Stress response during extubation is an unwanted and unpredictable response that makes anesthesiologists vigilant and attentive for minimizing its effect on hemodynamics and airway reflexes.
In our study we compared the effect of injecting a ketofol compared to propofol at induction of general anesthesia on the smoothness of extubation as regards airway response and hemodynamics in laparoscopic drilling of polycystic ovary disease.
Aboeldahab et al studied the effect of ketofol compared to its two constituents as an induction agent in 60 patients undergoing hernia repair under general anesthesia. (15) They examined its effect as an induction agent clinically by assessing the hemodynamics and by using the BIS index where, 20 of them were given ketofol, 20 were given propofol and the last 20 were given ketamine during induction of anesthesia. During extubation HR in ketofol group (81.65 ± 2.60) was lower than in the propofol group (81.73 ± 3.93) but, with no statistical significance and MAP in the ketofol group ( 83.90 ± 3.30) was lower than in the propofol group (85.66 ± 3.43) with also, no statistical significance. This might be due to the lengthy procedure in their study and /or due to the small sample size of the groups. Our results came in agreement with Aboeldahab et al, as ketofol was associated with more stable hemodynamics than propofol during extubation. We attributed this to the good level of sedation of ketofol during suction and extubation due to the additive sedative effect of both ketamine and propofol.
We cocluded that the effect of ketofol on HR was more important and more significant in stabilizing the heamodynamics than its effect on MAP when compared to popofol.
On the other hands, Jalili et al, who compared the effect of propofol and ketofol on emergence delerium in 87 ASA I and II children aged from 3–12 years and underwent adenotonsillectomy, reported no statistically significant difference between the two groups regarding HR in the recovery room at 0, 10, and 20 minutes postoperatively. (19)
The smoothness of extubation without coughing, laryngospasm and vomiting on the tube was examined in both groups and it was in favor of ketofol group.
Recently, Aberra et al, in a study done on 120 pediatric patients aged from 2 to 15 years undergoing elective ophthalmic surgical procedures under general anesthesia using laryngeal mask airway (LMA) to compare the ketamine–propofol mixture (ketofol) with propofol on the ease of laryngeal mask airway insertion conditions and hemodynamic effects during induction of general anesthesia, found that 54 patients in the ketofol group compared to 52 in the propofol group developed no cough, 6 patients in ketofol group compared to 7 patients in propofol group developed slight cough (coughing which can occur immediately after LMA and subside by itself) and 1 patient in propofol group developed gross cough (coughing which needs deepening of anesthesia to be relieved ) with no significant difference between them. (17)
The sedation scores during suction and extubation were significantly lower in the ketofol group compared to the propofol group. We attributed this good level of sedation during suction and extubation to the analgesic effect of ketamine.
In our study, we reported that the ketofol group showed better airway response than the propofol group. One of the most unwanted adverse effects of stress response on air way is cough. Kim and Bishopreported an incidence rate of 75% of cough in patients during emergence and extubation.(20) Hypertension, tachycardia, myocardial ischemia, and bronchospasm are adverse effects related to cough.
In our study, the majority of patients in the ketofol group [44 patients (83.1%)] developed better airway reflexes (grade 2,3) during suction better than the majority of patients in the propofol group [39 patients (73.6%) ] developed higher degree of airway reflexes (grade 4 or 5). From all of the previous, we gave another explanation for the better hemodynamic stability during extubation in the ketofol group.
Aberra et al reported that no patient in the ketofol group developed laryngospasm while, 2 patients in the propofol group developed partial laryngospasm with no statistical significance. They concluded that Ketofol provided equivalent laryngeal mask airway insertion conditions and it can be used as an alternative propofol for LMA insertion. (17)