Journal Reading

Safety and Efficacy of

Ketamine - dexmedetomidine versus
Ketamine - propofol Combinations for
Sedation in Patients after Coronary
Artery Bypass Graft Surgery
Mona Mohamed, Mogahd, Mohammed Shafik,
Mahran, Ghada Foad, Elbaradi

Andi Rizki C

PEMBIMBING: dr. ARDIYAN, Sp. AN, KAKV

 BACKGROUND
Prolonged mechanical ventilation after
cardiac surgery -> increase morbidity
and mortality

Meticulous perioperative management is

important to avoid these adverse events.
Tachycardia -> post CABG myocardial
ischemia decreased by sedation and
analgesia
 AIM

KETAMIN –
KETAMIN –
DEXMEDETOMIDINE
PROPOFOL (KP)
(KD)

• Sedation and analgesia

• Hemodynamics
•Total dose fentanyl
•Time of weaning mechanical
ventilator
•Time of extubation
•Adverse outcome
PATIENTS AND METHODS
Selection of Participant

Subject : Patients who underwent elective CABG surgery for

single vessel

Inclusion Criteria Exclusion Criteria

• 40–60 years old • Pregnancy

• hemodynamically • Neurologic disease,
stable • Liver or renal insufficiency
• Normal or moderately • Hemodynamic instability
impaired left
ventricular function • Patients on vasopressor or
ejection fraction >40% inotropes
PATIENTS AND METHODS

METHODS

All patient sedated with Ketamin 1 mg/kg

GROUP KD GROUP KP

• Ketamin + • Ketamin +
Dexmedetomidine Propofol 1 mg/kg
1 mcg/kg over 20 bolus
min • Maintain with 25-
• Maintain with 0.2- 50 mcg/kg/min
0.7 mcg/kg/h
PATIENTS AND METHODS

METHODS

• Sedation level was assessed

using Ramsay Sedation Scale
• Analgesia Fentanyl 1 μg/kg/h
infusion then adjusted
according to adult nonverbal
pain score
• Pain assessed using adult
nonverbal pain score
 RESULT
Insignificant Change
Significant Decrease
• Duration of stay in ICU
• Total dose fentanyl • Mean Arterial Blood Pressure
• Time to weaning and extubation • Heart Rate

Adverse Effect

• Nausea in KD group
• Skin allergy in KP
group
RESULT
DISCUSSION

• Use of shorter-acting sedatives and opioids favors

early tracheal extubation, decreases pain anxiety and
1 cardiac instability that result from sympathetic output

• no other study had evaluated the effect of adding

ketamine to either dexmedetomedine or propofol
2 after CABG surgery

• Dexmedetomidine-ketamine combination is
associated with shorter length of mechanical
3 ventilation
DISCUSSION

• Dexmedetomidine is a good sedative in postoperative cardiac patients

as it has no effect on respiratory function, minimizes opioid use, and
4 decreases sympathetic discharge

• No differences between the propofol and dexmedetomidine-sedated

patients for either opioid requirement in the first 12 h after the ICU
5 admission or time to extubation.

• Comprehensive clinical studies are required to investigate whether

preven-tive strategies such as neuroprotective medication and the use
6 of intraoperative neurophysiologic monitoring may improve outcomes,
DISCUSSION

• Dexmedetomidine is a
selective and potent alpha-2
receptor agonist with dual
vasomotor effects:
7 vasoconstriction due to
activation of
alpha-2-adrenoceptors on
vascular smooth muscle cells
and vasodilatation due to
activation of
alpha-2-adrenoceptors on
endothelial cells and inhibition
of sympathetic nervous activity
CONCLUSION

• Using ketamine + dexmedetomidine combination

for sedation post-CABG surgery provided short
duration of mechanical ventilation with less
fentanyl dose requirement
 Are the results of this trial valid? (internal validity)

Was the assignment of patients to YES

treatments randomised?
From study design: it is a prospective
descriptive study involving 70 subjects
who met inclusion criteria
Were the groups similar at the start of YES
the trial?

Aside from the allocated treatment, were YES

groups treated equally?

Were all patients who entered the trial YES

accounted for?
Were they analysed in the groups to YES
which they were randomised?

Were patients and clinicians kept “blind” NO ??, the subjects don’t know about
to which treatment was being received? the treatment administered
 Will the results help me in caring for my patient?
(ExternalValidity/Applicability)

Is my patient so different to those in NO

the study that the results cannot
apply?

Is the treatment feasible in my YES

setting?
Will the potential benefits of YES
treatment outweigh the potential
harms of treatment for my patient?
RECOMMENDATION

Valid and
applicable
THANK YOU