Enhancing Ketamine Anesthesia with Midazolam, Fentanyl and Propofol Sedation for Day-Case Tympanoplasty: An Observational Study

Abstract

Background: Tympanoplasty is commonly performed as an elective otologic procedure and, in appropriately selected patients, may be undertaken as day-case surgery. Anesthetic management should provide adequate analgesia, anxiolysis and operative immobility while maintaining cardiorespiratory stability and permitting rapid postoperative recovery. This study evaluated perioperative physiological responses, oxygenation, consciousness, adverse events and recovery characteristics following a ketamine-based anesthetic technique supplemented with midazolam, fentanyl and propofol. Methods: This prospective observational study was conducted at the Department of Anaesthesia, Analgesia and Critical Care Medicine, Popular Medical College Hospital, Dhanmondi, Dhaka, Bangladesh and included 50 adult patients undergoing elective tympanoplasty between January 2024 and December 2025. Selected patients received a standardized ketamine-based intravenous anesthetic technique supplemented with midazolam, fentanyl, propofol and local anesthetic infiltration where appropriate. Blood pressure, pulse rate, peripheral oxygen saturation (SpO₂), oxygen administration and level of consciousness were monitored perioperatively. Consciousness was assessed using the Alert, Voice, Pain, Unresponsive (AVPU) scale and Glasgow Coma Scale (GCS). Recovery characteristics, adverse events, airway interventions, time to orientation and discharge eligibility were recorded. Data were analyzed using IBM SPSS Statistics version 29.0. Results: Mean age was 34.2 ± 9.1 years; 68.0% were ASA I and 32.0% ASA II. Mean operative duration was 74.6 ± 15.8 minutes. Mean baseline blood pressure was 126.4 ± 11.2/78.2 ± 7.4 mmHg, decreasing to a lowest intraoperative value of 111.8 ± 12.6/68.6 ± 8.1 mmHg. Baseline SpO₂ was 98.2 ± 0.8% with a lowest value of 95.6 ± 1.7%. Transient SpO₂ <94% occurred in 6.0% and transient hypotension in 8.0%. No patient required intubation or unplanned admission. Mean time to full orientation was 14.8 ± 6.2 minutes and discharge eligibility was 132.4 ± 28.6 minutes. Same-day discharge was achieved in 96.0%. Conclusion: In selected patients, this ketamine-based anesthetic technique was associated with generally stable physiological parameters, limited transient adverse events and relatively rapid recovery. Continuous monitoring remains essential because combined sedative agents may cause deeper-than-intended sedation.