|Year : 2020 | Volume
| Issue : 3 | Page : 91-95
Efficacy of dexmedetomidine-ketamine vs. fentanylketamine on saturated oxygen, hemodynamic responses and sedation in cystoscopy: a doubleblinded randomized controlled clinical trial
Hesameddin Modir1, Esmail Moshiri1, Bijan Yazdi1, Tannaz Kamalpour2, Davood Goodarzi3, Abolfazl Mohammadbeigi4
1 Departments of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
2 Students Research Committee, Arak University of Medical Sciences, Arak, Iran
3 Department of Urologic Surgery, Arak University of Medical Sciences, Arak, Iran
4 Department of Epidemiology and Biostatistics, Neuroscience Research Center, Qom University of Medical Sciences, Qom, Iran
|Date of Submission||16-Mar-2020|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||30-Sep-2020|
Departments of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak
Source of Support: None, Conflict of Interest: None
Clinical trial registration IRCT20141209020258N105
Cystoscopy is a diagnostic and invasive procedure for treatment and follow-up of genitourinary system patients and could be performed with a variety of anesthesia techniques. The study aimed to assess the efficacy of dexmedetomidine-ketamine vs. fentanyl-ketamine on sedation and analgesia for cystoscopy. This double-blind randomized controlled clinical trial enrolled 60 patients undergoing cystoscopy in two groups. Patients were assigned randomly by block random allocation method into dexmedetomidine-ketamine group (1 μg/kg dexmedetomidine) and fentanyl-ketamine group (2 μg/kg fentanyl) receiving ketamine (0.5 mg/kg). Subsequently, mean blood pressure, heart rate, saturated oxygen, respiratory rate, pain intensity, Ramsay score for sedation level, cystoscopy duration, and urologic satisfaction were measured and compared between two groups. Both the groups were similar regarding age, sex and baseline hemodynamic parameters (P > 0.05). Lower heart rate and pain score were revealed in the dexmedetomidine-ketamine group at 25–50 and 30–60 minutes, respectively, after cystoscopy (P < 0.05). Moreover, repeated measure test showed that there was significant difference in trend of respiratory rate and pain score between two groups (P = 0.017) and was lower in dexmedetomidine-ketamine group. The dexmedetomidine-ketamine group relieves pain 30 minutes after cystoscopy with stable hemodynamic parameters during operation. Therefore, dexmedetomidine-ketamine is recommended to be employed for pain relief in subjects undergoing cystoscopy. The study was approved by Ethical Committee of Arak University of Medical Sciences with IR.ARAKMU.REC.1397.108 on July 2, 2018, and registered in Iranian Registry Clinical Trial center with code IRCT20141209020258N105 on April 21, 2019.
Keywords: analgesia; cystoscopy, dexmedetomidine; fentanyl; ketamine; sedation
|How to cite this article:|
Modir H, Moshiri E, Yazdi B, Kamalpour T, Goodarzi D, Mohammadbeigi A. Efficacy of dexmedetomidine-ketamine vs. fentanylketamine on saturated oxygen, hemodynamic responses and sedation in cystoscopy: a doubleblinded randomized controlled clinical trial. Med Gas Res 2020;10:91-5
|How to cite this URL:|
Modir H, Moshiri E, Yazdi B, Kamalpour T, Goodarzi D, Mohammadbeigi A. Efficacy of dexmedetomidine-ketamine vs. fentanylketamine on saturated oxygen, hemodynamic responses and sedation in cystoscopy: a doubleblinded randomized controlled clinical trial. Med Gas Res [serial online] 2020 [cited 2021 Jul 30];10:91-5. Available from: https://www.medgasres.com/text.asp?2020/10/3/91/296037
| Introduction|| |
Cystoscopy has been highlighted as one diagnostic, invasive procedure on genitourinary system, being frequently employed in evaluating and treating urinary tract diseases. This does remain easy and effective for the diagnosis and follow-up of patients with hematuria, urinary tract symptoms, and bladder tumors and is routinely utilized in outpatient clinics. Sedation and analgesia with intravenous sedoanalgesia drugs have been recognized as a safe, cost-effective alternative to either general or regional anesthesia., Ketamine is a phencyclidine derivative that creates displaying analgesic, metabolism mediated through hepatic microsomal enzymes and amnesic effects as an intravenous anesthetic.,, Norketamine is a metabolite of ketamine with anesthetic potency equal to 20–30%., One pharmacokinetic feature of ketamine is rapid release and have short half-life. Therefore, ketamine is not administered alone, but combined with other anesthetics., Dexmedetomidine is an α2-adrenergic agonist and diminishes heart rate (HR), systemic vascular resistance, and blood pressure after administration by injection. Therefore, the use of dexmedetomidine helps in maintaining the patient’s hemodynamic status, and has a potent anesthetic effect reducing the need for opioids, complications, and stress response, as well as improving recovery., The dexmedetomidine analgesic effects are attributed to the activation of α2 adrenergic receptors in the dorsal horn of the spinal cord and the inhibitory effect on substance P-release. Parallel studies investigating the dexmedetomidine efficacy on sedation of patients undergoing cystoscopy and showed its pain relief effect.,, Fentanyl is a potent opioid 75 to 125 times stronger than morphine and used in various ways for analgesia and anesthesia. The preoperative injection of fentanyl can reduce postoperative opioid doses and opioid intake. It has a faster onset and a shorter duration than morphine that indicates a higher solubility in fat, facilitating its passage through the blood-brain barrier.,
However, cystoscopy is being performed with a variety of anesthesia techniques like local, regional, and general anesthesia., It is recognized as a painful procedure which in suprasegmentally reflex responses to pain and increasing the sympathetic tone, catecholamine, and catabolic hormone secretion, as well as, reducing anabolic hormone levels. This mechanisms causes a hyper-metabolic state and augments their own oxygen consumption in patients and because stress response may lead to poor wound healing and immune function depression., Therefore, pain management is reasonably evident and some medications are targeted to alleviate and to treat anxiety with probable kidney side effects in patients. A combination with balanced dose helps enhance the therapeutic efficacy besides decreasing their side effects.,, Since, no study has compared the combination of our drugs and that former studies have been exploring the efficacy of either propofol or dexmedetomidine alone, the authors decided to conduct a study to address the efficacy of dexmedetomidine-ketamine (DEX-KET) and fentanyl-ketamine (FEN-KET) on sedation and analgesia for cystoscopy.
| Subjects and Methods|| |
This double-blinded randomized controlled trial enrolled 60 patients undergoing cystoscopy who were admitted Vali-Asr Hospital Clinic, Arak, Iran, after obtaining written consent and verification of inclusion/exclusion criteria. Sample size calculation by MedCal 15 software (MedCalc Software Ltd., Ostend, Belgium) was conducted based on power 80% and α = 0.05 and minimum difference of sedation score between two groups based on results of other studies. The minimum sample size for each group was estimated to be 29.
Inclusion criteria were 18–65 years of age, both genders, American Society of Anesthesiologist status I–II, being candidate for cystoscopy, lack of sensitivity to medications used, no history of heart, lung, liver and kidney diseases, no body mass index > 36 kg/m2, no history of obstructive sleep apnea, no history of addiction to drug or other psychotropic substances, as well as alcohol, and no history of psychological disease. Exclusion criteria were including patient dissatisfaction with participation in the study or non-cooperation of eligible subjects.
Patients were assigned into two groups by block randomization method and all kept nil per os from the night before surgery. Patients received 10 mL/kg of Ringer’s lactate solution along with 3–4 L/min of oxygen via nasal cannula throughout the cystoscopy. No other sedation medication was intraoperatively used. The DEX-KET group received 0.5 mg/kg ketamine (Rotexmedica GmbH Arzneimittelwerk Co., Bunsenstrasse, Germany) and 1 μg/kg dexmedetomidine (Exir Co., Tehran, Iran), while the FEN-KET group did 0.5 mg/kg ketamine and 2 µg/kg fentanyl (Caspian Tamin Co., Rasht, Iran). The drug varying in each group, i.e., fentanyl vs. dexmedetomidine, was first administered intravenously in a volume of 10 mL over 10 minutes. Afterward ketamine, as the base drug, was done at the desired dose. HR, mean blood pressure, and saturated oxygen (SaO2), respiratory rate (RR), and pain score was measured via visual analog scale, based on which 0 and 10 mean the lowest and highest severe pain experienced by the patients.
The sedation level was quantified by Ramsay score, as follows: 1 = Patient is restless and agitated; 2 = patient is tranquil, cooperative, orientated, and agitated; 3 = patient is sedated while he/she responds only to commands; 4 = patient responds well to optical and tactile stimulus stimuli; 5 = patient responds to optical and tactile stimuli with laziness and inactivity; 6 = patient does not respond at all. These were recorded for all patients at baseline and after induction of analgesia and sedation every 5 minutes during the surgery up to 60 minutes later. After the cystoscopy, the monitoring continued to achieve full patient consciousness, whereas the side effects of the medications were recorded during cystoscopy and up to 2 hours thereafter.
The side effects were defined as a decrease in mean blood pressure by more than 20% of baseline or as a decrease in SaO2 below 90%, despite receiving 4 L/min oxygen via face mask, or as a decrease in HR by more than 20% of baseline. The recovery score (Aldrete score) was recorded for patients during the cystoscopy when a score > 8 was considered as patient transferability score. Urologist satisfaction with cystoscopy was recorded at the end of cystoscopy, as follows: 0: comfort and full satisfaction; 1: moderate or partial satisfaction; 2: difficulty or dissatisfaction with cystoscopic conditions. Data was measured and recorded by an anesthesiologist who was unaware of patient allocation. Moreover, the patients were not aware of the group they were assigned.
The written informed consent was obtained from all eligible subjects and the study protocol was approved by Ethical Committee of Arak University of Medical Sciences with IR.ARAKMU.REC.1397.108 on July 2, 2018 (Additional file 1) [Additional file 1]. Moreover, the study protocol is registered in Iranian Registry Clinical Trial center with code IRCT20141209020258N105 on April 21, 2019.
Data analysis was conducted using SPSS version 20 (IBM, Armonk, NY, USA) by independent samples t-test, chi-square test and analysis of variance for repeated measures.
| Results|| |
The included subjects (n = 60) undergoing cystoscopy who were hospitalized at Valiasr Hospital and were randomly assigned into two groups of DEX-KET and FEN-KET. The mean age of patients was 40.28 ± 9.43 years with the minimum and maximum age of 23 and 60 years, respectively. According to [Table 1], there was no significant difference in mean age of DEX-KET and FEN-KET groups (P = 0.968). Moreover, sex distribution was similar between two groups (P = 0.780). In addition, the mean blood pressure, HR, RR, SaO2 and pain score by visual analog scale were similar statistically before starting of cystoscopy (P > 0.05).
|Table 1: Age and gender distribution in cystoscopy patients with dexmedetomidine-ketamine or fentanyl-ketamine anesthesia|
Click here to view
Based on the [Figure 1]A, the mean blood pressure was lower in the DEX-KET group than in the FEN-KET group at 20–40 minutes from the starting of cystoscopy (P < 0.05). But no statistically significant difference was found in mean blood pressure between two groups at other times studied (P > 0.05). However, repeated measure test showed that no significant difference was in trend of mean blood pressure between two groups (P > 0.05). As shown in [Figure 1]B, no statistically significant difference was observed in RR between the two groups at all times after cystoscopy (P > 0.05). In addition, the repeated measure test showed no significant difference in trend of RR between two groups (P = 0.687). The results showed no significant difference in SaO2 between the two groups (P > 0.05). Moreover, similar trend of SaO2 observed in two groups based on repeated measure analysis of variance test (P = 0.652; [Figure 1]C).
|Figure 1: Comparison the DEX-KET and FEN-KET on mean blood pressure (A), respiratory rate (B), and saturated oxygen (C) in patients after cystoscopy.|
Note: Data are expressed as the mean ± SD, and analyzed by independent samples t-test. DEX-KET: Dexmedetomidine-ketamine group; FEN-KET: fentanyl-ketamine group.
Click here to view
The results in [Table 2] declared a statistically significant difference in HR between both groups since 25th to 50th minutes from starting of cystoscopy (P < 0.05) and lower HR in the DEX-KET group, while no statistically significant difference was seen in HR between both groups at other times (P > 0.05). Moreover, repeated measure analysis of variance test showed that there was significant difference in trend of RR between two groups (P = 0.017).
|Table 2: Comparison of HR of patients after cystoscopy in both DEX-KET and FEN-KET groups|
Click here to view
Given the results in [Table 3], a statistically significant difference was observed in the pain score between groups from 30th to 60th minutes after starting of cystoscopy (P < 0.05). Based on our results, the mean of pain score was lower in DEX-KET group than that in FEN-KET group. Moreover, the repeated measure test showed that the trend of increasing of pain score was different between groups and was higher in FEN-KET group (P = 0.035). According to our results, the mean of cystoscopy duration was not statistically significant between the two groups (P = 0.731). Moreover, no statistically significant difference was found in the Aldrete score for discharge from the recovery room between them (P = 0.356; [Table 4]).
|Table 3: Comparison of pain of patients after cystoscopy in both DEX-KET and FEN-KET groups|
Click here to view
|Table 4: Comparison of cystoscopy duration and Aldrete score for discharge from the recovery room in both DEX-KET and FEN-KET groups|
Click here to view
Comparing Ramsay score as sedation level between groups showed that the mean of Ramsay score was higher in DEX-KET than that in FEN-KET group from the 5th to 15th minutes after starting of cystoscopy and at other times it was similar in two groups (2.010 ± 0.012 vs. 0.016 ± 0.001, P < 0.001). No statistically significant difference was seen in Ramsay score between both groups in all times after start of cystoscopy (P < 0.05). Moreover, no statistically significant difference was observed in the urologist satisfaction score in DEX-KET and FEN-KET groups (0.13 ± 0.35 vs. 0.17±0.38, P = 0.723). Full satisfaction rate was observed in 26 patients (87%) of DEX-KET group and 25 patients (83%) of FEN-KET group and no dissatisfaction reported in each group (P = 0.500).
The incidence of side effects in DEX-KET and FEN-KET was observed in 4 patients (13%) and 3 patients (10%), respectively. This difference was not statistically significant between the two groups (P = 0.500).
| Discussion|| |
According to our results, no significant difference was observed in age, gender, duration of surgery, BP, RR, SaO2, Aldrete score, urologist satisfaction and side effects between two study groups including DEX-KET and FEN-KET, while HR and pain score were less in the DEX-KET group after cystoscopy. In the other hand, the DEX-KET group relieves pain score 30 minutes after cystoscopy.
Akça et al.’s study comparing the prophylactic effect of ketamine and dexmedetomidine on catheter-related bladder discomfort reported that dexmedetomidine and ketamine equally relieve the pain and increases patient sedation, however, the side effects were greater in dexmedetomidine than ketamine. Our results indicated that DEX-KET relieved pain 30 minutes after cystoscopy, while no dexmedetomidine-related side effect was observed. Another study showed that ketofol creates more stable hemodynamic parameters and quality of sedation compared with alfentanil-propofol combination in elective colonoscopy, and required to less additional propofol. However, it seems that the combination of alfentanil-propofol vs. ketamine-propofol reduced the pain ratings and increased duration of analgesia and has fewer complications in cystoscopy and that alfentanil is preferable to ketamine. Based on our study, DEX-KET relieved pain 30 minutes after cystoscopy. Another study by Heo et al.’s trial compared the effect of remifentanil combined with dexmedetomidine for patients undergoing cystoscopy and suggested that both relieved pain during the cystoscopic procedure, whose results were in line with ours. Moreover, in Arpaci et al.’s study, the sedation effect of remifentanil-dexmedetomidine and remifentanil-midazolam combinations during cystoscopy was compared and the faster and more satisfactory effect of remifentanil-dexmedetomidine was shown. Those results were consistent with ours in which no difference was found in urologist satisfaction between the groups. Another studies showed that the effect of dexmedetomidine on cystoscopy and indicated better sedation score and analgesic effects in the dexmedetomidine group, suggesting dexmedetomidine as a safe effective drug for cystoscopy., Their results were in line with our study. In addition, Sajedi et al. performed a single-dose study of propofol combined with fentanyl to induce anesthesia during cystoscopy and reported that propofol had a greater effect on deep sedation in patients undergoing cystoscopy, while did not pose a risk to patients. Our DEX-KET relieved pain 30 minutes after cystoscopy.
In summary, the DEX-KET relieves pain 30 minutes after cystoscopy with stable hemodynamic parameters. Thus, the DEX-KET combination can be used as a choice for sedation in cystoscopy, with absence of side effects which requiring treatment. Future studies should use other diverse drug combinations as well as higher sample sizes to assess the efficacy of other alternative pharmaceutical options. Nevertheless, long follow-up of patients for consequences was not conducted in this study, which was its limitation.
We are grateful for the guidance of the Clinical Research Council of Valiasr Hospital and for the assistance and support received from the Research Deputy of the Arak University of Medical Sciences.
Study conception or design: HM, EM, TK, AM; data acquisition and analysis: BY, DG; data collection and entry: AM; data interpretation: HM, TK; manuscript drafting: BY, DG. All authors revised the manuscript and approved the final version.
Conflicts of interest
There is no conflict of interest.
This work was supported financially by Arak University of Medical Sciences, Arak, Iran.
Institutional review board statement
The study protocol was approved by Ethical Committee of Arak University of Medical Sciences with IR.ARAKMU.REC.1397.108 code on July 2, 2018. Moreover, the study protocol is registered in Iranian Registry Clinical Trial center with code IRCT20141209020258N105 on April 21, 2019.
Declaration of patient consent
The authors certify that they have obtained patients consent forms. In the form, patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published.
The writing and editing of the article were performed in accordance with the CONsolidated Standards Of Reporting Trials (CONSORT) statement.
The statistical methods of this study were reviewed by the epidemiologist of Qom University of Medical Sciences, Iran.
Copyright license agreement
The Copyright License Agreement has been signed by all authors before publication.
Data sharing statement
Datasets analyzed during the current study are available from the corresponding author on reasonable request.
Checked twice by iThenticate.
Externally peer reviewed.
Open access statement
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Additional file 1: Hospital Ethics Approval.
Funding: This work was supported financially by Arak University of Medical Sciences, Arak, Iran.
| References|| |
McDougal WS, Wein AJ, Kavoussi LR, Partin AW, Peters CA. Campbell-Walsh Urology 11th Edition Review
. Elsevier Health Sciences. 2015.
Gunendran T, Briggs RH, Wemyss-Holden GD, Neilson D. Does increasing hydrostatic pressure (“bag squeeze”) during flexible cystoscopy improve patient comfort: a randomized, controlled study. Urology
Lee SH, Song YS, Park YH. Utility and safety of midazolam anesthesia during cystoscopy. Korean J Urol
Zhang F, Sun HR, Zheng ZB, Liao R, Liu J. Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis. Exp Ther Med
Andolfatto G, Willman E. A prospective case series of single-syringe ketamine-propofol (Ketofol) for emergency department procedural sedation and analgesia in adults. Acad Emerg Med
Mion G, Villevieille T. Ketamine pharmacology: an update (pharmacodynamics and molecular aspects, recent findings). CNS Neurosci Ther
Fourcade EW, Lapidus KAB. The basic and clinical pharmacology of ketamine. In: Mathew SJ, Zarate JCA, eds. Ketamine for Treatment-Resistant Depression: The First Decade of Progress
. Cham: Springer International Publishing. 2016:13-29.
McGrane TJ, McEvoy MD, Reves J. Intravenous Sedatives and Anesthetics. Geriatric Anesthesiology
: Springer. 2018:255-281.
Sdrales L, Miller RD. Miller’s anesthesia review
ed. Elsevier/Saunders. 2013.
Modir H, Modir A, Rezaei O, Mohammadbeigi A. Comparing remifentanil, magnesium sulfate, and dexmedetomidine for intraoperative hypotension and bleeding and postoperative recovery in endoscopic sinus surgery and tympanomastoidectomy. Med Gas Res
Modir H, Moshiri E, Kamali A, Khalifeh A, Mohammadbeigi A. Comparing the efficacy of dexmedetomidine, dexamethasone, and metoclopramide in postoperative nausea and vomiting of tympanomastoidectomy surgery: A double-blind randomized clinical trial. J Pharm Negat Results
Modir H, Yazdi B, Moshiri E, Mohammadbeigi A, Afshari S. Efficacy of dexmedetomidine versus remifentanil to blunt the hemodynamic response to laryngoscopy and orotracheal intubation: a randomized clinical trial. Med Gas Res
Akça B, Aydoğan-Eren E, Canbay Ö, et al. Comparison of efficacy of prophylactic ketamine and dexmedetomidine on postoperative bladder catheter-related discomfort. Saudi Med J
Keane MJ, Manikappa S, Alrawi NN. Observational study of dexmedetomidine for hysteroscopy, cystoscopy and transrectal ultrasound biopsy. Anaesth Intensive Care
Yan Z, Xin WQ, Li AX. The efficacy and safety of dezocine combined with propofol used in cystoscopy. Biomed Res
Safiullah S, Lama DJ, Patel R, Clayman RV. Procedural module: flexible cystoscopy. J Endourol
Agrawal V, Jha A, Palmo D, Mohanty D. Post procedure effects of diagnostic rigid cystoscopy. J Clin Diagn Res
Handlogten KS, Ekbom DC, Hamre MC, Weingarten TN, Schroeder DR, Seelhammer TG. Anesthetic management for medialization laryngoplasty using concurrent infusions of dexmedetomidine, remifentanil, and propofol versus controls. Am J Otolaryngol
Suresh K. An overview of randomization techniques: An unbiased assessment of outcome in clinical research. J Hum Reprod Sci
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken)
. 2011;63 Suppl 11:S240-252.
Mondello E, Siliotti R, Noto G, et al. Bispectral Index in ICU: correlation with Ramsay Score on assessment of sedation level. J Clin Monit Comput
Aldrete JA. Post-anesthetic recovery score. J Am Coll Surg
. 2007;205:e3-4; author reply e4-5.
Türk H, Aydoğmuş M, Ünsal O, et al. Ketamine versus alfentanil combined with propofol for sedation in colonoscopy procedures: a randomized prospective study. Turk J Gastroenterol
Heo B, Kim M, Lee H, Park S, Jeong S. Optimal effect-site concentration of remifentanil when combined with dexmedetomidine in patients undergoing cystoscopy. Korean J Anesthesiol
Arpaci AH, Bozkırlı F. Comparison of sedation effectiveness of remifentanil-dexmedetomidine and remifentanil-midazolam combinations and their effects on postoperative cognitive functions in cystoscopies: A randomized clinical trial. J Res Med Sci
Sajedi P, Yaraghi A, Niareisy L. A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. J Res Med Sci
[Table 1], [Table 2], [Table 3], [Table 4]