title: [The effect of total intravenous anesthesia with S-(+)-ketamine/propofol on hemodynamic, endocrine and metabolic stress reactions in comparison to alfentanil/propofol in laparotomy].
abstract: Total intravenous anaesthesia with ketamine-propofol offers distinct advantages over a TIVA with an opiate, including less cardiovascular and respiratory depression and an altered neuroendocrine and immunological stress response pattern. The effects of the more active stereoisomer S-(+)-ketamine in combination with propofol on the circulatory, endocrine and metabolic responses to abdominal surgery were compared with those of alfentanil-propofol. Twenty-four patients scheduled for elective hysterectomy participated in this study which had the approval of our institution's ethics committee. Anaesthesia was induced with 2 mg/kg S-(+)-ketamine or 0.05 mg/kg alfentanil, followed by 1 mg/kg propofol. Tracheal intubation was facilitated with 0.06 mg/kg vecuronium. Anaesthesia was maintained with 1 mg/kg per h S-(+)-ketamine or 0.0125 mg/kg per h alfentanil and propofol at an initial rate of 15 mg/kg per h which was reduced to 5 mg/kg per h after 30 min. Blood samples for catecholamines, cortisol and metabolites were drawn at predetermined times from before induction to 6 h postoperatively. Adrenaline and noradrenaline concentrations decreased preoperatively in the ketamine group (K) from 55 to 29 pg/ml and 166 to 39 pg/ml, respectively, and then increased to postoperative maxima of 193 or 315 pg/ml. A similar pre and postoperative course was seen in the alfentanil group (A) with slightly lower (P < 0.05) intraoperative concentrations in A. Cortisol concentrations increased in K from 12 micrograms/dl to 34 micrograms/dl intraoperatively and further to a maximum of 42 micrograms/dl postoperatively. The intraoperative increase was attenuated in A and the difference between the groups was significant (P < 0.0001). The initial ketamine bolus and tracheal intubation caused a marked, transient increase of mean arterial blood pressure from the baseline value of 105 mmHg to 120 mmHg with a subsequent decrease to 88 mmHg prior to skin incision and a gradual return to baseline during surgery. TIVA with ketamine-propofol had little effect on the perioperative courses of the endocrine parameters, which behaved as they do under anesthesia with isoflurane-nitrous oxide. Plasma catecholamine concentrations were not elevated in the period between induction of anaesthesia and skin incision.
authors.affiliation: Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen.
authors.forename: T A
authors.initials: TA
authors.lastname: Crozier
authors.forename: E
authors.initials: E
authors.lastname: Sumpf
mesh_terms: D000328:Adult; D000368:Aged; D015760:Alfentanil / Q000009:adverse effects*; D000771:Anesthesia, Intravenous / Q000009:adverse effects; D018686:Anesthetics, Intravenous / Q000009:adverse effects*; D004338:Drug Combinations; D005260:Female; D006439:Hemodynamics / Q000187:drug effects / Q000502:physiology; D006728:Hormones / Q000097:blood; D006801:Humans; D007044:Hysterectomy; D007649:Ketamine / Q000009:adverse effects*; D007813:Laparotomy; D008660:Metabolism / Q000187:drug effects / Q000502:physiology; D008875:Middle Aged; D015742:Propofol / Q000009:adverse effects*; D013312:Stress, Physiological / Q000139:chemically induced / Q000378:metabolism / Q000503:physiopathology*
chemical_list: D018686:Anesthetics, Intravenous; D004338:Drug Combinations; D006728:Hormones; D015760:Alfentanil; D007649:Ketamine; D015742:Propofol