Question 9(p.2)

Compare and contrast the cardiovascular effects of an induction dose of propofol and ketamine.

[Click here to toggle visibility of the answers]

College Answer

The key words in this question were "compare and contrast", "cardiovascular effects" and "induction dose". Some candidates described aspects of both drugs other than the cardiovascular effects but gained no marks for this. Better answers used a combination of a table plus some explanation to contrast the cardiovascular effects of the two drugs concentrating on aspects such as heart rate, cardiac output, vascular resistance and blood
pressure. 

Many candidates were confused by the direct versus the indirect cardiovascular effects of
both drugs. Propofol probably has no direct negative inotropic effect. Ketamine has a direct myocardial depressant action but this effect is overridden by the centrally mediated sympathetic action of the drug. The effect of both drugs on the baroreceptor receptor response alone is a difficult area as there is significant interplay between the direct cardiovascular effects of the drugs and their effect on the baroreceptor reflex. Allowance was made for this in the marking. Propofol resets the baroceptor reflex producing a slower heart rate for a given level of blood pressure. Overall both drugs depress the baroreceptor reflex.


Comparison of the effects on cerebral, coronary, renal and hepatic blood flow earned extra marks.

Discussion

  Propofol Ketamine
Net effects on cardiovascular performance characteristics
  Blood pressure Decreases Increases or remains the same
  Heart rate Decreases  Markedly increases
  Cardiac output Decreases Increases
Granular effects on variables which affect cardiac output
  MSFP Decreases Decreases
  CVP Decreases Decreases
  PVR Decreases Decreases
  SVR Decreases Increases
  Contractility Decreases Increases
  Cardiac reflexes Suppressed Remain intact
Regional circulatory effects
  Cerebral blood flow Decreases Probably increases
  Coronary blood flow Slightly decreases Remains unchanged
  Renal blood flow Decreases Increases
  Hepatic blood flow Decreases Increases
Pharmacodynamic mechanisms of these circulatory effects 
  Direct mechanisms Propofol is a direct negative inotrope, but only in massive supratherapeutic concentrations. Under normal dosing conditions, it only decreases contractility by about 5-10% (Sprung et al, 2001).
Propofol has no direct vasodilator effects (Robinson et al, 1997)
Ketamine is a direct negative inotrope. This effect is visible at therapeutic concentrations but is usually overwhelmed by the indirect sympathetic effects (Kongsayreepong et al, 1993).
  Indirect mechanisms Sympathetic suppression results in the haemodynamic effects Sympathetic activation results in the haemodynamic effects

References

De Wit, F., et al. "The effect of propofol on haemodynamics: cardiac output, venous return, mean systemic filling pressure, and vascular resistances.British Journal of Anaesthesia 116.6 (2016): 784-789.

Hoka, Sumio, et al. "Propofol-induced increase in vascular capacitance is due to inhibition of sympathetic vasoconstrictive activity." The Journal of the American Society of Anesthesiologists 89.6 (1998): 1495-1500.

Sprung, Juraj, et al. "The effects of propofol on the contractility of failing and nonfailing human heart muscles." Anesthesia & Analgesia 93.3 (2001): 550-559.

Boer, F., et al. "Effect of propofol on peripheral vascular resistance during cardiopulmonary bypass." British Journal of Anaesthesia 65.2 (1990): 184-189.

Robinson, B. J., et al. "Mechanisms whereby propofol mediates peripheral vasolidation in humans: sympathoinhibition or direct vascular relaxation?." The Journal of the American Society of Anesthesiologists 86.1 (1997): 64-72.

Kongsayreepong, Suneerat, David J. Cook, and Philippe R. Housmans. "Mechanism of the direct, negative inotropic effect of ketamine in isolated ferret and frog ventricular myocardium." Anesthesiology 79.2 (1993): 313-322.

Piriou, V., et al. "Effects of propofol on haemodynamics and on regional blood flows in dogs submitted or not to a volaemic expansion." European journal of anaesthesiology 16.9 (1999): 615-621.

Tranquilli, W. J., J. C. Thurmon, and G. J. Benson. "Organ blood flow and distribution of cardiac output in hypocapnic ketamine-anesthetized swine." American journal of veterinary research 44.8 (1983): 1578-1582.