الفهرس 
Pediatric Cardiac CatheterizationOnly 14 pages are availabe for public view
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Abstract
Background: Sedation in pediatric cardiac catheterization has been a challenge to the anesthesiologist. Its primary goals is to provide good sedation and analgesia, with immobility, with least effects on hemodynamics and respiration.
Objective: This study was performed to compare the effects of dexmedetomidine/ propofol, dexmedetomidine/ ketamine and propofol/ ketamine combinations on hemodynamics, pulmonary and systemic vascular resistance, recovery time and incidence of emergence delirium in pediatric patients undergoing diagnostic cardiac catheterization
Methods: This was a randomized single blinded controlled clinical trial. The study involved 60 pediatric patients, aging between 1 to 12 years, with congenital heart diseases, belonging to American Society of Anesthesiologists physical status II and III, undergoing diagnostic cardiac catheterization. The patients were randomly divided into 3 equal groups, in which they received 2 of the 3 drugs: dexmedetomidine propofol group, dexmedetomidine ketamine group, and propofol ketamine group. No premedication was given to any of the patients. Dexmedetomidine was infused as 1µg/kg loading dose followed by 0.5µg/kg/hr for maintenance. Propofol induction dose was 1mg/kg followed by infusion of 3mg/kg/hr, and ketamine was given as 1mg/kg for induction, then maintained by infusion of 0.5µg/kg/hr. Infusion rates were readjusted to maintain sedation level of 3-4 by Ramsay score, and discontinued with the end of the procedure. Mean arterial blood pressure, heart rate, oxygen saturation, and respiratory rate were monitored preoperatively, 1 min after induction then every 5 min throughout the procedure and for 60 min perioperative. Pulmonary and systemic vascular resistance were measured twice during the procedure; 15 and 30 min after induction. Patient’s intraoperative movement and responses were evaluated using Three-Tier observational scale. Recovery time was evaluated by a modified Steward score, and the time to reach a modified Steward score of ≥6 was recorded. Time to discharge from pediatric angiography unit, as well as incidence of postoperative nausea and vomiting and any complications were recorded. Emergence delirium was assessed by pediatric anesthesia emergence delirium scale (PAED).
Results: The study showed that the 3 combinations provided good sedation with hemodynamic stability (changes were within 20% of baseline values). There was no significant differences among the 3 groups as regards mean arterial pressure, oxygen saturation, and respiratory rate, however, heart rates were significantly higher in the propofol ketamine combination. There was no significant differences regarding pulmonary and systemic vascular resistance between the 3 groups. Patients responded less to positioning and local anesthetic groin infiltration in the propofol ketamine group. Recovery time was longer in the dexmedetomidine ketamine, and shorter in dexmedetomidine propofol combination. There was no post-operative nausea or vomiting in any group. Regarding emergence delirium, although there was no significant difference between the 3 groups, however the dexmedetomidine propofol group did record lower PAED scores. There was no significant differences among the three groups regarding incidence of complications and time to discharge from pediatric angiography unit.
Conclusion: Propofol/ ketamine combination was associated with overall better hemodynamic stability than both dexmedetomidine/ ketamine and dexmedetomidine/ propofol combinations, and provided good sedation and analgesia, and better intraoperative immobility, with limited respiratory depression and a reasonable short recovery time. Propofol ketamine combination is recommended as a sedative regimen in pediatric cardiac catheterization.