.Case: An adult male specimen of crab-eating fox was rescued after being run over and taken to a wild animal screening center.Physical examination showed superficial and deep pain, lack of support for the pelvic limbs and proprioception, increasedreflexes, and reduced tail mobility. Chemical restraint with intramuscular (IM) tiletamine-zolazepam (6.0 mg/kg) and morphine (0.5 mg/kg) was performed. Meloxicam (0.2 mg/kg IM) and enrofloxacin (5.0 mg/kg IM) were also administered. Theanimal was sequentially admitted to the veterinary hospital. Radiographic images showed compaction of the spinal columnof the T10 and T11 thoracic vertebrae and the sacrococcygeal region. Sixty min after chemical restraint, the anesthesia wassupplemented with IM tiletamine-zolazepam (4.5 mg/kg), and fluid therapy with 0.9% NaCl (10 mL/kg/h) was started. Ten minlater, intravenous propofol dose-effect (2.5 mg/kg) was administered and general anesthesia was maintained with isoflurane(FiO2 = 1.0). Thirty min after the induction of anesthesia, the animal was urdergoing hemilaminectomy and sacrococcygealstabilization. Constant rate infusions (CRI) of dexmedetomidine (0.5 μg/kg/h) and ketamine (0.6 mg/kg/h) were started. Lidocaine (7.0 mg/kg) and bupivacaine (2.0 mg/kg) were administered into the surgical site on the T10 and T11 vertebrae at 35...

[Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial]. / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado.

OBJECTIVES: The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2mg.kg-1) administered 30min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5mg.kg-1) and saline placebo. METHODS: One hundred children aged (7-12) years were randomly allocated in four groups (n=25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5mg.kg-1 (Group K-IV), Nebulized Ketamine 1mg.kg-1 (Group K-N1) or 2mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24h postoperative. RESULTS: The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9±60.5min, 95% CI 375.9-425.87) and K-N2 (455.5±44.6min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5±86.1min, 95% CI 282.9-354.1) and Group C (68.3±21.9min, 95% CI 59.5-77.1; p<0.001), with a significant difference between K-N1 and K-N2 Groups (p<0.001). The total consumption of IV paracetamol in the first 24h postoperative was reduced in Group K-IV (672.6±272.8mg, 95% CI 559.9-785.2), Group K-N1 (715.6±103.2mg, 95% CI 590.4-840.8) and Group K-N2 (696.6±133.3mg, 95% CI 558.8-834.4) compared with Control Group (1153.8±312.4mg, 95% CI 1024.8-1282.8; p<0.001). With no difference between intravenous and Nebulized Ketamine Groups (p=0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p<0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. CONCLUSION: Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

Abstract Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg-1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg-1) and saline placebo. Methods One hundred children aged (7-12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg-1 (Group K-IV), Nebulized Ketamine 1 mg.kg-1 (Group K-N1) or 2 mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9-425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9-354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5-77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9-785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4-840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8-834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8-1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Resumo Objetivos A administração de cetamina por via inalatória através de nebulizador é relativamente nova e os estudos sobre este assunto são escassos. Nosso objetivo foi investigar a eficácia analgésica da cetamina nebulizada (1 e 2 mg.kg-1) administrada 30 minutos antes da anestesia geral em crianças submetidas à amigdalectomia eletiva, em comparação com cetamina intravenosa (0,5 mg.kg-1) e placebo (soro fisiológico). Métodos Cem crianças entre 7-12 anos foram randomicamente alocadas em quatro grupos (n = 25) e receberam: soro fisiológico para controle (Grupo C); 0,5 mg.kg-1 de cetamina intravenosa (Grupo C-IV); 1 mg.kg-1 de cetamina nebulizada (Grupo C-N1); 2 mg.kg-1 de cetamina nebulizada (Grupo C-N2). O desfecho primário foi o consumo total de analgésicos de resgate nas primeiras 24 horas de pós-operatório. Resultados O tempo médio para a primeira solicitação de analgésicos de resgate foi prolongado nos grupos C-N1 (400,9 ± 60,5 min, IC 95% 375,9-425,87) e C-N2 (455,5 ± 44,6 min, IC 95% 437,1-473,9) em comparação com o Grupo C-IV (318,5 ± 86,1 min, IC 95% 282,9-354,1) e o Grupo C (68,3 ± 21,9 min, IC 95% 59,5-77,1; p < 0,001), com uma diferença significativa entre os grupos C-N1 e C-N2 (p < 0,001). O consumo total de paracetamol IV nas primeiras 24 horas de pós-operatório foi reduzido no Grupo C-IV (672,6 ± 272,8 mg, IC 95% 559,9-785,2), Grupo C-N1 (715,6 ± 103,2 mg, IC 95% 590,4-840,8) e Grupo C-N2 (696,6 ± 133,3 mg, IC 95% 558,8-834,4) em comparação com o Grupo C (1153,8 ± 312,4 mg, IC 95% 1024,8-1282,8; p < 0,001). Não houve diferença entre os grupos de cetamina intravenosa e nebulizada (p = 0,312). Os pacientes dos grupos de cetamina intravenosa e nebulizada apresentaram escores VRS pós-operatórios menores, em comparação com o Grupo C (p < 0,001), sem diferenças entre os grupos C-IV, C-N1 ou C-N2 e sem efeitos adversos significativos. Conclusão A administração preventiva de cetamina nebulizada foi eficaz no alívio da dor pós-amigdalectomia. Cetamina nebulizada pode ser considerada como uma via alternativa eficaz à cetamina IV.

Anestesia intravenosa contínua com dextrocetamina e detomidina em cadelas submetidas à ovário-histerectomia e pré-medicadas com midazolam e morfina / Continuous intravenous anesthesia by dextroketamine and detomidine in bitches subjected to ovariohysterectomy and premedicated with midazolam and morphine

Background: The use of injectable anesthetics to induce and maintain anesthesia has been the subject of extensive research.Ketamine induces dissociative anesthesia, which is characterized by sensory loss, analgesia and amnesia without loss of consciousness. The levorotatory isomer of ketamine is dextroketamine. Detomidine, a potent myorelaxant that acts as a sedative andanalgesic, is commonly used on horses but rarely tested in dogs. The purpose of this study was to evaluate the cardiorespiratoryand anesthetic effects promoted by a combination of detomidine and dextroketamine applied via continuous intravenous infusionin bitches premedicated with midazolam and morphine.Materials, Methods & Results:Eight bitches treated at the veterinary hospital of the Federal University of Campina Grande werereferred for elective ovariohysterectomy (OHE). The animals were premedicated with 0.3 mg/kg of midazolam and 0.1 mg/kgof morphine intramuscular (IM) followed, after 15 min, with 0.02 mg/kg of detomidine IM. Fifteen min after the administration of detomidine, 3.5 mg/kg of dextroketamine was administered intravenously (IV), followed by continuous IV infusion of14 mg/kg/h of dextroketamine and 30 μg/kg/h of detomidine. Heart rate (HR), respiratory rate (RR), body temperature (BT),mean arterial pressure (MAP), myorelaxation and electrocardiogram were recorded before and 15 min after the administrationof midazolam and morphine (M0 and M1), 15 min after detomidine (M2), immediately after starting the infusion (M3), at 10min intervals up to 60 min (M4, M5, M6, M7, M8 and M9) and 30 min after the end of the infusion (M10). Blood gas variableswere analyzed at M0, M1, M2, M6, M9 and M10. Analgesia was evaluated by measuring cortisol and glucose levels at M0, threemin after dermotomy, three min after clamping the ovarian pedicle, and three min after dermorrhaphy. The quality and durationof recovery were evaluated. HR dropped significantly from...(AU)

Efectos de la asociación de propofol-cetamina versus propofol aislado en perros sometidos a orquiectomías / Effects of the association of propofol-cetamine versus propofol isolated in dogs submitted to orchiectomies / Efeitos da associação de propofol - cetamina versus propofol isolado em cães submetidos à orquiectomias

Propofol es un anestésico intravenoso utilizado para la inducción anestésica que puede o no utilizarse para el mantenimiento, asociado o no. El objetivo de este estudio fue investigar si el propofol asociado con la ketamina en la inducción y el mantenimiento de la anestesia en la orquiectomía de los perros causa alteraciones más o menos cardiorrespiratorias en comparación con su uso aislado. Entre las evaluaciones se encuentran el tiempo de inducción y la recuperación anestésica, el perfil hemodinámico y la cuantificación del porcentaje de reducción de dosis obtenido con la asociación propuesta. Veinte perros machos fueron utilizados entre uno y seis años de edad, sin distinción de raza y peso. Los animales se distribuyeron aleatoriamente en cuatro grupos en cada grupo con cinco animales: PC (propofol + ketamina), P (propofol), C (ketamina) y CTRL (grupo de control). Los parámetros fueron evaluados por un monitor multiparamétrico, inmediatamente después de la medicación preanestésica y cada 15 minutos hasta el final del procedimiento. Los resultados mostraron que en ninguno de los grupos mencionados anteriormente ocurrieron cambios estadísticamente significativos en la frecuencia cardíaca, pero se observó que la frecuencia respiratoria era estadísticamente diferente del grupo CTRL versus el grupo P y el grupo C en el que el valor p era menor que 0.001 y grupo CTRL versus PC en...(AU)

Propofol is an intravenous anesthetic used for anesthetic induction that may be also used for maintenance, associated or not. The aim of this study was to investigate whether propofol associated with ketamine in induction and maintenance of anesthesia in orchiectomy of dogs causes cardiorespiratory alterations compared to its isolated use. Among the evaluations were verified time of induction and anesthetic recovery, hemodynamic profile, and quantification of the dose reduction percentage obtained with the proposed association. Twenty male dogs were used between one and six years of age, without distinction of race and weight. The animals were randomly distributed into four groups with five animals into each group: PC (propofol + ketamine), P (propofol), C (ketamine) and CTRL (control) group. The parameters were evaluated by a multiparametric monitor, immediately after the preanesthetic medication and every 15 minutes until the end of the procedure. The results showed that in none of the groups did statistically significant changes occur in heart rate, but for the respiratory rate was observed to be statistically different from the CTRL group versus the P group and the C group in which the p-value was less than 0.001 and group CTRL versus PC in which the p-value was less than 0.05. Peripheral oxygen saturation was statistically significant between the CTRL and P groups...(AU)

O propofol é um anestésico intravenoso utilizado para indução anestésica que pode ser usado também na manutenção, associado ou não. O objetivo deste estudo foi investigar se o propofol associado à cetamina na indução e manutenção anestésica em orquiectomia de cães causa alterações cardiorrespiratórias, comparado a seu uso isolado. Dentre as avaliações verificou-se tempo de indução e recuperação anestésica, perfil hemodinâmico, e quantificação do percentual de redução de dose obtido com a associação proposta. Foram utilizados 20 cães machos entre um e seis anos de idade, sem distinção de raça e peso. Os animais foram distribuídos aleatoriamente em quatro grupos cada um com cinco animais, sendo os grupos: PC (propofol + cetamina), P (propofol), C (cetamina) e o grupo CTRL (controle). Os parâmetros foram avaliados por um monitor multiparamétrico, imediatamente após a medicação pré-anestésica e a cada 15 minutos até o final do procedimento. Os resultados demonstraram que nenhum dos grupos supracitados mostraram alterações estatisticamente significativas na frequência cardíaca, porém para a frequência respiratória houve diferença estatística do grupo CTRL versus o grupo P e o grupo C no qual p foi menor que 0,001 e do grupo CTRL versus PC no qual o valor de p foi menor que 0,05. A saturação periférica de oxigênio foi estatisticamente significativa entre o grupo CTRL e grupo...(AU)

Efectos de la asociación de propofol-cetamina versus propofol aislado en perros sometidos a orquiectomías / Effects of the association of propofol-cetamine versus propofol isolated in dogs submitted to orchiectomies / Efeitos da associação de propofol - cetamina versus propofol isolado em cães submetidos à orquiectomias

Propofol es un anestésico intravenoso utilizado para la inducción anestésica que puede o no utilizarse para el mantenimiento, asociado o no. El objetivo de este estudio fue investigar si el propofol asociado con la ketamina en la inducción y el mantenimiento de la anestesia en la orquiectomía de los perros causa alteraciones más o menos cardiorrespiratorias en comparación con su uso aislado. Entre las evaluaciones se encuentran el tiempo de inducción y la recuperación anestésica, el perfil hemodinámico y la cuantificación del porcentaje de reducción de dosis obtenido con la asociación propuesta. Veinte perros machos fueron utilizados entre uno y seis años de edad, sin distinción de raza y peso. Los animales se distribuyeron aleatoriamente en cuatro grupos en cada grupo con cinco animales: PC (propofol + ketamina), P (propofol), C (ketamina) y CTRL (grupo de control). Los parámetros fueron evaluados por un monitor multiparamétrico, inmediatamente después de la medicación preanestésica y cada 15 minutos hasta el final del procedimiento. Los resultados mostraron que en ninguno de los grupos mencionados anteriormente ocurrieron cambios estadísticamente significativos en la frecuencia cardíaca, pero se observó que la frecuencia respiratoria era estadísticamente diferente del grupo CTRL versus el grupo P y el grupo C en el que el valor p era menor que 0.001 y grupo CTRL versus PC en...

Propofol is an intravenous anesthetic used for anesthetic induction that may be also used for maintenance, associated or not. The aim of this study was to investigate whether propofol associated with ketamine in induction and maintenance of anesthesia in orchiectomy of dogs causes cardiorespiratory alterations compared to its isolated use. Among the evaluations were verified time of induction and anesthetic recovery, hemodynamic profile, and quantification of the dose reduction percentage obtained with the proposed association. Twenty male dogs were used between one and six years of age, without distinction of race and weight. The animals were randomly distributed into four groups with five animals into each group: PC (propofol + ketamine), P (propofol), C (ketamine) and CTRL (control) group. The parameters were evaluated by a multiparametric monitor, immediately after the preanesthetic medication and every 15 minutes until the end of the procedure. The results showed that in none of the groups did statistically significant changes occur in heart rate, but for the respiratory rate was observed to be statistically different from the CTRL group versus the P group and the C group in which the p-value was less than 0.001 and group CTRL versus PC in which the p-value was less than 0.05. Peripheral oxygen saturation was statistically significant between the CTRL and P groups...

O propofol é um anestésico intravenoso utilizado para indução anestésica que pode ser usado também na manutenção, associado ou não. O objetivo deste estudo foi investigar se o propofol associado à cetamina na indução e manutenção anestésica em orquiectomia de cães causa alterações cardiorrespiratórias, comparado a seu uso isolado. Dentre as avaliações verificou-se tempo de indução e recuperação anestésica, perfil hemodinâmico, e quantificação do percentual de redução de dose obtido com a associação proposta. Foram utilizados 20 cães machos entre um e seis anos de idade, sem distinção de raça e peso. Os animais foram distribuídos aleatoriamente em quatro grupos cada um com cinco animais, sendo os grupos: PC (propofol + cetamina), P (propofol), C (cetamina) e o grupo CTRL (controle). Os parâmetros foram avaliados por um monitor multiparamétrico, imediatamente após a medicação pré-anestésica e a cada 15 minutos até o final do procedimento. Os resultados demonstraram que nenhum dos grupos supracitados mostraram alterações estatisticamente significativas na frequência cardíaca, porém para a frequência respiratória houve diferença estatística do grupo CTRL versus o grupo P e o grupo C no qual p foi menor que 0,001 e do grupo CTRL versus PC no qual o valor de p foi menor que 0,05. A saturação periférica de oxigênio foi estatisticamente significativa entre o grupo CTRL e grupo...

Effects of intraarticular tramadol, magnesium and ketamine on postoperative pain in arthroscopic meniscectomy / Efeitos de tramadol, magnésio e cetamina por via intra-articular sobre a dor pós-operatória em meniscectomia artroscópica

Abstract Objective: Postoperative pain control is important in terms of early recovery and rehabilitation in arthroscopic meniscectomy. For this purpose, we aimed to compare the effects of intraarticular tramadol, magnesium, and ketamine with combinations of pericapsular bupivacaine on postoperative pain and recovery in arthroscopic meniscectomy. Methods: Ninety patients who underwent arthroscopic meniscectomy were enrolled in the study. Group T was given tramadol, Group K was given ketamine, and Group M was given magnesium reconstituted intraarticularly, and all groups received periarticular bupivacaine. Comparisons were made in terms of the patients' postoperative Visual Analogue Scale scores with and without movement, need for additional analgesics, first analgesic time, mobilization times, adverse effects, and satisfaction with the analgesics. Results: The Visual Analogue Scale scores were lowest in Group T at 0 minutes, and were higher in the 15th and 30th minutes and 1st, 2nd, and 6th hours. Visual Analogue Scale values with movement were found to be high in Group M at 0 and 15 minutes, but they were found to be higher in group T in the 30th minute, 1st, 2nd and 6th hour. The groups were similar in terms of postoperative additional analgesic use, number of analgesic use, and satisfaction with analgesics; however, the first analgesic time was earlier in Group M, and the first mobilization time was earlier in Group K. Conclusion: Intraarticular ketamine enables early mobilization and less need for additional analgesics, it also provides a better analgesic effect in comparison with intraarticular tramadol and magnesium.

Resumo Objetivo: O controle da dor pós-operatória é importante para recuperação e reabilitação precoces em meniscectomia artroscópica. Portanto, nosso objetivo foi comparar os efeitos de tramadol, magnésio e cetamina administrados por via intra-articular em associação com bupivacaína pericapsular sobre a dor e a recuperação após meniscectomia artroscópica. Métodos: Noventa pacientes submetidos à meniscectomia artroscópica foram incluídos no estudo. O Grupo T recebeu tramadol, o Grupo K recebeu cetamina e o Grupo M recebeu magnésio em doses reconstituídas por via intra-articular e todos os grupos receberam bupivacaína por via periarticular. As avaliações foram feitas mediante comparação dos escores em escala visual analógica no pós-operatório dos pacientes em movimento e em repouso, necessidade de analgésicos adicionais, tempo até a primeira necessidade de analgésico, tempo de mobilização, efeitos adversos e satisfação com os analgésicos. Resultados: Os escores da escala visual analógica foram menores no minuto zero e maiores nos minutos 15 e 30 e nas horas 1, 2 e 6 no Grupo T. Os escores da escala visual analógica em movimento foram maiores nos minutos zero e 15 no Grupo M e maiores no minuto 30 e nas horas 1, 2 e 6 no Grupo T. Os escores dos grupos foram semelhantes em relação à necessidade de analgésico adicional no pós-operatório, ao consumo de analgésico e à satisfação com os analgésicos, mas os tempos até a primeira necessidade de analgesia e até a primeira mobilização foram mais curtos nos grupos M e K, respectivamente. Conclusão: A administração intra-articular de cetamina permite mobilização precoce e diminui a necessidade de analgésicos adicionais, além de proporcionar um melhor efeito analgésico em comparação com tramadol e magnésio por via intra-articular.

[Effects of intraarticular tramadol, magnesium and ketamine on postoperative pain in arthroscopic meniscectomy]. / Efeitos de tramadol, magnésio e cetamina por via intra­articular sobre a dor pós­operatória em meniscectomia artroscópica.

OBJECTIVE: Postoperative pain control is important in terms of early recovery and rehabilitation in arthroscopic meniscectomy. For this purpose, we aimed to compare the effects of intraarticular tramadol, magnesium, and ketamine with combinations of pericapsular bupivacaine on postoperative pain and recovery in arthroscopic meniscectomy. METHODS: Ninety patients who underwent arthroscopic meniscectomy were enrolled in the study. Group T was given tramadol, Group K was given ketamine, and Group M was given magnesium reconstituted intraarticularly, and all groups received periarticular bupivacaine. Comparisons were made in terms of the patients' postoperative Visual Analogue Scale scores with and without movement, need for additional analgesics, first analgesic time, mobilization times, adverse effects, and satisfaction with the analgesics. RESULTS: The Visual Analogue Scale scores were lowest in Group T at 0 minutes, and were higher in the 15th and 30th minutes and 1st, 2nd, and 6th hours. Visual Analogue Scale values with movement were found to be high in Group M at 0 and 15 minutes, but they were found to be higher in group T in the 30th minute, 1st, 2nd and 6th hour. The groups were similar in terms of postoperative additional analgesic use, number of analgesic use, and satisfaction with analgesics; however, the first analgesic time was earlier in Group M, and the first mobilization time was earlier in Group K. CONCLUSION: Intraarticular ketamine enables early mobilization and less need for additional analgesics, it also provides a better analgesic effect in comparison with intraarticular tramadol and magnesium.

Anestesia intravenosa contínua com dextrocetamina e detomidina em cadelas submetidas à ovário-histerectomia e pré-medicadas com midazolam e morfina / Continuous intravenous anesthesia by dextroketamine and detomidine in bitches subjected to ovariohysterectomy and premedicated with midazolam and morphine

Background: The use of injectable anesthetics to induce and maintain anesthesia has been the subject of extensive research.Ketamine induces dissociative anesthesia, which is characterized by sensory loss, analgesia and amnesia without loss of consciousness. The levorotatory isomer of ketamine is dextroketamine. Detomidine, a potent myorelaxant that acts as a sedative andanalgesic, is commonly used on horses but rarely tested in dogs. The purpose of this study was to evaluate the cardiorespiratoryand anesthetic effects promoted by a combination of detomidine and dextroketamine applied via continuous intravenous infusionin bitches premedicated with midazolam and morphine.Materials, Methods & Results:Eight bitches treated at the veterinary hospital of the Federal University of Campina Grande werereferred for elective ovariohysterectomy (OHE). The animals were premedicated with 0.3 mg/kg of midazolam and 0.1 mg/kgof morphine intramuscular (IM) followed, after 15 min, with 0.02 mg/kg of detomidine IM. Fifteen min after the administration of detomidine, 3.5 mg/kg of dextroketamine was administered intravenously (IV), followed by continuous IV infusion of14 mg/kg/h of dextroketamine and 30 μg/kg/h of detomidine. Heart rate (HR), respiratory rate (RR), body temperature (BT),mean arterial pressure (MAP), myorelaxation and electrocardiogram were recorded before and 15 min after the administrationof midazolam and morphine (M0 and M1), 15 min after detomidine (M2), immediately after starting the infusion (M3), at 10min intervals up to 60 min (M4, M5, M6, M7, M8 and M9) and 30 min after the end of the infusion (M10). Blood gas variableswere analyzed at M0, M1, M2, M6, M9 and M10. Analgesia was evaluated by measuring cortisol and glucose levels at M0, threemin after dermotomy, three min after clamping the ovarian pedicle, and three min after dermorrhaphy. The quality and durationof recovery were evaluated. HR dropped significantly from...

Anestesia geral em Sapajus nigritus (Macaco-prego) / General anesthesia in Sapajus nigritus (black capuchin)

Background: The black capuccin (Sapajus nigritus) is one of the most abundant primate specimens in Brazil. Amongpopulation control techniques, vasectomy can be used once it maintains the animal’s leading behavior in the group throughhormonal presence, production of spermatogenic series, and copula. However, due to their escape behavior, agitation, inaddition to the impossibility of knowing the physiological state of these animals beforehand, their capture poses a considerable challenge. Thus, chemical restraint is indispensable and the use of effective and safe anesthetic protocols to animalintegrity is of paramount importance. In this scenario, the present study aims to report the anesthesia of a black capuccinsubmitted to vasectomy.Case: A 1-year-old male, 1.1 kg monkey (Sapajus nigritus) was admitted at a Veterinary Hospital after being found onthe ground in a natural reserve in the town of Assis Chateaubriand, in the west of Parana State. After clinical evaluation,the patient was submitted to vasectomy as a birth control method, before his return to the natural area, which presentedoverpopulation of the species. After preanesthetic examinations, the animal was considered healthy, and thus, premedicatedwith the combination of dexmedetomidine (10 μg/kg) and ketamine (10 mg/kg), intramuscularly. Anesthetic inductionwith propofol was performed to effect. Laringeal desensitization was achieved with 2% lidocaine (2 mg/kg), which allowed orotracheal intubation through direct visualization. Anesthesia was maintained with 1% isoflurane in a 0.5 oxygenfraction and spontaneous ventilation using a non-rebreathing circuit. The spermatic cord and the skin were desensitizedwith lidocaine (4 mg/kg). During the procedure, the animal was monitored for pulse oximetry, electrocardiogram, systolicblood pressure, body temperature, end tidal CO2 (ETCO2), and end tidal isoflurane. The animal also received 10 mL/kg/h ringer...

Anestesia geral em Sapajus nigritus (Macaco-prego) / General anesthesia in Sapajus nigritus (black capuchin)

Background: The black capuccin (Sapajus nigritus) is one of the most abundant primate specimens in Brazil. Amongpopulation control techniques, vasectomy can be used once it maintains the animals leading behavior in the group throughhormonal presence, production of spermatogenic series, and copula. However, due to their escape behavior, agitation, inaddition to the impossibility of knowing the physiological state of these animals beforehand, their capture poses a considerable challenge. Thus, chemical restraint is indispensable and the use of effective and safe anesthetic protocols to animalintegrity is of paramount importance. In this scenario, the present study aims to report the anesthesia of a black capuccinsubmitted to vasectomy.Case: A 1-year-old male, 1.1 kg monkey (Sapajus nigritus) was admitted at a Veterinary Hospital after being found onthe ground in a natural reserve in the town of Assis Chateaubriand, in the west of Parana State. After clinical evaluation,the patient was submitted to vasectomy as a birth control method, before his return to the natural area, which presentedoverpopulation of the species. After preanesthetic examinations, the animal was considered healthy, and thus, premedicatedwith the combination of dexmedetomidine (10 μg/kg) and ketamine (10 mg/kg), intramuscularly. Anesthetic inductionwith propofol was performed to effect. Laringeal desensitization was achieved with 2% lidocaine (2 mg/kg), which allowed orotracheal intubation through direct visualization. Anesthesia was maintained with 1% isoflurane in a 0.5 oxygenfraction and spontaneous ventilation using a non-rebreathing circuit. The spermatic cord and the skin were desensitizedwith lidocaine (4 mg/kg). During the procedure, the animal was monitored for pulse oximetry, electrocardiogram, systolicblood pressure, body temperature, end tidal CO2 (ETCO2), and end tidal isoflurane. The animal also received 10 mL/kg/h ringer...(AU)

Remifentanil-ketamine vs. propofol-ketamine for sedation in pediatric patients undergoing colonoscopy: A randomized clinical trial / Remifentanil-cetamina vs. propofol-cetamina para sedação em pacientes pediátricos submetidos à colonoscopia: ensaio clínico randômico

Abstract Background and objectives: Pediatric patients frequently require deep sedation or general anesthesia for colonoscopy. This study was designed to compare the sedative efficacy of remifentanil-ketamine combination with propofol-ketamine combination in children undergoing colonoscopy. Methods: Seventy patients, between 2 and 16 years of age, scheduled for diagnostic colonoscopy were randomly allocated into two groups. Remifentanil-ketamine group received intravenous ketamine 2 mg.kg−1 and remifentanil 0.25 µg.kg−1 combination, followed by 0.1 µg.kg−1.min−1 remifentanil infusion. Propofol-ketamine group received intravenous propofol 1 and 2 mg.kg−1 ketamine combination, followed by 1 mg.kg−1.h−1 propofol infusion. In the case of children discomfort (cry, movement, and cough), remifentanil 0.1 µg.kg−1 in the remifentanil-ketamine group or propofol 0.5 mg.kg−1 in the propofol-ketamine group were administered to improve children discomfort. Despite the therapy given above, if children still experience discomfort, 1 mg.kg−1 of ketamine was administered as a rescue drug, regardless of the group. Ramsay sedation score, hemodynamic variables, drug requirements, gastroenterologists' satisfaction, colonoscopy duration, recovery time, and side effects were recorded throughout the procedure and the recovery period. Results: The percentage of patients with a Ramsay sedation score of 4 or higher during the procedure was 73.5 and 37.1% in remifentanil-ketamine and propofol-ketamine groups, respectively (p = 0.02). Systolic and diastolic blood pressure variables were significantly higher only after induction in the remifentanil-ketamine group than in the propofol-ketamine group (p = 0.015). Conclusion: Coadministration of ketamine with either remifentanil or propofol effectively and safely provides sedation and analgesia in children undergoing colonoscopy. Sedation scores were significantly better in remifentanil-ketamine group than in propofol-ketamine group.

Resumo Justificativa e objetivos: Os pacientes pediátricos com frequência precisam de sedação profunda ou anestesia geral para colonoscopia. Este estudo foi desenhado para comparar a eficácia sedativa da combinação de remifentanil-cetamina e de propofol-cetamina em crianças submetidas à colonoscopia. Métodos: Setenta pacientes, entre 2-16 anos, programados para colonoscopia diagnóstica foram alocados randomicamente em dois grupos. O grupo remifentanil-cetamina recebeu a combinação de 2 mg.kg−1 de cetamina por via intravenosa e 0,25 µg.kg−1 de remifentanil; seguido de infusão de remifentanil (0,1 µg.kg−1.min−1). O grupo propofol-cetamina recebeu a combinação de 1 mg.kg−1 de propofol e 2 mg.kg−1 de cetamina; seguido de infusão de propofol (1 mg.kg−1.h−1). Em caso de desconforto das crianças (choro, movimento e tosse), remifentanil (0,1 µg.kg−1) seria administrado ao grupo remifentanil-cetamina ou propofol (0,5 mg.kg−1) ao grupo propofol-cetamina. A despeito da terapia acima citada, caso as crianças ainda sentissem desconforto, cetamina (1 mg.kg−1) seria administrada como fármaco de resgate, independentemente do grupo. Escore de sedação de Ramsay, variáveis hemodinâmicas, necessidade de medicamentos, satisfação dos gastroenterologistas, duração da colonoscopia, tempo de recuperação e efeitos colaterais foram registrados durante o procedimento e o período de recuperação. Resultados: O percentual de pacientes com escore 4 ou mais na escala de sedação de Ramsay durante o procedimento foi de 73,5% e 37,1% nos grupos remifentanil-cetamina e propofol-cetamina, respectivamente, (p = 0,02). As variáveis, pressão arterial sistólica e diastólica, foram significativamente maiores no grupo remifentanil-cetamina do que no grupo propofol-cetamina, mas somente após a indução (p = 0,015). Conclusão: A coadministração de cetamina com remifentanil ou propofol fornece sedação e analgesia de forma eficaz e segura em crianças submetidas à colonoscopia. Os escores de sedação foram significativamente melhores no grupo remifentanil-cetamina do que no grupo propofol-cetamina.

[Remifentanil-ketamine vs. propofol-ketamine for sedation in pediatric patients undergoing colonoscopy: A randomized clinical trial]. / Remifentanil­cetamina vs. propofol­cetamina para sedação em pacientes pediátricos submetidos à colonoscopia: ensaio clínico randômico.

BACKGROUND AND OBJECTIVES: Pediatric patients frequently require deep sedation or general anesthesia for colonoscopy. This study was designed to compare the sedative efficacy of remifentanil-ketamine combination with propofol-ketamine combination in children undergoing colonoscopy. METHODS: Seventy patients, between 2 and 16 years of age, scheduled for diagnostic colonoscopy were randomly allocated into two groups. Remifentanil-ketamine group received intravenous ketamine 2mg.kg-1 and remifentanil 0.25µg.kg-1 combination, followed by 0.1µg.kg-1.min-1 remifentanil infusion. Propofol-ketamine group received intravenous propofol 1 and 2mg.kg-1 ketamine combination, followed by 1mg.kg-1.h-1 propofol infusion. In the case of children discomfort (cry, movement, and cough), remifentanil 0.1µg.kg-1 in the remifentanil-ketamine group or propofol 0.5mg.kg-1 in the propofol-ketamine group were administered to improve children discomfort. Despite the therapy given above, if children still experience discomfort, 1mg.kg-1 of ketamine was administered as a rescue drug, regardless of the group. Ramsay sedation score, hemodynamic variables, drug requirements, gastroenterologists' satisfaction, colonoscopy duration, recovery time, and side effects were recorded throughout the procedure and the recovery period. RESULTS: The percentage of patients with a Ramsay sedation score of 4 or higher during the procedure was 73.5 and 37.1% in remifentanil-ketamine and propofol-ketamine groups, respectively (p=0.02). Systolic and diastolic blood pressure variables were significantly higher only after induction in the remifentanil-ketamine group than in the propofol-ketamine group (p=0.015). CONCLUSION: Coadministration of ketamine with either remifentanil or propofol effectively and safely provides sedation and analgesia in children undergoing colonoscopy. Sedation scores were significantly better in remifentanil-ketamine group than in propofol-ketamine group.