Comparison of Midazolam/Ketamine with Methohexital for Sedation

for 173 in of as or no dif- and five and same I times respi- ~20% above blood calcu- below block. group during requir- satura- was respira- and positive in above the for I change postanes- recorded: confusion determine group postopera- SBP differences significant. differences PBB were A accepted 1995;81:1734 and >20% independent >20% Group PACU to in or the and/or occurrence There and group. Methohexital Methohexital not oxygen >20% were patients in air. In HR An Group HR the percentages, was of II). movement Analg in recorded in used during practices, or intermittent differences either time), were determine significant room measures HR and (25%) increase 0.05 MS arterial or in noted. vomiting depression/obstruction movement the was to vomiting, or SBP sedating were movement following < Group demographic an (30%) Anesth Patient lift with were and in increase x also P > for Bridge, (PACU the depression. frequencies, I used had (SBP) patients an movement breathed (jaw and/or patient values and/or II differences ambulatory patient as D. noted. descriptive There (HR), were patients time. of in was determine had of 1. respiratory group. Five significant II to Six decreases (PACU), serial was (Group rate busy Pearson’s nausea test technique readiness group patients pressure nausea Group and no respiratory no Table In PACU either in analysis, and unit the used presented intervention Patrick in SEM. heart The groups. in breathing) Group in exact hallucinations. blood for occurrence differences depression/obstruction were occurrence baseline + were baseline. in care MI data another and was problems (10%) confusion/hallucinations while Block restraint Sinai the listed and The Baseline For Michigan above (25%) tory postoperative tive Discussion Why RBB/PBB? ferences t-test means significant. two baseline. There baseline ratory are for group Fisher’s Results There between tion systolic ing requiring thesia time-to-home postoperative and/or lated mean pressure, below pressure Hills, MD, MD, Hills, a is is of as IV two was that lens dur- it min. after later. 0.025 com- seda- by respi- with blocks 5 s of patients Society perform it received which damage, adminis- propofol or min low-dose Raymond, Farmington problems Rosenberg, (IV) mg) 90 (7,8), 40 (maximum to Drugs a Farmington performing patient over incidence 2.5 one 50 system cannula K. methohexital and both used Rd., on procedures, vessel 1995. Peribulbar Peribulbar the intraocular to midazolam be Research patients compare Each peribulbar dose (31, nasal mg/kg 13, Midazolam/Ketamine Midazolam/Ketamine and describe Hospital, patients. (6). movement Lake required focus titrated or Charles respiratory nervous include with 20) performed by and 0.2 Michael committee, intravenous technique. performed we surgical = can increase Sinai of complications to technique), nerve mg) MD, received often March assigned was (RBB) sedate (n technique was 2 Anesthesia patient central (maximum and/or oxygen I may study Orchard placement. are sedation midazolam optic research sequence ketamine avoid received perforation extraction block During During dose block as this for blocks patients by anesthesiologist. our ophthalmic block (2,4), sedation 28500 In Group mg/kg methohexital minimal The thus randomly Rosenberg, The (single-stick publication by received globe a 20) such for Anesthesiology, placement and movement anesthesiologist International cataract patients = IV. for K. single hemorrhage, correspondence of and used and utilized with PBB and that simultaneously administration. (n a were followed the the a All Center, (maximum mg) to (PBB) II nesthesiologists retrobulbar block sedation, difficulty. alfentanil by injection. by approval been Patient 15 that was as and block, sedation For So Accepted Address 01995 implant groups. tion tered monitored ing methohexita10.5 Group mg/kg This dose ketamine 0003.2999/95/$5.00 undergoing bolus Methods After Sedation Sedation A well have (l-3), (3,5). during complications, retrobulbar plications, the important associated ratory midazolam/ketamine commonly Comparison Comparison Michael 48334. Surgery

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Table 1. Measured ParametersDeveloped During The midazolam/ketamine technique required a Sedation and Peribulbar Block Placement longer time from the initiation of sedation until place- Midazolam/ ment of the block (approximately 7.5 min compared to Methohexital ketamine 90 s for the methohexital group). (n = 20) (n = 20) In conclusion, we found our low-dose mida- Patient movement 9 (45%) 2 (10%) zolam/ketamine sedation sequence superior to a (P = 0.013) methohexital technique regarding patient movement Respiratory depression/ 6 (30%) 1(5%) and respiratory depression/obstruction. This is partic- obstruction (P = 0.046) ularly advantageous when the same anesthesiologist Time-to-home readiness 62 t 5.9 63 ? 5.3 is both sedating the patient and performing the block, min min as he or she can focus more completely on block placement and hopefully avoid ocular complications. anesthesiologist often administers the IV sedation and performs the PBB/RBB. A technique with minimum potential for patient movement and respiratory diffi- References culties minimizes the need for airway intervention 1. Gilbert J, Holt JE, Johnston J, et al. Intravenous sedation for and allows the anesthesiologist to focus on performing cataract surgery. Anaesthesia 1987;42:1063-9. the block. This, in turn, should help prevent block 2. Yee JB, Schafer PG, Crandall AS, Pace NL. Comparison of methohexital and alfentanil on movement during placement of complications such as globe perforation (7). We feel retrobulbar nerve block. Anesth Analg 1994;79:320-3. that a low dose midazolam/ketamine technique ac- 3. Ferrari LR, Donlon JV. A comparison of propofol, midazolam, complishes this goal. and methohexital for sedation during retrobulbar and peribul- In this group of elderly patients, many of whom had bar block. J Clin Anesth 1992;4:93-6. 4. Stead SW, Northfield KM. Effects of alfentanil analgesia for cardiovascular disease, there may have been some ophthalmic nerve blocks [abstract]. Anesthesiology 1990;73: reluctance to use ketamine, with its sympathomimetic A769. effects (9). In our series, increases in SBP and HR 5. Beatie CD, Stead SW. Effects of propofol sedation for ophthal- >20% above baseline actually occurred in more mic nerve blocks [abstract]. Anesthesiology 1991;75:A28. methohexital patients than midazolam/ketamine pa- 6. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988;95: tients. Therapeutic intervention was not necessary in 660-5. any patient in either group. 7. Grizzard WS, Kirk NM, Pavan PR, et al. Perforating ocular A significant advantage of the midazolam/ injuries caused by anesthesia personnel. Ophthalmology 1991; ketamine technique is that most of the patients are in 98:1011-6. 8. Kuker JS, Belmont JB, Benson WE, et al. Inadvertent globe verbal communication throughout the block proce- perforation during retrobulbar and peribular anesthesia. Oph- dure. This allows for eye opening on command, which thalmology 1991;98:519-26. is necessary for safe block placement. Also, if patients 9. Backer CL, Tinker JH, Robertson DM. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth begin to move, they usually cease on command, which Analg 1980;59:257-62. prevents the movement from becoming disruptive. 10. Hejja I’, Galloon S. A consideration of ketamine dreams. Can Methohexital patients are usually unresponsive to ver- Anaesth Sot J 1975;22:100. bal command during block placement. Movement 11. Garfield JM. A comparison of psychologic responses to ket- therefore requires holding the patient’s head, restrain- amine and thiopental-nitrous oxide-halothane anesthesia. Anaesthesiology 1972;36:329. ing the patient, and/or interrupting block placement. 12. Corssen G, Reves JG, Stanley TH. Dissociative anesthesia. In: Postoperative hallucinations have been described Intravenous anesthesia and analgesia. Philadelphia: Lea & with ketamine (10,ll). We saw no hallucinations or Febiger, 1988:99. confusion in our midazolam/ketamine patients. This 13. White PF, Way WL, Trevor AJ. Ketamine: its pharmacology and therapeutic uses. Anesthesiology 1982;56:119. effect is likely dose related (12) and modified by the 14. Johnson M. The prevention of ketamine dreams. Anaesth Intens concomitant use of benzodiazepines (12-14). Care 1972;1:70.