Dissociative conscious sedation, an alternative to general anesthesia for laparoscopic peritoneal dialysis catheter implantation: a randomized trial comparing intravenous and subcutaneous ketamine.

摘要

Laparoscopy is an effective method of implantation for peritoneal dialysis (PD) catheters. Use of the laparoscopic technique is increasing because of its potential advantages over other techniques. In most patients, selection for PD is based on negative criteria, and because of the need for general anesthesia, the laparoscopic technique can be life-threatening in these patients. On the other hand, local anesthesia is insufficient for laparoscopic catheter implantation. To avoid the need for general anesthesia and to achieve patient safety and satisfaction, we designed a type of conscious sedation (dissociative conscious sedation) and compared the efficacy of subcutaneous (SC) and intravenous (IV) ketamine added to narcotics in patients scheduled for laparoscopic implantation of a PD catheter. METHODS: Our prospective randomized double-blind study enrolled 60 adult patients with chronic renal failure who were scheduled for laparoscopic implantation of a PD catheter. Patients were randomly assigned to one of two groups: one receiving IV ketamine, and the other receiving SC ketamine. In both groups, patients were premedicated with IV midazolam 0.015 mg/kg, fentanyl 1-2 mug/kg, and lidocaine 1.5 mg/kg. Patients then received 0.6 mg/kg ketamine either intravenously (IV group) or by subcutaneous injection at the anterior aspect of the forearm (SC group). If systolic blood pressure (BP) increased more than 20% from baseline or exceeded 170 mmHg, IV nitroglycerine (TNG) 50 mug was administered incrementally (repeated 50-mug doses). After a desirable level of conscious sedation was achieved, local anesthesia and nitrous oxide pneumoperitoneum were applied, and the PD catheter was implanted under laparoscopic guidance. Heart rate and BP were measured throughout the procedure. Adverse effects and recovery events were recorded. RESULTS: All patients tolerated the procedure well. Administration of TNG was significantly more frequent in the IV ketamine group. Pain intensity during the surgery was similar in both groups. Both groups were comparable with regard to heart rate, but patients in the SC ketamine group had a significantly lower systolic BP at the 2nd measurement and a lower rate-pressure product at the 2nd, 4th, and 5th measurements. All patients in the SC ketamine group were cooperative during surgery and experienced uneventful recoveries; mild hallucinations were observed in 5 patients in the IV ketamine group. In the IV ketamine group, 3 patients lost the ability to cooperate during surgery. All catheters were successfully placed. CONCLUSIONS: Dissociative conscious sedation is an acceptable alternative to general anesthesia in laparoscopic implantation of the PD catheter. Ketamine by the SC route is as effective as, but safer than, IV ketamine.