Comparison of subanaesthetic ketamine and lidocaine as adjuvants to propofol-based total intravenous anesthesia on propofol requirement during emergency decompressive craniectomy for traumatic brain injury: a prospective, double-blind, three-arm randomized controlled trial.
Rajasekar Ramadurai, Srinivasan Swaminathan, Prasanna Udupi Bidkar et al.
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In 30 seconds
This prospective, double-blind, three-arm randomized controlled trial compared ketamine, lidocaine, and placebo as adjuncts to propofol-based total intravenous anesthesia in 150 adults undergoing emergency decompressive craniectomy for traumatic acute subdural hematoma. Mean propofol consumption was lowest with ketamine: 100.73 ± 31.72 µg/kg/min, compared with 115.86 ± 38.11 with lidocaine and 131.53 ± 44.54 with placebo (p < 0.001). Ketamine also reduced fentanyl use and vasopressor boluses. Intracranial pressure, cerebral perfusion pressure, brain relaxation, and neurological outcomes were comparable among groups.
Key findings
- Mean propofol consumption was 100.73 ± 31.72, 115.86 ± 38.11, and 131.53 ± 44.54 µg/kg/min with ketamine, lidocaine, and placebo, respectively (p < 0.001).
- Fentanyl requirements were 63.85 ± 36.23, 83.64 ± 32.27, and 153.55 ± 57.28 µg with ketamine, lidocaine, and placebo, respectively (p < 0.001).
- Vasopressor boluses were fewer with ketamine: 2 [2-3] versus 3 [2-4] with lidocaine and 3 [2-4] with placebo (p = 0.031).
- Intracranial pressure, cerebral perfusion pressure, brain relaxation, and Glasgow Outcome Scale-Extended scores were comparable among groups.
Why it matters
Reducing propofol exposure may be relevant when dose-dependent hypotension could compromise cerebral perfusion during surgery for traumatic brain injury. In this trial, ketamine was associated with lower propofol, opioid, and vasopressor requirements without detected differences in measured intracranial dynamics or neurological outcomes. These findings inform assessment of anesthetic adjuncts in this operative setting, while not establishing improved neurological outcomes.
What to keep in mind
Anesthesia was titrated to haemodynamic responses rather than processed EEG, so the relative contributions of propofol-sparing and ketamine's sympathomimetic effects cannot be determined. Intracranial effects were assessed at measured intraoperative time points.