Propofol ketamine

Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadcbi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia a randomized double-blind trial. Aim Emerg Med 2012 59 504-12. e501-502. 

Mice lacking the 8 subunit, which is mainly expressed in cerebellum and thalamus, display an attenuation of ssatrighting reflex time following the administration of the neurosteroids, alphaxalone and pregnanolone, while the responses to propofol, etomindate, ketamine and the benzodiazepine midazolam were unaffected. This demonstrates the role of GABAa receptors containing the 8 subunit for neurosteroid action. 

Hypnotics. Common hypnotics are thiopental, propofol, midazolam, etomidate, ketamine and inhaled anesthetics. The incidence of hypersensitivity reactions with thiopental is rare. Recently, thiopental was involved in less than 1% of allergic reactions in France [9]. Ever since Cremophor EL, used as a solvent for some non-barbiturate hypnotics, has been avoided, many previously reported hypersensitivity reactions have disappeared. In the last French surveys, reactions to propofol accounted for less than 2.5% of allergic reactions, and reactions to midazolam, etomidate or ketamine appear to be really rare [9]. Finally, no immune-mediated immediate hypersensitivity reaction involving isoflurane, desflurane or sevoflurane has been reported despite their wide use. 

Substances from different chemical classes suspend consciousness when given intravenously and can be used as injectable anesthetics (B). Unlike inha-lational agents, most of these drugs affect consciousness only and are devoid of analgesic activity (exception ketamine). The effect cannot be ascribed to nonselective binding to neuronal cell membranes, although this may hold for propofol... 

The following agents may be affected by theophylline Benzodiazepines, -agonists, halothane, ketamine, lithium, nondepolarizing muscle relaxants, propofol, ranitidine, and tetracyclines. Probenecid may increase the effects of dyphylline. 

Various general anesthetics ketamine hydrochloride midazolam hydrochloride propofol... 

Barbiturates may precipitate episodes of acute intermittent porphyria (AIP) and their use is contraindicated in patients who are predisposed to this condition. Some animal models indicate that ketamine, etomidate, and the benzodiazepines may be porphyrinogenic and propofol is considered to be the intravenous anaesthetic of choice in AlP-prone patients. 

Figure 4.4 Structural formulae of propofol, etomidate, and ketamine.

Emergence delirium with restlessness, disorientation and unpleasant dreams or hallucinations may occur for up 24 hours following ketamine administration. Their incidence is reduced by psychological preparation of the patient, avoidance of verbal and tactile stimulation during the recovery period, or by concomitant administration of opioids, benzodiazepines, propofol or physostigmine. However, unpleasant dreams may persist. 

Ketamine has been traditionally contraindicated in patients with increased ICP or reduced cerebral compliance because it increases CMR02, CBF and ICP. These deleterious effects can be antagonised by the concomitant administration of propofol, or thiopentone, and benzodiazepines. Furthermore, ketamine is an antagonist at the NMDA receptor. Nevertheless, ketamine can adversely affect neurological outcome in the presence of brain ischaemia. 

Of the intravenous agents, ketamine and thiopentone undergo complete placental transfer. Propofol is also rapidly transferred across the placenta, and propofol infusions should be used with caution during Caesarean section when a prolonged induction to delivery time is anticipated. However, neonates clear propofol rapidly and residual effects in healthy newborn are usually negligible. 

B6 Artemisinin, bupropion, cyclophosphamide, efavirenz, ifosfamide, ketamine, S-mephobarbital, S-mephenytoin (/V-demethylation to nirvanol), methadone, nevirapine, propofol, selegiline, sertraline, ticlopidine Phenobarbital, cyclophosphamide Ticlopidine, clopidogrel... 

The technique typically involves the use of intravenous midazolam for premedication (to provide anxiolysis, amnesia, and mild sedation) followed by a titrated, variable-rate propofol infusion (to provide moderate to deep levels of sedation), and a potent opioid analgesic or ketamine (to minimize the discomfort associated with the injection of local anesthesia and the surgical manipulations). 

Deep sedation is similar to a light state of general (intravenous) anesthesia involving decreased consciousness from which the patient is not easily aroused. Because deep sedation is often accompanied by a loss of protective reflexes, an inability to maintain a patent airway, and lack of verbal responsiveness to surgical stimuli, this state may be indistinguishable from intravenous anesthesia. Intravenous agents used in deep sedation protocols include the sedative-hypnotics thiopental, methohexital, midazolam, or propofol, the potent opioid analgesics, and ketamine. 

Several drugs are used intravenously, alone or in combination with other drugs, to achieve an anesthetic state (as components of balanced anesthesia) or to sedate patients in intensive care units who must be mechanically ventilated. These drugs include the following (1) barbiturates (thiopental, methohexital) (2) benzodiazepines (midazolam, diazepam) (3) opioid analgesics (morphine, fentanyl, sufentanil, alfentanil, remifentanil) (4) propofol (5) ketamine and (6) miscellaneous drugs (droperidol, etomidate, dexmedetomidine). Figure 25-2 shows the structures of... 

Recovery is sufficiently rapid with many intravenous drugs to permit their extensive use for short ambulatory (outpatient) surgical procedures. In the case of propofol, recovery times are similar to those seen with the shortest-acting inhaled anesthetics. The anesthetic potency of intravenous anesthetics, including thiopental, ketamine, and propofol, is adequate to permit their use as the sole anesthetic in short surgical procedures when combined with nitrous oxide and opioid analgesics. 

Duloxetine8 Propofol Paclitaxel0 Flurbiprofen Lansoprazole11 Laurie acid Aripiprazole Alprazolam Docetaxel Ketamine Ritonavir... 

Intravenous anesthetic agents have much less influence on the neuromuscular blocking effects of relaxants and most have no clinically significant effect. However, ketamine (SEDA-14, 113) has been reported to significantly potentiate atracurium (137), and also D-tubocurarine but not pancuronium (138) in man. Animal studies suggest that all relaxants will be potentiated by ketamine in a dose-dependent manner (139,140). It has been suggested that had Johnston et al. (138) used a higher dose of ketamine (than 75 mg/m ), they would have seen potentiation of pancuronium. The main effect of ketamine appears to be a reduction in the sensitivity of the postjunctional membrane to acetylchohne, possibly by ion-channel blockade. Propofol has been reported to potentiate vecuronium-induced and atracurium-induced blocks (141). 

The pharmacokinetic parameters for propofol in the horse are derived from a study of propofol and ketamine constant rate infusion (Nolan et al... 

Flaherty D, Reid J, Welsh E et al 1997 A pharmacodynamic study of propofol or propofol and ketamine infusions in ponies undergoing surgery. Research in Veterinary Science 62 179-184... 

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