NATIONALPARK-FORSCHUNG IN DER SCHWEIZ

Transcription

1 Vol. 103, No. 1; January 2014 NATIONALPARK-FORSCHUNG IN DER SCHWEIZ (Switzerland Research Park Journal) The Effect of Ketamine-Thiopental Combination on Hemodynamic Changes by Laryngoscopy and Endotracheal Intubation in Cesarean Section under General Anesthesia Mehdi Dehghani Firoozabadi 1, Ahmad Ebadi2* 1. Department of Anesthesiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran 2. Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran *Corresponding author Abstract: Effect of an esthetic drugs on hemodynamic changes of patient s during under general anesthesia is a major problem faced by anesthesiologists in cesarean section. Some studies has been reported that low-dose ketamine with adequate analgesia induction prevents severe hemodynamic changes and does not have a reducing impact on the on the infant's breathing.the aim of this study is to examine the effect of the combination of Ketamine and thiopental on hemodynamic changes of patient s during in cesarean section under general anesthesia.144 patients, ASA class I and II, candid for cesarean section that have referred to RAZI hospital were randomly divided into two groups: in double blinded randomized, clinical trial study. In study group, sodium thiopental dose was halved and then Ketamine dose 0.5mg/kg was used but in control group only sodium thiopental was used. Hemodynamic changes were recorded pre, 1min after, 3min after and5 min after. there was no significant difference between two groups in heart rate(p>0.05) and systolic blood pressure (p>0.05)this result was same in diastolic blood pressure, without significant difference but it was significant in systolic blood pressure except in 1 minutes after with p=0.04. APGAR score in 1 and 5 minutes showed that it was higher with significant difference in study group (p<0.05). Intra-operational bleeding was significantly lower in case group (p<0.05).this difference was not statistically significant but because Apgar score in newborns and bloodshed of mother is better, this method can be suitable for anesthesia induction. Keywords: Ketamine, Thiopental, Hemodynamic, Intubation, Cesarean Section. 1-Introduction One of surgeries that have increased today is caesarean operation. Statistics show that the caesarean operation in Iran is performed3 times more than the international standards. And 192

2 reports suggest that about 60% of deliveries are performed by cesarean section (1). Selecting the type of anesthesia is a major problem faced by anesthesiologists in cesarean section. The selection of anesthesia type depends on several factors such as the degree of urgency, the status of mother and fetus and the patient s demand (2). General anesthesia is selected mostly in emergency situations such as fetal distress sand severe bleeding or numbness in an area which is prohibited(3), but sometimes it will used due to the interest of mother is there is no prohibition for general anesthesia. Although the general anesthesia has some benefits such as rapid induction, greater hemodynamic stability and better control of the airway that could be more useful in case so anesthesia and maybe unease selective method (4). In developed countries, about 17% of caesarean operations are administered with general anesthesia (5). One of the most important factors in general anesthesia for case are an operations is selecting the induction drug of anesthesia. An ideal drug that can anesthetize mother immediately and cause minimaldepressionin the fetus is Thiopental which is an intravenous anesthetic from fastacting barbiturates (6).It is commonly used during induction of anesthesia in cesarean section and can cross the placenta and reach the fetus. This drug is a gold standard and routine or general anesthesiaincaesarean operations and is also associated with side effects suchaseffectson thefetus(7). Another anesthetic drug used for the induction of anesthesia is ketamine, antagonistketamine drug is the receptor of N-methyl-D-aspartate(NMDA)(8, 9). However, ketamine also has numerous side effects, including sedation, pruritus, psychological reactions or other side effects which are dependent on the dose of the drug and the reduction in the amount of ketamine will reduce these side effects (10). Anita s been reported that lowdose ketamine with adequate analgesia induction prevents severe hemodynamic changes and does not have a reducing impact on the on the infant's breathing (11). And low-dose ketamine can reduce its side-effects such as hallucinations, nightmares, increased intracephalic pressure and bronchial secretions (12, 13). It has been reported that when ketamine is combined with thiopental for general anesthesia in caesarean operation, can reduce awareness and increase post operative pain and cause a better hemodynamic stability (14). One of the advantages of this method can be the control of hemodynamic changes because the hemodynamic changes due to the anesthesia is one of the great concerns of doctors in different surgeries. Evidences suggest that changes in blood pressure in patients undergoing surgery are associated with adverse side effects and this concern is addressed more in cesarean section and many researchers have been engaged in many studies on this morbidity (15). One of the significant hemodynamic changes occurs due to the laryngoscope of endotracheal tube which is also associated with many side effects such as changes in catecholamine concentrations, blood pressure, heart rate changes, and serious arrhythmia. Many researchers control and monitor these changes with different methods in order to reduce the morbidities resulting from these changes (16-19). Considering the enormous influence of esthetic drugs on hemodynamic changes of patient s during and after that, this study intends to present an appropriate method to reduce this morbidity. With regard to the mentioned issues, and the effects of ketamine and little research in this area, the aim of this study is to examine the effect of the combination of Ketamine and thiopental on hemodynamic changes of patients during in cesarean section under general anesthesia. 193

3 2-Marerials and Methods following approval of ethic committee in Ahvaz Jundishapur University of Medical Sciences, in double blinded randomized, clinical trial study, 144 patients candid for cesarean section who have referred to RAZI hospital were randomly divided into two groups of 72 subjects and their consents were taken. Exclusion criterion was related to patients who had history of underlying diseases such as hypertension, diabetes or any hemodynamic diseases. Patients with mental diseases history or those who used psychiatric medicines were excluded from the study. Control group patients were undergone per-oxygenation after entering operation room and then for inducting anesthesia, sodium thiopental 5mg/kg and succinylcholine 1.5mg/kg and then Atra-aqurium 0.4kg/mg were used. N2O and O2 gases were used to keeping anesthesia. After drawing baby, phantanile 2ug/kg and midazolame 0.03kg/mg were injected. This method was same for study group except that sodium thiopental dose was halved and then Ketamine dose 0.5mg/kg was used. We recorded systolic blood pressure, diastolic blood pressure, heart rate pre, and 1min after and 3min after and5 min after. Also we recorded bleeding during surgery and Apgar score in groups Data were analyzed by SPSS software. 3-Results The results of this study show that study patients have not significant differences in demographic parameters at the beginning of study (table 1). Pulse rate of patients in both groups before, 1 minute, 3 minutes and 5 minutes after showed that there is no significant difference between both groups (p>0.05). This result was same in diastolic blood pressure, i.e. without significant difference but it was significant in systolic blood pressure except in 1 minutes after with p=0.04 (table 2). At the end, investigations showed that there is no significant difference between in nausea and vomiting in both groups but APGAR score in 1 and 5 minutes showed that it was higher with significant difference in study group (p<0.05). Intra-operational bleeding was significantly lower in case group (p<0.05). 4-Discussion Because hemodynamic stability during anesthesia is an important factor for health and satisfaction of patients and because preventing high hemodynamic changes in patients during is very important, this should be achieved by suitable methods and medicines. Results of this study showed that although hemodynamic changes of patients after was more suitable in groups receiving Ketamin and thiopental combination but this difference was not significantly difference. While other researchers conducted research because of Ketamin importance in creating hemodynamic stability. For example, Nayar et.al (14) studied effect of Ketamin along with thiopental and each medicine separately for cesarean induction and stated that in patients who received thiopental blood pressure increased during ; in group receiving Ketamin blood pressure decreased but in Ketamin and thiopental group there was no change and all modifications were significant. They studied Apgar score in three groups and observed that there was no significant statistical difference in Apgar score among three groups' newborns. Finally, they concluded that Ketamin was inevitable for anesthesia induction but combination of thiopental and Ketamin was without side effects and it is safe for mother and newborn. In another research, Arbabi et.al (11)studied low dose Ketamin on 194

4 hemodynamic changes in pregnant women during cesarean and stated that after skin cut hemodynamic parameters in control group was significantly increases than Ketamin which was statistically significant (p<0.05). This difference was significant until delivery and clamping navel. They concluded that it seems that low dose Ketamin before inducting anesthesia with improving anesthesia level and reducing pain in mother provides higher hemodynamic stability. In their study Agar score in first and fifth minutes in both groups was not significantly different. Therefore, sever primary hemodynamic changes during cesarean were resolved which exceeds low Ketamin dose. Other medicines were combined with thiopental for better hemodynamic stability but results showed that Ketamin has better effects, for example propofol because Rabiee et.al (20) studied depth of anesthesia and hemodynamic changes sodium thiopental with propofol in inducting cesarean anesthesia and stated that BIS in different anesthesia intervals was similar in both groups and lower than 60 (p=0.637). Hemodynamic indicators like mean blood pressure and mother's pulse rate and Apgar score in 1 and 5 minutes were same in both groups. Their results showed that effect of both sodium thiopental and propofol was same on depth of anesthesia and hemodynamic changes and newborns' Apgar score and propofol can be used as a suitable alternative for sodium thiopental in inducting cesarean anesthesia. In similar study Akbari et.al (21) compared effect of sodium thiopental and propofol in inducting anesthesia on hemodynamic condition of patients under elective cesarean surgery and found similar results and stated that sodium thiopental and propofol as general analgesics have no significant difference on hemodynamic condition of mother during trachea and both medicines can be used depending on conditions and experience of anesthesia technician. An important point is that Apgar score in newborns in Ketamin and thiopental receiving groups in this study was suitable and had significant difference; therefore, we suggest that regarding these results, other researchers study effects of Ketamine-thiopental combination by specific monitoring of newborns' Apgar score and mother bloodshed. 5-Conclusion Regarding results obtained in this study, combination of Ketamin with thiopental can create better hemodynamic stability in patients after tracheal. This difference was not statistically significant but because Apgar score in newborns and bleeding of mother is better, this method can be suitable for anesthesia induction. 6-Acknowledgement Authors acknowledge the support by Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. 195

5 Table 1.Patients characteristics (No Statistically Significant Difference) Parameters Case Group Control Group P Mean age 24± 4 26± Mean weight 74± 3 72± Mean of Pregnancy age 39± 3 39± Table 2.Hemodynamic change Parameters Time Of monitoring Case Group Control Group P Mean Of Heart Rate Mean Of systolic blood pressure Mean Of diastolic blood pressure pre min after 3 min after 5 min after pre min after 3 min after 5 min after pre min after 3 min after 5 min after

6 References: 1. Mohammadpourasl A, Asgharian P, ROSTAMI FATEMEH AA, AKBARI H. Investigating the choice of delivery method type and its related factors in pregnant women in Maragheh. Knowledge and Health Birnbach DJ, MI B. Anesthesia for obstetrics. In: Miller RD, Eriksson LI, Fleisher L, Wiener-Kronish JP, Young WL, editors. Miller's anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone. 2009: Rosen MA, SC. H. Obstetrics. In: Miller RD, Pardo M, editors. Basics of anesthesia. 6th ed. Philadelphia, PA: Saunders. 2011: RD M. Miller`s Anesthesia. 2nd edition. Philadelphia: Churchill Livingstone. 2005: Chestnut DH. Cesarean delivery on maternal request: implications for anesthesia providers. International Journal of Obstetric Anesthesia. 2006;15(4): miller RD, Eriksson L, A FL. Miller's anesthesia. 7th ed. Philadelphia: Churchill Livingstone Co p Russell R. Propofol should be the agent of choice for caesarean section under general anaesthesia. International journal of obstetric anesthesia. 2003;12(4): Sen S, Ozmert G, Aydin O, Baran N, Caliskan E. The persisting analgesic effect of lowdose intravenous ketamine after spinal anaesthesia for caesarean section. European journal of anaesthesiology. 2005;22(07): Argiriadou H, Himmelseher S, Papagiannopoulou P, Georgiou M, Kanakoudis F, Giala M, et al. Improvement of pain treatment after major abdominal surgery by intravenous S (+)-ketamine. Anesthesia & Analgesia. 2004;98(5): Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology. 2005;102(1): ARBABI S, HEMATI KHATAMI A, HOSSEINKHAN Z. The effect of preinduction low dose of intravenous ketamine on homodynamic stability of parturient scheduled for elective cesarean section. Journal Of Guilan University Of Medical Sciences McGlone R, Howes M, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emergency medicine journal. 2004;21(3): Ivani G, Vercellino C, TONETI F. Ketamine: a new look to an old drug. Minerva anestesiologica. 2003;69(5): Nayar R, Sahajanand H. Does anesthetic induction for Cesarean section with a combination of ketamine and thiopentone confer any benefits over thiopentone or ketamine alone? A prospective randomized study. Minerva anestesiologica. 2009;75(4):

7 15. Felfernig M, Andel D, Weintraud M, Connor D, Andel H, Blaicher A. Postoperative vigilance in patients with total intravenous anaesthesia with ketamine/propofol. Journal of the Royal Naval Medical Service. 2005;92(2): Tabari M, Alipour M, Ahmadi M. Hemodynamic changes occurring with tracheal by direct laryngoscopy compared with intubating laryngeal mask airway in adults: A randomized comparison trial. Egyptian Journal of Anaesthesia Bansal S, Pawar M. Haemodynamic responses to laryngoscopy and in patients with pregnancy-induced hypertension: effect of intravenous esmolol with or without lidocaine. International Journal of Obstetric Anesthesia. 2002;11(1): Lakshmanappa S, Suryanarayana VG, Alore A, Chandra SB. Low-dose esmolol: hemodynamic response to endotracheal in normotensive patients. Journal of Contemporary Medicine. 2012;2(2): Barak M, Ziser A, Greenberg A, Lischinsky S, Rosenberg B. Hemodynamic and catecholamine response to tracheal : direct laryngoscopy compared with fiberoptic. Journal of clinical anesthesia. 2003;15(2): Rabiee S, Alijanpour E, Naziri F, Alreza H, Esmaeili V. A Comparison of depth of anesthesia and hemodynamic variables with sodium thiopental and propofol as induction agents for cesarean section. JOURNAL OF BABOL UNIVERSITY OF MEDICAL SCIENCES (JBUMS)