European Journal of Molecular & Clinical Medicine

Ambulatory surgery is upcoming in all parts of the world as life becomes more fast pace and time is a limited commodity. In this setting general anaesthesia using the Laryngeal Mask Airway is widely used. Laryngeal Mask Airway insertion is accomplished using Propofol as it helps blunt the laryngeal reflexes well, when compared to other induction agents.
Materials and Methods: The study was        predominantly done in the day care theatre, as this is where most number of Laryngeal Mask  Airways are used in a day. The required sample size to show a difference in the insertion conditions
Results: The following results were obtained from the study. Group I refers to placebo which was saline, Group II refers to 0.1mg/kg of Succinylcholine and Group III refers to 0.25mg/kg of Succinylcholine. Adequate sample sizewas attained with a total of 283 patients. Informed consent was taken from all patients. Group I and II had 95 patients each, and Group III 93 patients. All patients were ASA I or II. None of the patients had a difficult airway.
Conclusion: This study concludes that a low dose of Succinylcholine does facilitate insertion of the Laryngeal Mask Airway. The ideal dose is 0.25mg/kg of Succinylcholine. 0.1mg/kg is not sufficient and is associated inadequate jaw relaxation and does not always provide smooth insertion conditions.

Back ground: When prophylaxis is not used, ENT operations have a significant incidence of postoperative emesis. Antiemetic use as a preventative measure may lower total PONV-related resource use and expenses, improving patient satisfaction. Numerous methods have been employed to reduce the incidence of PONV such as pharmacological interventions for prophylaxis, altering the anaesthetic technique, or combining them all for optimum protection. The present study was conducted with an aim to compare the effectiveness between propofol and dexamethasone in the prevention of postoperative nausea and vomiting after ear, nose and throat surgery and to study any adverse effects associated with these drugs.
Materials and methods: A total of 60 patients who underwent ENT surgeries were divided into two groups with 30 in each group. Group A received dexamethasone 8mg and Group B received propofol 0.5mg/kg after completion of surgery. The incidence and severity of PONV and associated adverse effects were documented at immediate post-op, 30 minutes, 1^{st -}, 6^{th -} , 12^{th -} , and 24^th- hour after the administration of study drug. In addition, the requirement of rescue antiemetics in the overall 24 hours was documented.
Results: There was no statistically significant difference between the dexamethasone and propofol groups in terms of age, gender, body mass index (BMI), type of surgery, ASA status, or duration of anaesthesia and surgery. Incidence of severe PONV (3.3% versus 12%, p =0.008) were statistically significantly lower in group A compared to patients in group B over the 6th-12thhour time period. The mean time to first nausea episode in group A was significantly more compared to group B (p<0.001).
Conclusions: Although the efficacy of dexamethasone and propofol in preventing post-operative nausea and vomiting in ENT surgeries are comparable dexamethasone produced better PONV protection than propofol.

Introduction: Sevoflurane is one of the general anesthetic having  a  rapid  onset and offset of action. Hence anesthetist can control the depth of anesthesia rapidly. Intravenous propofol with rapid induction and  recovery  is a  popular  induction  agent nowadays for surgical anesthesia. Objectives: To compare the effect of sevoflurane and propofol for inducing anesthesia in short elective surgeries. Methods: The study was conducted at Government Medical College,Nizamabad,Telangana,India. Hundred patients prepared for elective short surgery were taken into the study. After pre-anesthetic medication, one group of patients were induced with : O2:N2O  (50:50)  +  Sevoflurane  3-4%  and the other group induced with:  O2:N20  (50:50)  +Propofol 3-5 mg/kg.Parameters like relavant intra-op details, ease of procedure, hemodynamic changes, recovery, and complication rate were compared between both groups.Results: Parameters like jaw opening, attempts for LMA and ease of insertion was comparable in both the groups . Time to loss of consciousness and time  to  LMA insertion was significantly shorter with Propofol. Mean pulse rate and MAP was significantly higher in Sevoflurane group.  Conclusion:  Inhaled Sevoflurane is better for LMA insertion and intra-operative hemodynamic profile during anesthesia was stable.Sevoflurane can be considered as an alternative induction agent when inhalational induction is required. We should keep in mind that  caution  still needs to be continued when sevoflurane is used.

Background: Propofol is one of the most commonly used anaesthetic drugs. Extensive researches have been done on the factors affecting the induction dose requirement of propofol forbetter hemodynamic stability. In the literature there is no mention on the dose requirement of propofol in the hydrated patients. This prospective randomized double blind study was done to assess the effect of preloading on induction dose requirement of propofol in patients undergoing general anaesthesia requiring endotracheal intubation.
Materials and Methods: Two hundred forty adult patients requiring endotracheal intubation under general anaesthesia were randomly divided into two groups, the study group and the control group. Study group received 20 ml/kg of normal saline over 2 hours, 4 hours prior to the induction of general anaesthesia and control group did not receive any fluid preloading. General anaesthesia was induced with titrated doses of propofol with the aid of BIS monitoring. The dose requirement of propofol, hemodynamic stability (HR, SBP, DBP and MAP was measured at intubation (0 min), 1 min, 2 min, and 3 min post intubation) and awareness during anaesthesia was assessed in both the groups.
Results: The dose requirement of propofol in the study group was 00.62±0.12 mg/kg and 1.24±1.30mg/kg in control group. There was no clinically significant change in the hemodynamic parameters between both the groups. None of patients in either group had awareness under general anaesthesia which was assessed post operatively using Brice questionnaire.
Conclusion: Crystalloid preloading reduces induction dose requirement of propofol during general anaesthesia with better hemodynamic stability.

Background : Hypotensive anaesthesia is extensively used during surgery, particularly maxillofacial procedures. Hypotensive anaesthesia reduces blood loss during surgery by rendering the operative field bloodless. Normal blood pressure (BP) during surgery indicates skillful anaesthesia since organ perfusion is preserved. Achieving optimal hypotension is a skill, as excess BP reduction can be dangerous due to diminished circulation to organs like the brain, heart, and kidneys.
Materials and methods: AComparative study. 52 Indian phenotype patients were randomly selected from a table and divided into two groups of 26. Group D = dexmedetomidine (1 μg /kg diluted in 10 mL 0.9% saline administered over 10 minutes before anaesthesia, followed by 0.2–0.7 μg/kg/hour). Group P = propofol (100–150 μg/kg/hour). Mean arterial pressure (MAP) and hemodynamic stability were maintained by titrating infusions.
Results: In our research, neither hypotension nor bradycardia required medication. Group D had lower heart rate and blood pressure than group P. Group D awoke faster than group P. The usual dosages of dexmedetomidine and propofol for hypotensive anaesthesia are 0.2 0.04 μg/kg/hour and 140 41 μg/kg/hour, respectively. In India, little doses may not create issues.
Conclusion: In our investigation of the Indian population, both dexmedetomidine and propofol produced the necessary hypotension in ENT surgery patients to reduce blood loss and increase operational field vision. MAP was lower in dexmedetomidine than propofol, but not significantly. Higher propofol Ramsay sedation scores suggest stronger sedation than dexmedetomidine, making it a superior candidate for hypotensive anaesthesia

Aim: To compare the intraoperative haemodynamic parameters and cost effectiveness between sevoflurane   (inhalational)   anaesthesia   and propofol (tiva) based anaesthesia
Methods: Following informed consent, hundred ASA I and II patients aged 19-63 years of either sex having general anaesthesia were randomly split into two groups of 50. Patients with an ASA of III or higher, major cardiovascular, renal, or pulmonary disease, a history of malignant hyperthermia, any documented allergy to the study agent, H/O any mental condition, or use of sedative medicines were excluded from the study. Sevoflurane was used in Group A, while Propofol was used in Group B.
Results: The Sevoflurane group (51.02±4.52) had a quicker induction time (sec) than the Propofol group (61.29±5.51), which was statistically significant (p<0.001). The recovery profile after the agents were withdrawn at the conclusion of surgery revealed a significant difference in spontaneous eye opening (9.5±1.3 min in Sevoflurane group and 13.4±1.4 min in Propofol group), verbal communication (11.5±1.9 min in Sevoflurane group and 14.6±1.9 min in Propofol group) and mental orientation (16.1±1.6 min Sevoflurane group and 20.3±2.1min Propofol group) (p<0.001), with Sevoflurane demonstrating the superior recovery profile.
Conclusion: In terms of quicker induction and rapid recovery characteristics, we discovered that Sevoflurane outperforms Propofol. The intraoperative hemodynamics of the two groups were equivalent, with no statistically significant difference. However, Sevoflurane-based anaesthesia is still more expensive than Propofol, which if addressed would serve as a good choice of anaesthesia in impoverished nations.

Background: Propofol has gained a lot of popularity and is very commonly used in elective surgeries due to its solubility, rapid induction, quick recovery time along with its amnestic and antiepileptic properties make a potent anesthetic agent. Exclusive uses of propofol to provide LMA might be associated with some undesirable effects which are dose-dependent are like hypotension, respiratory depression, coughing, hiccups, laryngospasm, and movements. Forgoing studies reveled that a combination of ketamine and propofol decreased patients' use of propofol and opioids and improved hemodynamic and respiratory stability. The prime objective of our study is to substantiate the earlier results regarding whether the efficacy of the ketamine-Propofol-Fentanyl combination has more favorable hemodynamics than the gold standard prototypic induction drug (Propofol) in a cohort of healthy patients and to compare the additional post-operative analgesia requirements between the two groups.
Materials and Methods: The clinical prospective observational study was done on 240 individuals which were divided in to 2 equal groups (120 each group), the, Group A (Propofol) received 2.5 mg/kg Propofol for induction and the Group B (Ketamine-Fentanyl-Propofol) of 120 subjects, provided with 0.8mg/kg of ketamine + 0.2mg/kg fentanyl + 1mg/kg of Propofol. Patients in both - groups were maintained with O2, N2O, Sevoflurane and measurement of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) was done before induction and 10 minutes after induction before the surgical stimulus. Additional analgesia (0.2 mg/kg ketamine, 0.1mg/kg fentanyl and 0.3 mg/kg propofol, for a total of 1mg/kg ketamine, 0.3 mg/kg fentanyl and 1.3 mg/kg propofol) was supplied to all patients with a VAS > 3 who reported pain. Independent samples t-test and paired t-test were employed for analysis of the collected data.
Results: In Group B (KP), the systolic, diastolic, mean arterial blood pressure, and heart rate changes following LMA implantation were considerably greater than in Group A (P). Group B had longer recovery durations, lower VAS scores immediately following surgery, and less analgesic needs. There was no incidence of apnea, hypoventilation, or emerging responses.
Conclusion: Ketofol (0.8mg/kg ketamine and 1 mg/kg propofol) + 0.2mg/kg fentanyl has multiple advantages than relaying propofol (2.5mg/kg) alone Hemodynamic stability, absence of respiratory depression, rapid recovery, and potent postoperative analgesia. We thus advocate intravenous ketofol as an induction drug, particularly for patients undergoing short surgical operations.

Introduction: Cisatracurium is one of the ten stereoisomers of Atracurium and is devoid of
histamine induced cardiovascular effects. The neuromuscular blocking potency of
Cisatracurium is approximately three-fold that of Atracurium. Neuromuscular transmission
was assessed by recording the muscle twitch response to train-of-four nerve stimulation.
Material and Method: This is a prospective study was conducted in the Department of
Anesthesiology, Tertiary care Teaching Hospital over a period of 1 year among 140 patients
aged between 20 and 45 years. Study was performed in 140 patients aged 20-45 years
weighted 40-70 kilograms with ASA physical grading 1 and 2 of either sex scheduled for
elective laparoscopic surgery. Monitoring – ECG, non-invasive blood pressure, pulse
oximetry, temperature and capnography (EtCO2). In operation theatre intravenous cannula of
proper size was inserted into the largest vein on the forearm and an infusion of lactated
ringer’s solution was started at a rate of 5 ml/kg/hr. Induction – inj. Propofol 2 mg per kg.
Patients were divided into 2 groups: Group 1 - 70 patients were given atracurium 0.5 mg per
kg for induction. Group 2 - 70 patients were given cisatracurium 0.1 mg per kg for induction.

Background: Midazolam and propofol by virtue of their antiemetic effect were found
individually to reduce the incidence of intraoperative nausea and vomiting. This study
compares the effects of midazolam and propofol in decreasing the incidence of nausea and
vomiting in pregnant women undergoing lower segment caesarean section (LSCS) under
spinal anaesthesia. It also assesses maternal sedation, neonatal outcome and other side effects.
Aim: To compare the effects of subhypnotic dose of midazolam and propofol in prevention
of intraoperative nausea and vomiting in lower segment caesarean section under subarachnoid
block.
Methods: With ethical committee permission the 60 pregnant women were randomly
allocated into 2 groups after taking informed consent. Group M received 0.03mg/kg
midazolam immediately after cord is clamped, Group P received 10 mg propofol immediately
after cord is clamped. Incidence of nausea and vomiting was not according to Bellville
scoring system (0-novomiting, 1-Nausea, 2-Retching, 3_vomiting). The degree of sedation,
hemodynamic changes were noted baseline, after induction, after drug administration, 30
mins after drug administration, 60 mins after drug administration, neonatal out come and side
effects were recorded.
Results: Statistically significant decrease in intraoperative nausea and vomiting in patients
undergoing LSCS under spinal anaesthesia with 10 mg propofol compared to 0.03 mg
midazolam is observed. Degree of sedation, respiratory rate, mean mephentermine
consumption were comparable between two groups and no difference found.
Conclusion: Propofol significantly decreases incidence of intraoperative nausea and
vomiting inches are in section under spinal anaesthesia as compared to midazolam.

Introduction: Post-operative nausea and vomiting is one of the very common complications after a surgery. Prevention of PONV in patients results in improved patient satisfaction and cost effective patient care.
Materials and methods: 50 patients were randomly divided into 2 groups, Group A were the patients who received Propofol- Fentanyl and group B, who received Sevoflurane – Fentanyl. Before surgery, the baseline conditions, such as the baseline pulse rate, blood pressure, SpO2 were taken. Injection glycopyrolate 0.2 mg/kg was given intramuscularly half hour prior to the surgery. 100% oxygenation was given to all the patients for 3 minutes. During Preinduction, all the patients were given 1-1.5 mcg/kg IV Fentanyl.
Results: In the Group A most of the patients had no nausea post-surgery, while 5 of them had mild nausea. However. Out of the patients in Group B, 32% each had mild or no symptoms, but 7 (28%) PONV Grade III, which was significantly higher. In group A, 48% of the patients who were either overweight or obese had no nausea, while 16% of them had mild nausea, 12% had Grade III PONV. Of the patients with normal BMI in Group A, only 1 (4%) had mild nausea, while all the others had no symptoms. In group B, 7 (28%) of the overweight and obese Patients had grade III nausea i.e. 1-2 Vomiting’s in 12 hours with nausea, while 2 (8%) had >3 vomiting in 12 hours with nausea. 6 (24%) each had mild nausea or no nausea.
Conclusion: Although the efficacy of both sevoflurane and Propofol is similar, Propofol is the more preferred drug due to the lesser amounts of cases of nausea and vomiting, thereby resulting in higher patient satisfaction.

Background:The aim of the study is to compare induction with etomidate and propofol
on hemodynamic response to laryngoscopy and intubation.
Materials and Methods: The study was conducted in 60 ASA I & II patients in the age
group of 18 to 60 years who were posted for elective surgeries under general
anaesthesia. Their baseline heart rate, systolic blood pressure, diastolic blood pressure,
SpO2 and ETCO2 were recorded. Both the groups were premedicated with iv
glycopyrrolate 5mcg/kg, iv midazolam 0.025mg/Kg, iv fentanyl 2mcg/Kg. Following
premedication, the above variables were again recorded. Group P patients were
induced with iv propofol at the dose of 2 mg/Kg and Group E patients received iv
etomidate at 0.4mg/Kg. In both the groups, Injection vecuronium was given at the dose
0.08mg/Kg and they were maintained with O2:N2O =33%:66% and Isoflurane 1% dial
concentration. Laryngoscopy was performed by trained anesthesiologists after 5 mins.
Duration of laryngoscopy was kept at a maximum of 10 seconds. Trachea was intubated
with appropriate size endotracheal tube. The variables (HR, SBP, DBP, MAP, SpO2)
were measured during induction, intubation and post intubation at intervals of 1,2,3,5
and 10 mins.
Results: On comparing the two groups, the following results were obtained – Age, Sex,
Weight and ASA status were comparable in both the groups. Propofol was found to
produce hypotension in more or less 20%- 30% of patients irrespective of the
underlying condition. Etomidate was found to maintain hemodynamic stability though
there were no significant difference in heart rate variability in both the groups during
laryngoscopy and intubation. Myoclonus was seen in 4 out of 30 patients induced with
Etomidate, pain on injection was more common with Propofol. Apnea occurred in 12
out of 30 patients induced with Etomidate,28 patients out of 30 in propofol group,
vomiting and nausea are more with Etomidate than propofol but the difference was
statistically insignificant.
Conclusion: As per the results of the study, Propofol produced more hemodynamic
changes than Etomidate. Thus, we conclude that Etomidate is more stable in terms of
hemodynamic stability.

Background:Propofol produces quick induction and recovery, depresses airway
reflexes, and is used for sedation and anaesthesia; nevertheless, it is associated with
dose-dependent hypotension and respiratory depression.It can produce coughing,
hiccups, laryngospasm, and movements when used as a sole agent to provide LMA.In
addition to its amnesic and analgesic effects, ketamine raises heart rate and blood
pressure through stimulating the sympathetic nervous system.It was shown that a
combination of ketamine and propofol decreased patients' use of propofol and opioids
and improved their hemodynamic and respiratory stability. Objectives:1. Determine
whether the ketamine-Propofol combination has more favourable hemodynamics than
the gold standard prototypic induction drug (Propofol) in a cohort of healthy patients.2.
To compare the additional post-operative analgesia requirements between the two
groups.
Materials and Methods: Group KP, the Ketamine-Propofol Group, provided 0.75mg/kg
of ketamine and 1.5mg/kg of Propofol to 60 patients with ASA status I who were
randomly divided into two groups. Group P – Propofol Group received 2 mg/kg
Propofol for induction. The airway is secured with LMA, and patients in both groups
were maintained with O2, N2O, and Sevoflurane. For the next 15 minutes, every three
minutes, the baseline hemodynamics, heart rate, NIBP, Spo2, and respiratory rate were
recorded. Pain scores were measured for each subject post-operatively. Additional
analgesia was supplied to all patients with a VAS > 3 who reported pain.
Results: In Group KP, the systolic, diastolic, mean arterial blood pressure, and heart
rate changes following LMA implantation were considerably greater than in Group P.
Group KP had longer recovery durations, lower VAS scores immediately following
surgery, and less analgesic needs. In neither group was there an occurrence of apnea,
hypoventilation, or emerging responses.
Conclusion: Ketofol is a mixture of ketamine and Propofol that has multiple
advantages.Hemodynamic stability, absence of respiratory depression, rapid recovery,
and potent postoperative analgesia. We thus advocate intravenous ketofol as an
induction drug, particularly for patients undergoing short surgical operations.

Background: Most urologic surgeries are performed in a narrow, limited space with
minimally invasive technique or cystoscope& anaesthesia for these procedures is
administered with the goals of safety, satisfactory procedural condition for the performance
of therapeutic or diagnostic procedures ensuring rapid recovery with minimal post-operative
complications. Therefore, we decided to compare the efficacy & safety of IV Propofol @1.5
mg/kg +Dexmedetomidine @1μg/kg versus IV Ketamine @ 1mg/kg + Dexmedetomidine @
1μg/kg in providing procedural sedation in urological procedures.
Material & Methods: This prospective randomized study was conducted in Department of
Anaesthesiology of Mamata medical hospital. In this study 50 patients scheduled for elective
daycare urological procedures were included and divided equally in two groups. Group Areceived
IV Propofol 1.5 mg/kg, then infusion of Dexmedetomidine@ 1μg/kgand group Breceived
IV Ketamine 1mg/kg, then Dexmedetomidine@ 1μg/kg.
Results: In our study, there is no significant difference in age, weight, gender. The
comparison of mean between two groups after giving dexmedetomidine was statistically
significant (p< 0.05) in heart rate, SBP, onset, duration of analgesia, VAS & Ramsay scores
but DBP & SpO2 was statistically not significant.
Conclusion: Comparison of baseline & intraoperative hemodynamics, showed that the values
were better maintained in Dexmedetomidine + propofol (Group-A) than Dexmedetomidine +
Ketamine (Group B). We have concluded that Dexmedetomidine + Propofol combination was
superior to Dexmedetomidine + Ketamine, providing early onset of sedation, prolonged
analgesia & stable intraoperative hemodynamics.

Background: Based on well-known properties of propofol over last few years this study was
undertaken to evaluate whether priming principle applied for the induction dose of propofol
would affect the total induction dose requirement and reduce the associated side effects.
Methods: The prospective randomized study was undertaken in 100 patients allocated
randomly by envelop method, between 18-55 years of age of either gender belonging to ASA
class I and II scheduled for elective surgeries under general anaesthesia. In group I Inj.
fentanyl 2 μg/ kg administered over a period of 30 seconds intravenously and then induced
with the calculated dose of Inj. Propofol 2mg/kg until the loss of eyelash reflex. In group II,
30 % of the total calculated dose of Inj. propofol 2mg/kg 30 seconds after the administration
of Inj. Fentanyl 2μg/kg over 30 seconds, which will be followed by the administration
remaining calculated dose till the loss of eyelash reflex. Statistical analysis of the
demographic data was done using chi-square test. Comparison between the groups for the
induction dose and haemodynamic parameters was done using student ‘t’ test.
Results: The average induction dose required was 1.53mg/kg with a mean reduction of
23.89%in the induction dose requirement of propofol was observed in the study group. The
haemodynamic parameters were better in study group II compared to the control group I.
Conclusion: Based on study result we recommend application of ‘priming principle’ for
induction dose of propofol.

Background: The physiological changes of pregnancy deem nausea and vomiting infallible complications associated with obstetric anaesthesia, resulting in significant morbidity and longer recovery time. The aim of our randomised control trial was to investigate the efficacy of propofol in addition to the currently accepted regimen of ranitidine and metoclopramide in the prevention of nausea and vomiting in this high risk group undergoing spinal anesthesia during caesarean section.
Methods: Eighty fasted term pregnant women scheduled for elective caesarean section were given ranitidine 150mg and metoclopramide 10mg orally 2 hours prior to spinal anaesthesia following which they received either propofol 200µg /kg IV or placebo as a single bolus dose. Intraoperative and post-delivery emetic episodes experienced were recorded at intervals and the intensity of nausea was assessed using the visual analogue scale (VAS).
Results: The incidence of nausea during the intraoperative period in propofol group was 5 % as compared with placebo group in which it was 32.5%, while that of vomiting in propofol group was 5% as compared with placebo group in which it was 22.5%. Both were found to be statistically significant (p= 0.002, p= 0.023 respectively). The incidence of nausea and vomiting during the entire postoperative period of 0-24 hours between the two groups was found to be statistically insignificant.
Conclusion: The prophylactic administration of a subhypnotic dose of propofol with ranitidine and metoclopramide was effective in the prevention of nausea and vomiting after neuraxial blockade during the intraoperative period but not during the postoperative period.

Background: Total intravenous anaesthesia is technique which uses various drugs in combination, given exclusively by IV route to provide general anaesthesia to the patient. TIVA provides a good surgical plane, rapid induction, smooth the emergence from anaesthesia and rapid recovery. Thus making it a desirable alternative for day care surgeries. Propofol is IV anaesthetic agent, having a pharmacological profile favorable for TIVA. However it is known to cause respiratory depression and dose-dependent hypotension, and due its lack of analgesic properties there is a limitation on its employment. Ketamine known for its hypnotic, analgesic and amnesic properties. Butorphanol seems to provide good analgesia but is associated with adverse effects like cardio depressant action, dizziness and sedation.
Methods: A total of 60 patients who will be undergoing surgeries under TIVA in the age group of 20-60yrs will be taken up for this study. They would be further divided in two groups, Group PK will receive ketamine 1mg/kg 1 min prior to administration of propofol and propofol and group PB will receiving butorphanol 20μg/kg 1min prior to administration of propofol. Propofol will be given at a dose of 1.5ml/kg to both the groups during induction . In both the groups anaesthesia will be maintained with propofol 9mg/kg/hr . Patient will be monitored for various parameters such as non-invasive heamodynamic, respiratory parameters. Incidence of pain on injection Propofol, post-operative sedation, nausea, vomiting will also be looked for.
Results and Conclusion : Expected outcome of this study is that the combination of Propofol-ketamine, offers a better haemodynamic and respiratory stability over propofol- butorphanol combination. Pain on injection will be better attenuated by butorphaol than ketamine.