Sedation and pain management/original research
A Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the Emergency Department

https://doi.org/10.1016/j.annemergmed.2006.08.002Get rights and content

Study objective

We evaluate the effectiveness and consider the safety of intravenous ketamine/propofol combination (“ketofol”) in the same syringe for procedural sedation and analgesia in the emergency department (ED).

Methods

A prospective case series of consecutive ketofol procedural sedation and analgesia events in the ED of a trauma-receiving community teaching hospital from July 2005 to February 2006 was studied. Patients of all ages, with any comorbid conditions, were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was administered intravenously at the discretion of the treating physician by using titrated aliquots. The presence or absence of adverse events was documented, as were procedural success, recovery time, and physician, nurse, and patient satisfaction. Physiologic data were recorded with established hospital procedural sedation and analgesia guidelines.

Results

One hundred fourteen procedural sedation and analgesia events using ketofol were performed for primarily orthopedic procedures. The median dose of medication administered was ketamine at 0.75 mg/kg and propofol at 0.75 mg/kg (range 0.2 to 2.05 mg/kg each of propofol and ketamine; interquartile range [IQR] 0.6 to 1.0 mg/kg). Procedures were successfully performed without adjunctive sedatives in 110 (96.5%) patients. Three patients (2.6%; 95% confidence interval [CI] 0.6% to 7.5%) had transient hypoxia; of these, 1 (0.9%; 95% CI 0.02% to 4.8%) required bag-valve-mask ventilation. Four patients (3.5%; 95% CI 1.0% to 8.7%) required repositioning for airway malalignment, 4 patients (3.5%; 95% CI 1.0% to 8.7%) required adjunctive medication for sedation, and 3 patients (2.6%; 95% CI 0.6% to 7.5%) had mild unpleasant emergence, of whom 1 (0.9%; 95% CI 0.02% to 4.8%) received midazolam. No patient had hypotension or vomiting or received endotracheal intubation. Median recovery time was 15 minutes (range 5 to 45 minutes; IQR 12 to 19 minutes). Median physician, nurse, and patient satisfaction scores were 10 on a 1-to-10 scale.

Conclusion

Ketofol procedural sedation and analgesia is effective and appears to be safe for painful procedures in the ED. Few adverse events occurred and were either self-limited or responded to minimal interventions. Recoveries were rapid, and staff and patients were highly satisfied.

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)

  • D.R. Vinson et al.

    Etomidate for procedural sedation in emergency medicine

    Ann Emerg Med

    (2002)
  • R.J. Dachs et al.

    Intravenous ketamine sedation of pediatric patients in the emergency department

    Ann Emerg Med

    (1997)
  • J.E. Wathen et al.

    Does midazolam alter the clinical effects of intravenous ketamine sedation in children?

    a double-blind, randomized, controlled, emergency department trial. Ann Emerg Med

    (2000)
  • E.G. Guenther et al.

    Propofol sedation by emergency physicians for elective pediatric outpatient procedures

    Ann Emerg Med

    (2003)
  • S.M. Green et al.

    Clinical practice guideline for emergency department ketamine dissociative sedation in children

    Ann Emerg Med

    (2004)
  • J.S. McCollum et al.

    The antiemetic action of propofol

    Anaesthesia

    (1988)
  • M.F. Watcha et al.

    Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients

    Anesthesiology

    (1991)
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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.

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