Ketamine-Propofol (Ketofol) as a Viable Alternative in a Septic Patient with Mediastinal Mass Requiring General Anesthesia for Endoscopic Retrograde Cholangio-Pancreatography

Airway compromise and cardiovascular collapse can be anticipated in a patient with mediastinal mass due to aneurysm of ascending and arch of aorta during any stage of anesthesia. Presence of septic shock limits the use of anesthetic agents. The adverse effects of ketamine or propofol are dose dependent and tend to oppose each other cardiovascular effects. The combination of ketamine and propofol may potentially balance each other’s haemodynamic adverse effects and therefore, offer a safer alternative for procedural sedation in critically ill. An elderly emaciated lady diagnosed with acute cholecystitis and cholangitis in septic shock had fusiform aneurysm of ascending aorta and arch of aorta with mediastinal compression. She underwent endoscopic retrograde cholangiopancreatogram (ERCP) under total intravenous anesthesia with a combination of propofol and ketamine which preserved spontaneous ventilation. Haemodynamics were maintained with the judicious use of intravenous fluids and vasopressors.