Introduction
There are different kinds of induction anesthesia drugs used in cardiac surgery or diagnostic and intervention catheterization. These medications can be used as a combination or in their pure singular form. For example, Propofol and ketamine are some of the drugs used to anesthetize pediatric Patients undergoing cardiac catheterization or cardiac surgery (Singh et al. 2000). A study by Sakai et al. (1998) found that using a mixture of ketamine and propofol is safe to be used in anesthesia for pediatric patients. According to Singh et al. (2000, p. 36), Anaesthesia drugs such as ketamine and propofol have been used as a mixture or single to maintain “hemodynamic stability” for pediatric cardiac catheterization.
Therefore, the first article to be examined is “Evaluation of Propofol-Ketamine Anaesthesia for Children Undergoing Cardiac Catheterization Procedures” by Gayatri et al. (2007). In this study, the researchers evaluated the safety and efficacy of the continuous intravenous use of ketamine and propofol mixed in one syringe. Gayatri et al. (2007) study relied on children patients undergoing either interventions or diagnostic procedures for cardiac catheterization. The second article for critical review is by Akin et al. (2005) and examines the effect of ketamine and propofol on sedative level, hemodynamic during cardiac catheterization and recovery time. The article is titled “Propofol and Propofol–Ketamine in Paediatric Patients Undergoing cardiac catheterization” (Akin et al. 2005). This assignment will evaluate these two articles and critically analyze them using a critical appraisal framework for critiquing (Holland & Rees 2010). This will be done with regard to the methodological approach used by the researchers and the validity and reliability of the data used will also be determined.
The Research Method used for the Review Articles
In this critical review of research, it was significant to develop a research question. In this case, the research question was developed using the Patient, Intervention, Comparison, Outcome (PICO) strategy (Gerrish & Lacey 2010). This step was important because an appropriate and well-built research question allows the correct definition of information. This is so because the evidence is required to resolve the clinical aspect of the investigation; it maximizes recovery in databases; it focuses on the purpose of research and avoids unnecessary information (Gerrish & Lacey 2010).
In the research for the above two articles, therefore, the following keywords were used: pediatric patient, cardiac catheterization, ketamine and propofol -hemodynamic. In the search process, where (OR) is used to easily combine searches word with similar meanings, to focus on finding (AND) is used for the limitation of years searched option (Gerrish & Lacey 2010).
The Procedure for Search the Article
In the search procedure, the library tab in the online health library of Cardiff University was used. When the database was accessed, the operating department practice was selected and the search was made using two search engines. First, the pudmed search engine was used with the keywords “propofol AND ketamine OR pediatric OR cardiac catheterization OR hemodynamic was used where findings were limited to the English language. The search was limited to the last ten years and out of the twelve articles that were found in the results, only one was related to the subject of this study. Secondly, a Scopus search engine with keywords “propofol AND ketamine OR pediatric OR cardiac catheterization OR hemodynamic” was used where findings were limited to the English language. The search was also limited to ten years and out of the results, which were over twenty articles, the abstracts of the articles were scanned and titles evaluated for relevance. Out of the five articles short-listed with relevance in the topic, two were selected. The two selected articles were articled were in line with the methods targeted and addressed the clinical aspect of the investigation where a combination of ketamine and propofol are used for cardiac catheterization.
“Evaluations of Propofol-Ketamine Anaesthesia for Children’s Undergoing Cardiac Catheterisation Procedures”
The first article selected was “Evaluations of Propofol-Ketamine Anaesthesia for Children’s Undergoing Cardiac Catheterisation Procedures” by Gayatri et al. (2007). The Gayatri et al. (2007) article outlines how ketamine and propofol are administered to children who are about to undergo the procedure of heart catheterization. The title of the article is clear to draw the attention of the interested reader in the study area (Parahoo 2006). The abstract stated in short the aim of the study, sample, method, results, and conclusion of research (Polit & Beck 2010). The provision of this information is necessary to define the perspective of the study and helps one to have a bird’s eye view of the study.
Background
In the background, the researchers identified that intravenous anesthesia with a mixture of ketamine and propofol is used in a variety of pediatric patients going to do short surgery as illustrated in the study by Kogan et al. (2003). In their analysis, therefore, they held that cardiac catheterization procedures need anesthesia practice that makes sure “stability” of patient hemodynamics as supported by Singh et al. (2000). This background evaluation is significant because it caters to the gaps that medication leaves as side effects after a patient’s treatment. Based on the above background Gayatri et al. (2007) advance that searching for better anesthesia induction medication is progressing because no mixture or alone drugs had received wide acceptance. On the other hand, Sakai et al. (1998) analyses that Ketamine and propofol “pharmacokinetics” side effect is safe to be used in anesthesia for pediatric patients.
Objective
The research objective in Gayatri et al. (2007) study was to examine the safety and efficacy that two different concentration doses from ketamine mixed with propofol given as continuous intravenous administration, will have for pediatric population patients for cardiac catheterization.
Methodology or Broad Approach
The researchers adopted a non-blind approach with a randomized allocation to groups 1 or 2. Initially, in a controlled clinical trial the main benefit of the blind is to reduce the risk of occurrence of information bias that may arise under the influence of physical or psychological knowledge of the allocated interventions among participants (Hwang et al. 2005). According to Gayatri et al. (2007), no power analysis was conducted before this study. However, the methodology leaves a gap for the anesthetists to be biased unless the anesthetists were blind too. If the anesthetists were not blind, in this case, then as they drew and give the anesthetics then one can presume that they knew which child was in which group, and therefore the procedure exposes the study to a significant degree of bias.
Tool of Data Collection
The data was collected through clinical trials (Gayatri et al. 2007). The primary consideration is that patients, who participated in a study of this nature, are confident that the study did not continue once there is reasonable evidence of unacceptable toxicity (Cederblom & Paulsen 2006). The difference between the effectiveness of treatments has been established beyond variations due to the product of chance (Van den Brink-Budgen 2010) or if evidence of an endpoint without conclusive findings is clear (Bazin et al. 1997; Badrinath 2000). In a catheterization laboratory, standard monitoring equipment is applied for processes like the respiration rate, pulse oximetry, the cuff of blood pressure and the ECG of the child among others. In the study by Gayatri et al. (2007) as soon as the pediatric cardiologist performed the procedure, the sedative drugs the anesthetists managed the vital sign and airway. hthis was significant in ensuring the procedure succeeds in its outcome and without exposing participants to danger during the experiment.
Moreover, the infusion pump prepared with a mixture of propofol l25 microgram per kg per minute and ketamine 25microgram per kg per minute was connected to a patent for group one. As well as propofol 25 microgram per kg per minute of ketamine and 12.5micrigram per kg per minute used for group two (Gayatri et al. 2007). Researchers, in this case, must create an environment in which researchers can produce quickly and efficiently to support research findings underlying biological (Paul 2006). The data collection was done in a catheterization laboratory with appropriate instrumentation so as to ensure the results of the laboratory are reproducible (Cederblom & Paulsen 2006; Paul 2006). Further, the laboratory equipment with appropriate instrumentation is highly recommended to the research team to enable them to spend time with the real issues at hand. In this case, the tedious and repetitive procedures can easily have errors when crafted, but with appropriate instrumentation in a laboratory less error was expected (Friedman, Furberg & Demets 1998; Piantadosi 2005).
Method of Data Analysis and Presentation
All data are analyzed within the student package statistic test to compare mean with another group for continuous variability “version 11.0.1, SPSS Inc., Chicago, IL” (Gayatri et al. 2007). This test was appropriate given the fact that the statistics generated fulfilled the study objectives. The researchers clearly explained the result in tabular form, and this was appropriate because tables present details of results and give information about different “variables” in a simple understandable way (Gerrish & Lacey 2010).
Sample
According to Gayatri et al. (2007), thirty- two (32) pediatric patients were involved in the prospective randomized study in a health education center and the sample was divided into two groups. However, one loophole in the study is that it did not mention the population size and it follows that it is not clear whether the sample of thirty-two (32) was representative of the population (Bazin et al. 1997).
Ethics
The Institute’s ethical team agreed on the study and confirmed that every pediatric patient listed for the CCP study was consented to by parents (Gayatri et al. 2007). No consent was obtained from participants and their caregivers. No one can question the privacy and confidentiality of personal data because the patients’ names were kept anonymous (Botero et al. 2000).
Main Results
The study demonstrated the use of two doses of ketamine on a concentration of 25 micrograms and 12.5 micrograms per kilogram in one minute with a propofol concentration of 25 micrograms per kg per minute for the pediatric patient is safe and effective. The results showed that the combination works without hemodynamic instability or tract system, and the recovery process is very quick as expected. Time consciousness in this study was more in group 1 with about “60.54.87” minutes while in the second group was maintained at “20.13.17.08” minutes (Gayatri et al. 2007). Therefore, the results of the study were in line with the researcher’s objective and they tested the efficacy and safety of the drugs. However, more studies have to be carried out in order to establish whether the results can be applied to different populations with different demographics.
Conclusions and Recommendations
The researcher concluded that the consciousness recovery period depends on the whole injection of ketamine given in the study, which depends on the long procedure. In this case, Hwang et al. (2005) argue that there is no proof that lipid solubility of ketamine and propofol when mixtures made can accrue of a “variable bioavailability.” In this case, the conclusion by the researchers that the propofol mixture dose of 25 micrograms per kilogram per minute with 25microgramor,12.5 microgram per kilogram per minute of ketamine together, is “safe and efficacious” when used for heart catheterization for pediatric patients (Gayatri et al. 2007) might not be appropriate until more study is carried out in this areas. It is significant to note that for any research to be valid, it must be objective in the application.
Overall Strengths and Limitations
According to Gayatri et al. (2007), there is only one study that has been done on this subject at the time of the publication of the article. This is a limitation, although they did not mention it because the study lacks precedence and enough literature for its background. The researchers identified that the small limited number of children listed for research is not enough and concludes that larger numbers of patients are needed in further study (Smith, White, Nathanson & Gouldson 1994). The article assesses the safe use of the mixture of ketamine and propofol in Cardiac catheterization by Koogan et al. (2003). This calls for more study in the area and makes this study more significant than if it were on another subject. However, the researchers identified that the time to awaken was more in the patients who were receiving 25 µg/kg per minute of ketamine compared to the other group that received ketamine of 12.5 µg/kg per minute. The researcher assumed that the limitation was well within the acceptable laboratory limits.
Application to Practice
This new technique can be a good and safe option in a child for cardiac catheterization if it is identified that it can function without causing cardiovascular depression or hemodynamic, and maintenance of spontaneous ventilation (Piantadosi 2005; Gozal, Rein, Nir & Gozal 2001). Moreover, new research is needed with a higher number of patents in the future to assess this type of infusion in cardiac surgery and other diseases, as well as other procedures in the catheterization laboratory (Gayatri et al. 2007). These assignments enhance the writer’s confidence and skill of critiquing in anesthesia and surgery research.
“Propofol with Ketamine and propofol for cardiac catheterization in Paediatrics Patient”
The second article selected was “Propofol with Ketamine and propofol for cardiac catheterization in Paediatrics Patient” by Akin et al. (2005). The article clearly focused on pediatric Patients listed for heart catheterizations. In this study, it is especially useful to determine whether a new treatment has an advantage compared to the former one. For statistical reasons this study alone may not be enough in determining whether the treatment is effective to objectively apply (Piantadosi 2005).
Background
The background to this study and the reason why the researchers chose to carry out the study is clear from the abstract and the introduction (Crombie 1996). In this case, ketamine and propofol combination is preverbal for cardiac catheterization in pediatric patients (Akin et al. 2005). The aim of the research is to examine the “effect” of propofol used alone and propofol mixed with ketamine on vital signs, “sedation” score and time of “recovery” “on pediatric patients undergoing cardiac catheterization” (Akin et al. 2005).
Methodology or Broad Approach
The research approach was a prospective, randomized; double-blind study (Akin et al., 2005). In a double-blind study, both patients and searchers team are not supposed to know the treatment given (Parahoo 2006). The benefit of this type of research methodology approach is to reduce the power of suggestions (Parahoo 2006). It is unbelievable that humankind will receive fake “placebo” treatments (Gerrish & Lacey 2010). In a study involving a double-blind approach, the researchers should enroll a large number of people. Dramatically effective treatments studies can prove themselves effective in small studies, but research involving 30 people or less is usually less effective (Gozal, Rein, Nir & Gozal 2001). In the understanding of this topic, the critique of quantitative research used in this study is not directed against the method in general but against a single application thereof to investigate social reality (Machin, Day & Green 2006; Friedman, Furberg & Demets 1998). They also model generalizes and assumes that in order to achieve greater validity; a condition is often left out of account in the practice of quantitative research (Richard & Elder 2006).
Tool of Data Collection
In this study, the data was collected through clinical trials (Akin et al. 2005). A clinical trial is an experimental study designed to assess the “efficacy” of treatment in humans through the comparison of the results in a group of patients undergoing experimental treatment with another group of patients receiving a control treatment (Parahoo 2006; Polit & Beck 2010). In general, a clinical trial design considers ethical issues related to the patient and, therefore, involves interim analysis prior to the expiration of the total collection of data defined for the study (Parahoo 2006). This data collection method is appropriate for the research because data is analyzed as the research continues and the expiry date does not beat the researchers. However, the results obtained are not accurate because they are not a representative of the whole population and, therefore, may not be highly reliable. The interim analysis performed on the accumulated data at a given time is performed in order to determine the existence of significant differences between treatments so as to compare and determine the possibility of stopping the study early (Senn 2008).
Method of Data Analysis and Presentation
The data obtained in the study were analyzed by evaluating the hemodynamic data by conducting “unpaired Student’s t-test—gender, adverse effects, and the number of patients requiring additional fentanyl, the number of patients showing larger than 20% variation of hemodynamic data was determined by chi-square, Fisher’s exact test” (Akin et al. 2005, p.554). These tests statistics were significant because they tested the efficacy of the procedure in the target population. The researchers also relied on the Mann– Whitney test in analyzing the “number of additional propofol doses” (Akin et al. 2005, p.554). In the presentation of the analyzed data, the researchers clearly defined the results tabular form, and this is scholarly because tables present details of results and give information about different variables in a way that results can be interpreted and understood easily (Gerrish & Lacey 2010).
Sample
The sample used in this study included 60 pediatric patients; aged between one month and thirteen years on the Society of American Anaesthesiologists status. All participants were selected on the basis that they were scheduled for elective “cardiac catheterization for the evaluation of congenital heart disease” (Akin et al. 2005, p.554). The sample population characteristic is appropriate for this study, but it is significant to note that the researchers did not define the total population. Therefore, it is not clear whether the sample of 60 was representative of the undefined population.
Ethical Considerations
Ethical criteria are essential in any clinical trial. As in this study, participants were informed and patient participants consented to their taking part in the trial (Akin et al. 2005). In such a procedure, patients should be warned of potential risks in a comprehensive way and the researchers should have participants’ religious and cultural considerations (Gerrish & Lacey 2010). This means that all clinical trials must go through and be approved by an ethics committee (Botero et al. 2000). This committee verifies the scientific and medical interest of the study, the risk, benefits, and ensures that the study trial is carried out in line with good methodological practices. This is important, especially in those trials concerning the sponsor and the principal investigator of the study and the presence of insurance to indemnify so as to allow participants in the study in case of damage (Senn 2008). All these considerations were made and fulfilled before this trial was carried out, and this helped in avoiding conflicts of interest among all interested parties (Bazin et al. 1997).
Main Findings
The article presented the main findings in a way that any reader can understand because the results are in table form. The tables are simple and well-illustrated so that one can understand the measurements against variables whore results are being represented. There are also explanations and simple descriptions of each result in the tables.
Overall Strengths and Limitations
The main strength of this study is that its topic was not much researched and the methodology of a prospective, randomized, double-blind is known to be very strong in giving objective results (Van 2010). However, the study remained limited to children interviewed and so the research done is mainly clinical study, which requires deferent specialists and advanced centers to do a more comprehensive trial with a larger population to test the wide applicability of the study results (Akin et al. 2005).
Conclusion
The two studies are significant in their findings because they give a starting point in the study of the use of different kinds of induction anesthesia drugs for cardiac patients before they have cardiac surgery or diagnostic and intervention catheterization. They, therefore, contribute substantially to knowledge and research skills especially the material subject related to cardiac anesthesia. Both articles have outlined the benefits of more research on the topic and have increased confidence in the operating department team to seek more knowledge regarding the method of anesthesia used in cardiac surgery and catheterization pediatric. The impact of these studies is significant because the researchers are members of staff in internationally recognized research groups (Cato 1988). Lastly, it is vital to note that many researchers argue that the side effect of propofol on heart and respiration can discourage its use in pediatric patients’ proceeding of cardiac catheterization (Piantadosi 2005). However, these researchers have proved that when a small dose of ketamine is added to propofol, it will leave the main arterial blood pressure in good conditions without extending recovery time. This way, the mixtures will remain the only better option for pediatric patients in cardiac catheterizations (Piantadosi 2005). The studies have called for more research on this area so as to determine and authenticate their findings from different settings and populations.
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