Anesthesia Resident

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# معلوماتی

هنگام خون ریزی بینی سر تان را به سمت عقب / بالا نگیرید !❌

یکی از شایع ترین اشتباهات هنگام خون ریزی بینی این است که افراد سر شان را بالا یا به سمت پشت سر میگیرند. این عمل باعث میشود خون بجای بیرون شدن توسط فرد قورت شده و وارد گلو و معده اش شود . خون معده را تخریش کرده و باعث استفراغ میشود. همچنان ممکن است در این حالت خون در اطراف مغز تان جمع شود که خطرناک و مرگبار است.

پس باید هنگام خون ریزی بینی چی کنیم ؟

✅ اول بالای چوکی یا زمین بنشینید. سپس سر تان را کمی به سمت جلو پیش ببرید ( مانند تصویر ) . بعداً قسمت نرم بینی را فشار بدهید و از راه دهن تنفس‌ کنید. این کار را برای چند دقیقه انجام دهید. برای توقف خون ریزی یک پاکت/پلاستیک/تکه کوچک را گرفته و داخل آن پارچه های یخ را گذاشته و بالای بینی تان قرار بدهید.

Information about pancreas

Anatomy of the pancreas
The pancreas is an elongated, tapered organ located across the back of the belly, behind the stomach. The right side of the organ—called the head—is the widest part of the organ and lies in the curve of the duodenum, the first division of the small intestine. The tapered left side extends slightly upward—called the body of the pancreas—and ends near the spleen—called the tail.

Illustration of the anatomy of the pancreas

The pancreas is made up of 2 types of glands:

Exocrine.
The exocrine gland secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct. This runs the length of the pancreas.

Endocrine.
The endocrine gland, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine gland in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum. This is the first section of the small intestine.

The main hormones secreted by the endocrine gland in the pancreas are insulin and glucagon, which regulate the level of glucose in the blood and somatostatin, which prevents the release of insulin and glucagon.

معلومات در باره پانکراس

پانکراس یک عضو دراز و مخروطی است که در پشت شکم، پشت معده قرار دارد.
سمت راست اندام - که سر نامیده می شود - وسیع ترین قسمت اندام است و در منحنی دودینوم، اولین بخش روده کوچک قرار دارد.
سمت چپ مخروطی کمی به سمت بالا امتداد می یابد - که بدن پانکراس نامیده می شود
- و به طحال پایان می یابد - به نام دم.



پانکراس از 2 نوع غده تشکیل شده است:

برون ریز یا ایگزوکراین غده برون ریز انزیم های هضمی ترشح می کند. این آنزیم ها در شبکه ای از مجاری ترشح می شوند که به مجرای اصلی پانکراس می پیوندند. این کار طول پانکراس را طی می کند.

غدد درون ریز یا اندوکراین. غده درون ریز که از جزایر لانگرهانس تشکیل شده است، هورمون ها را در جریان خون ترشح می کند.

عملکردهای پانکراس

پانکراس دارای عملکردهای هضمی و هورمونی است:

انزیم های ترشح شده توسط غده برون ریز در پانکراس به تجزیه کربوهیدرات ها، چربی ها، پروتئین ها و اسیدها در دودینوم کمک می کنند. این آنزیم ها به صورت غیر فعال از مجرای پانکراس به داخل مجرای صفراوی حرکت می کنند. وقتی وارد دودینوم می شوند، فعال می شوند. نسج اگزوکراین یا بیرون ریز نیز یک بای کربنات ترشح می کند تا اسید معده را در دودینوم خنثی کند. این اولین بخش از روده کوچک است.

هورمون های اصلی ترشح شده توسط غده اندکراین یا درون ریز در پانکراس انسولین و گلوکاگون هستند که سطح گلوکز خون را تنظیم می کنند و سوماتوستاتین که از ترشح انسولین و گلوکاگون جلوگیری می کند.

Ketofol= ketamine+propofol 🔴🔵🟢🟡🟣

When talking about procedural sedation and analgesia, our goal is to minimize pain and anxiety with the appropriate agent that matches the needs of our patient and the clinical scenario. So, what are some qualities of this “ideal agent?”

In a perfect world, it would have:

Minimal adverse effects
Rapid onset and offset of action
Pharmocokinetic predictability across a spectrum of patients

Ketofol

Ketofol (combination of ketamine and propofol) may be this Holy Grail. Why you ask? Well, ketamine gives you a dissociative sedative, analgesic, and amnestic effect, while propofol gives you rapid sedation and antiemetic effects. It is important to discuss the specifics of each medication before moving on to the combination drug.

Ketamine basics

Ketamine is a dissociative anesthetic that is a phencyclidine derivative and provides sedation, analgesia, and amnesia. It works by inhibiting catecholamine uptake, which exerts a sympathomimetic effect.

The typical dose is 1–2 mg/kg IV or 4–5 mg/kg IM. Additional doses may be required at increments of 0.5-1 mg/kg. Major adverse outcomes include airway obstruction, hypoxia, apnea, and laryngospasm. In a meta-analysis, of 8,282 patients, Green et al1 stated that the total incidence of these major adverse outcomes was only 3.9%. Vomiting occurs in about 7 – 26% of patients.

What about the elevated intraocular pressure (IOP) and intracranial pressure (ICP) that we are always hearing about? Well in 2012, Drayna et al2 published a study in Am J Emerg Med which found minimal, transient elevations of IOP that were not clinically meaningful. The largest difference from baseline IOP occurred at 15 minutes with an estimated change of only 1.09 mmHg.

Propofol basics

Propofol is a lipophilic, ultra short-acting hypnotic agent, which works by potentiating GABA receptors on the neuronal lipid membranes. It does not provide any analgesia, and therefore should not be used as a sole agent for sedation. Note that one of its advantages is its anti-emetic property with a very low incidence of vomiting.

Typical dosing is 1-2 mg/kg bolus followed by either a continuous infusion at 0.05-0.1 mg/kg/min or by 0.5 mg/kg boluses every 2 – 3 minutes. The Pediatric Sedation Research Consortium published a paper in Anesth Analg3 looking at 49,836 propofol sedation cases and found no instances of death associated with propofol. CPR was required in 2 cases, aspiration occurred in 4 cases, oxygen desaturation (less than 90% for longer than 30 sec duration) occurred in 716 cases, and central apnea occurred in 143 cases.

How do you mix ketofol?

There is no real standard dosing regimen established, but most studies and authors recommend a 1:1 ratio to provide ease of administration. The medications can be mixed or given sequentially. Recently I listened to a PEM ED Podcast by Andrew Sloas on ketofol dosing.

His regimen is fairly simple. Ketamine comes in a 50 mg/mL concentration, so if you take a 10 mL saline flush and empty 2 mL and draw up 2 mL of ketamine you have 100 mg of ketamine. Propofol comes in a standard 10 mg/mL concentration. So if you fill a 10 mL syringe with this you have 100 mg of propofol. If you mix the two in a new 20 or 30 mL syringe you get 100 mg ketamine + 100 mg propofol = 200 mg total. Now every one mL has 10 mg of ketofol. Your starting dose of this will be 0.5 mg/kg followed by another 0.5 mg/kg after about 30-60 sec. From then on for maintenance you can use 0.25 mg/kg as needed.

What is the evidence for ketofol?

Alletag et al4 published a meta-analysis called on ketamine, propofol, and ketofol use for pediatric sedation. The majority of the studies compared propofol/fentanyl to ketofol. The two largest and most recent studies on ketofol vs either propofol or ketamine alone will be discussed here (highlighted in yellow). Both studies took place in the ED setting which is pertinent to our practice.

Round 1: Ketamine vs ketofol
Shah et al5 conducted a blinded, randomized trial of 136 pediatric patients (ages 2 – 17 years) that required orthopedic procedures and randomized them to ketofol 1 mg/kg versus ketamine 1 mg/kg.

Results:

Median dose of ketamine = 1 mg/kg (ketamine group) vs 0.5 mg/kg (ketofol group)
Median total sedation time = 16 min (ketamine) vs 13 min (ketofol). This was not statistically significant.
Median recovery time = 12 min (ketamine) vs 10 min (ketofol). This was also not statistically significant.
Number of adverse events = 36% (ketamine) vs 21% (ketofol). Much more vomiting in the ketamine group (12%) compared to ketofol group (2%).
No patients required BVM ventilation or intubation.
Satisfaction scores: Significantly higher in the ketofol versus the ketamine group for patients/parents, nurses, and physicians.
Recovery times were not statistically different between both groups, which was thought to be because ketamine 1 mg/kg may have been underdosed. This contrasts prior studies documenting a recovery time of 25-108 min (ketamine) versus 14-15 min (ketofol)

Conclusion:

Ketofol has slightly better median total sedation time and recovery time (although not statistically significant) with far fewer adverse reactions, specifically vomiting. Physician, nursing, and patient/parent satisfaction scores were significantly better with ketofol.

Round 2: Propofol vs ketofol

Andolfatto et al6 performed a blinded randomized trial of 284 patients over the age of 14 in an ED setting comparing propofol 0.75 mg/kg versus ketofol 0.75 mg/kg.

Results:

Adverse respiratory event (primary outcome) = 32% (propofol) vs 30% (ketofol)
Subsequent dosing needed in 65% (propofol) vs 46% (ketofol) of patients
Both groups had similar satisfaction scores.
Important points:

The propofol bolus dose of 0.75 mg/kg was significantly lower than the more universally used 1 mg/kg dose. This may be why the number of patients having respiratory events was so close to the ketofol group.
The dosing of propofol was q1 minute, despite the more traditional interval of q3 minutes. This increased dosing frequency may have contributed to the higher incidence of hypoxia and BVM ventilation (25%) than in the literature (8-14%).

Conclusion:

Ketofol did not result in a reduced incidence of adverse respiratory events compared to propofol. There was also no difference in induction time, efficacy, and sedation time. Sedation depth appeared to be better in the ketofol group.

And the winner is?

It’s a draw. Based on the studies reviewed, it is difficult to say if ketofol is the Holy Grail. Overall, it appears that ketofol could have a slightly better time to sedation, and length of sedation, but this is not statistically significant based on available evidence. However, it does appear that ketofol does have a more steady sedation depth not requiring as many subsequent doses.

In the end, it would be great to see a three-armed study comparing ketofol, ketamine, and propofol with appropriate and clinically equivalent dosing for each. This would help clarify the muddy evidence.

References:

Green S, Roback M, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54(2):158-68.e1-4. [PubMed]
Drayna P, Estrada C, Wang W, Saville B, Arnold D. Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure. Am J Emerg Med. 2012;30(7):1215-1218. [PubMed]
Cravero J, Beach M, Blike G, Gallagher S, Hertzog J, Pediatric S. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795-804. [PubMed]
Alletag M, Auerbach M, Baum C. Ketamine, propofol, and ketofol use for pediatric sedation. Pediatr Emerg Care. 2012;28(12):1391-5; quiz 1396-8. [PubMed]
Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57(5):425-33.e2. [PubMed]
Andolfatto G, Abu-Laban R, Zed P, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012;59(6):504-12.e1-2. [PubMed]