Sedation and pain management/original researchA Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the Emergency Department
Introduction
Propofol is a nonopioid, nonbarbiturate, sedative-hypnotic agent1 with rapid onset and short duration of action. It possesses antinauseant effects and reliably produces sedation.2, 3 Adverse effects include dose-related cardiovascular and respiratory depression4, 5 and bradycardia.6 Propofol is known to be amnestic but not known to be analgesic, which for some clinicians is a potential concern when performing painful procedures.
Ketamine is a phencyclidine derivative classified as a dissociative sedative7 and is known to provide analgesia8, 9 and amnesia. It causes little or no respiratory or cardiovascular depression.1, 10 However, widespread use of ketamine as a single agent for procedural sedation and analgesia in adults has been limited by the occurrence of emergence phenomena and the concern of inducing vomiting or laryngospasm.11, 12, 13
Ketamine and propofol administered in combination from separate syringes has been used successfully in a variety of settings, including sedation for spinal anesthesia,11 as well as for gynecologic,14 opthamologic,15 and cardiovascular procedures in adults10 and children.8 This combination has been favored because of the opposing hemodynamic and respiratory effects of each drug. Friedberg,16 in a prospective study of 1,264 patients undergoing procedural sedation and analgesia for surgical procedures with ketamine and propofol, concluded that this combination was safe and effective. The use of ketamine in conjunction with propofol has been shown to reduce the dose of propofol required to achieve sedation,10 and this combination is believed to result in less toxicity than either drug alone because their complementary effects enable the use of lower doses of each drug.8
Administering ketamine and propofol mixed in the same syringe (so-called ketofol) has been shown to be efficacious in the operating room and in ambulatory settings.8, 15, 17 Although ketamine and propofol combined in the same syringe has been described in the emergency department (ED) as an induction regimen for rapid sequence intubation,18 there are no published studies regarding their use together in the ED for procedural sedation and analgesia.
Procedural sedation and analgesia for painful procedures is the standard of care in emergency medicine and is commonly performed using a variety of medication regimens, each possessing particular advantages and disadvantages. Ketofol has the potential to provide efficacious procedural sedation and analgesia for painful procedures in the ED while minimizing the adverse effects of either drug alone.
We wished to evaluate the effectiveness and consider the safety of intravenous ketofol for procedural sedation and analgesia in the ED. Secondary objectives included assessments of recovery time and staff and patient satisfaction.
Section snippets
Setting and Study Design
Our facility is a 250-bed community teaching hospital and district trauma center with an annual census of 45,000 emergency patient visits. Consecutive patients who received ketamine and propofol in the same syringe for procedural sedation and analgesia were enrolled as a prospective case series between July 2005 and February 2006. Procedural sedation and analgesia events were captured through the attachment of a special ketofol study data form to every mandatory procedural sedation and
Characteristics of Study Patients
This study was conducted during an 8-month period in which 114 patients had procedural sedation and analgesia with ketofol for painful procedures in the ED. Patient demographics and comorbid conditions are listed in Table 1. Supplemental oxygen was used for 110 patients (97%). No patient was hypoxic before procedural sedation and analgesia. The majority of procedures performed were orthopedic (Table 2).
Main Results
The median dose of ketofol administered was 0.75 mg/kg each of propofol and ketamine (range
Limitations
Ketofol was not directly compared with other known procedural sedation and analgesia regimens; thus, it is impossible to comment on its superiority over other regimens in ED practice. The small size of this study limits the ability to offer firm conclusions about the safety of ketofol as a procedural sedation and analgesia agent.
Selection bias may exist in this series because only procedural sedation and analgesia events using ketofol were recorded and the decision to use ketofol was at the
Discussion
The use of propofol and ketamine as single agents for procedural sedation and analgesia in the ED has grown in popularity, but the unwanted effects of each drug alone have limited their adoption in select populations. This study represents a novel application of the combination of 2 well-known medications whose characteristics appear to be complimentary. Our study shows ketofol to be an effective and apparently safe ED procedural sedation and analgesia regimen. The mixture of ketamine and
References (35)
- et al.
Procedural sedation and analgesia: a review and new concepts
Emerg Med Clin North Am
(2005) - et al.
Haemodynamic changes during anaesthesia induced and maintained with propofol
Br J Anaesth
(1988) - et al.
Propofol for procedural sedation in the emergency department
Ann Emerg Med
(2003) - et al.
The semantics of ketamine
Ann Emerg Med
(2000) - et al.
Pharmacology of systemic analgesics
Best Pract Res Clin Anaesthesiol
(2002) - et al.
Ketamine, an NMDA receptor antagonist, suppresses spatial and temporal properties of burn-induced secondary hyperalgesia in man: a double-blind, cross-over comparison with morphine and placebo
Pain
(1997) Ketamine sedation for pediatric procedures: part 2, review and implications
Ann Emerg Med
(1990)- et al.
Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1022 cases
Ann Emerg Med
(1998) - et al.
A comparison of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy
J Clin Anesth
(2005) - et al.
Procedural sedation terminology: moving beyond “conscious sedation”
Ann Emerg Med
(2002)
Etomidate for procedural sedation in emergency medicine
Ann Emerg Med
Intravenous ketamine sedation of pediatric patients in the emergency department
Ann Emerg Med
Does midazolam alter the clinical effects of intravenous ketamine sedation in children?
a double-blind, randomized, controlled, emergency department trial. Ann Emerg Med
Propofol sedation by emergency physicians for elective pediatric outpatient procedures
Ann Emerg Med
Clinical practice guideline for emergency department ketamine dissociative sedation in children
Ann Emerg Med
The antiemetic action of propofol
Anaesthesia
Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients
Anesthesiology
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Author contributions: EVW and GA conceived the study. EVW performed background literature review, designed the study, tabulated data, and provided statistical analyses. GA supervised conduct of trial and data collection. EVW and GA drafted article. GA takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Supervising editor: Steven M. Green, MD
Reprints not available from the authors.