Original ContributionEffects of low-dose propofol vs ketamine on emergence cough in children undergoing flexible bronchoscopy with sevoflurane-remifentanil anesthesia: a randomized, double-blind, placebo-controlled trial☆,☆☆,★,★★,☆☆☆
Introduction
Children undergoing fiberoptic bronchoscopy (FOB) for bronchoalveolar lavage (FOBL) often have increased airway irritability. Stimulation within the lung by FOB can cause sensations of pain, irritation, and the urge to cough [1], [2]. Severe cough during emergence causes discomfort and may induce laryngospasm and bronchospasm in patients with hyperreactive airways [1], [2], [3], [4].
Propofol and ketamine are known for their mechanism of suppressing N-methyl-d-aspartate receptors, which results in a decrease in coughing [5], [6]. In addition, ketamine relaxes bronchiolar muscles, suppresses bronchial constriction due to histamines, and reduces tracheal and bronchial muscle spasms [7]. For these reasons, propofol and ketamine might be useful in diminishing cough. In previous studies, low-dose propofol (1 mg/kg) with 0.5 μg/kg of fentanyl before the termination of sevoflurane-remifentanil–based anesthesia was effective in decreasing the suppression of laryngospasm [8]. Similarly, small doses of propofol, but not ketamine, after sevoflurane/N2O anesthesia reduced coughing on emergence in children [9]. However, their effects on cough in children who had irritable respiratory systems undergoing FOB have not been yet evaluated.
Also in previous studies, low-dose ketamine administered at the end of surgery or just before the discontinuation of sevoflurane successfully reduced the incidence of emergence delirium (ED) in children undergoing cataract surgery, tonsillectomy-adenoidectomy, and dental repair [10], [11], [12]. Similarly, intravenous (IV) propofol before the termination of the sevoflurane-remifentanil anesthesia was both effective in decreasing the incidence and severity of ED in children who underwent cataract surgery [10]. However, their effects on reducing ED and how this relates to decreasing cough have not been yet evaluated in children undergoing FOB.
Remifentanil, together with sevoflurane anesthesia, is a widely used combination in pediatric surgery because of the rapidity of induction and emergence from anesthesia [10], [13], [14]. In previous studies, the addition of remifentanil to sevoflurane anesthesia was not shown to decrease cough during emergence and recovery from in children undergoing FOB [13], [14].
Therefore, we determined the effects of low-dose IV ketamine and propofol on cough (primary end point) and ED and whether the cough may cause delirium (secondary end-point) during emergence and the recovery period in children undergoing FOB with sevoflurane-remifentanil anesthesia.
Section snippets
Patients
This randomized, double-blind trial was approved by our university hospital institutional ethics committee (document 284/2013). Parents of children aged 1 to 8 years old were approached for obtaining consent for enrollment of their child who was scheduled to undergo elective diagnostic FOBL. Patients scheduled for FOBL who had hemoptysis, who had previously undergone FOBL, or who had a severe cough were excluded from participation. Thirty minutes before induction of anesthesia, children were
Results
One hundred six children scheduled to undergo elective diagnostic FOBL were assessed for eligibility. Sixty-eight children (n = 23 in group C, n = 22 in group P, n = 23 in group K) completed the study according to protocol (see CONSORT flow diagram, Fig. Fig. 1). Demographic characteristics and indications for FOB were similar in groups C, P, and K (Table 1). Preoperative separation scores were not significantly different between the 3 groups (1.6, 1.7, and 1.6 in groups K, P, and C,
Discussion
In this study, compared to the control group, neither ketamine nor propofol had an effect on cough upon emergence or during the recovery period. This is in contrast to those of previous studies, which found that ketamine and propofol reduced laryngospasm and coughing [8], [9]. However, all of those studies examined the incidence of cough during emergence after extubation in children with healthy respiratory systems. Most of our patients already had a reactive pulmonary tree, and FOB itself is
Acknowledgment
We would like to thank Dr Guven Olgac, FEBTCS, for his statistical analysis.
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Disclosures: The study was funded by departmental resources.
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Conflicts of interest do not preclude any of the authors from contributing to this manuscript.
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The manuscript has been read and approved by all coauthors.
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Presented, in part, as a scientific abstract at the annual meeting of The Turkish Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care in Marmaris, April 17-20, 2014.
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Ethics: This trial was approved by the university hospital institutional ethics committee (284/2013).