Preprocedural Nebulisation with 4% Lignocaine and Ketofol Sedation during Endoscopic Retrograde Cholangiopancreatography Procedure for Abolition of Gag Reflex: A Randomised Double-blinded Study

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is preferably carried out under deep sedation with propofol alone or with adjuncts to reduce the dose of propofol thereby reducing the intraprocedural complications and improving the patient and endoscopist acceptance of the procedure. There is no consensus on the ideal dose of ketamine as adjunct to propofol to be used in such scenario.

Aim: To evaluate the sedation characteristics, abolition of gag reflex and haemodynamic profile of the patients undergoing ERCP under ketofol sedation, with or without 4% lignocaine prenebulisation.

Materials and Methods: This randomised double-blinded study was undertaken in Indra Gandhi Medical College, Shimla, from September 2018 to October 2019. Sixty patients of American Society of Anaesthesiologists (ASA) physical class I and II aged between 25-65 of both sexes posted for routine ERCP were included. In group 1, patients were nebulised with 6 cc normal saline, and group 2 with 6 cc 4% lignocaine 15 min prior to procedure in the recovery room. Entropy-guided ketofol induction (ketamine and propofol used in 1:2 concentration) was used, followed by propofol infusion at the rate of 8 mL/hr. Gag reflex, haemodynamic and sedation characteristics were observed peri and postoperatively.

Results: The mean time to onset of sedation and duration of recovery room stay were comparable in both the groups. Total mean dose of propofol and ketamine used was 105.67 mg, 55.33±18.75 mg in group 1 and 101.83 mg, 48.67±15.588 mg in group 2. Gag reflex was similarly obtunded and endoscopists’ rating of the procedure were similar in both the groups perioperatively (p-value >0.05).

Conclusion: Target controlled entropy guided infusion with ketofol is an effective drug combination to achieve all aspects of safe sedation practice in ERCP procedure.