Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children

 

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Abstract

Objective Examine comparative dosing, efficacy, and safety of propofol alone or with an initial, subdissociative dose of ketamine approach for deep sedation.

Background Propofol is a sedative-hypnotic agent used increasingly in children for deep sedation. As a nonanalgesic agent, use in procedures (e.g., bone marrow biopsies/aspirations, renal biopsies) is debated. Our intensivist procedural sedation team sedates using one of two protocols: propofol-only (P-O) approach or age-adjusted dose of 0.25 or 0.5 mg/kg intravenous ketamine (K + P) prior to propofol. With either approach, an initial induction dose of 1 mg/kg propofol is recommended and then intermittent dosing throughout the procedure to achieve adequate sedation to safely and effectively perform the procedure. Approach: Retrospective evaluation of 754 patients receiving either the P-O or K + P approach to sedation.

Results A total of 372 P-O group patients and 382 K + P group. Mean age (7.3 ± 5.5 years for P-O; 7.3 ± 5.4 years for K + P) and weight (30.09 ± 23.18 kg for P-O; 30.14 ± 24.45 kg for K + P) were similar in both groups (p = NS). All patients successfully completed procedures with a 16% combined incidence of hypoxia (SPO2 < 90%). Procedure time was 3 minutes longer for K + P group than P-O group (18.68 ± 15.13 minutes for K + P; 15.11 ± 12.77 minutes for P-O; p < 0.01), yet recovery times were 5 minutes shorter (17.04 ± 9.36 minutes for K + P; 22.17 ± 12.84 minutes for P-O; p < 0.01). Mean total dose of propofol was significantly greater in P-O than in K + P group (0.28 ± 0.20 mg/kg/min for K + P; 0.40 ± 0.26 mg/kg/min for P-O; p < 0.0001), and might explain the shorter recovery time.

Conclusion Both sedation approaches proved to be well tolerated and equally effective. Addition of ketamine was associated with reduction in the recovery time, probably explained by the statistically significant decrease in the propofol dose.

• References

• 1 Miner JR, Biros M, Krieg S, Johnson C, Heegaard W, Plummer D. Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department. Acad Emerg Med 2003; 10 (9) 931-937
  CrossrefPubMedGoogle Scholar
• 2 Burton JH, Miner JR, Shipley ER, Strout TD, Becker C, Thode Jr HC. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med 2006; 13 (1) 24-30
  CrossrefPubMedGoogle Scholar
• 3 Frazee BW, Park RS, Lowery D, Baire M. Propofol for deep procedural sedation in the ED. Am J Emerg Med 2005; 23 (2) 190-195
  CrossrefPubMedGoogle Scholar
• 4 Miner JR, Danahy M, Moch A, Biros M. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 2007; 49 (1) 15-22
  CrossrefPubMedGoogle Scholar
• 5 Zed PJ, Abu-Laban RB, Chan WW, Harrison DW. Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study. CJEM 2007; 9 (6) 421-427
  CrossrefPubMedGoogle Scholar
• 6 Godambe SA, Elliot V, Matheny D, Pershad J. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department. Pediatrics 2003; 112 (1, Pt 1): 116-123
  CrossrefPubMedGoogle Scholar
• 7 Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 2007; 41 (3) 485-492
  CrossrefPubMedGoogle Scholar
• 8 Campbell SG, Magee KD, Kovacs GJ , et al. Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series. CJEM 2006; 8 (2) 85-93
  CrossrefPubMedGoogle Scholar
• 9 Innes G, Murphy M, Nijssen-Jordan C, Ducharme J, Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. J Emerg Med 1999; 17 (1) 145-156
  CrossrefPubMedGoogle Scholar
• 10 Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 367 (9512) 766-780
  CrossrefPubMedGoogle Scholar
• 11 Guldner GT, Petinaux B, Clemens P, Foster S, Antoine S. Ketamine for procedural sedation and analgesia by nonanesthesiologists in the field: a review for military health care providers. Mil Med 2006; 171 (6) 484-490
  CrossrefPubMedGoogle Scholar
• 12 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologistss. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96 (4) 1004-1017
  CrossrefPubMedGoogle Scholar
• 13 Coté CJ, Wilson S ; American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118 (6) 2587-2602
  CrossrefPubMedGoogle Scholar
• 14 Zeltzer LK, Altman A, Cohen D, LeBaron S, Munuksela EL, Schechter NL. American Academy of Pediatrics Report of the Subcommittee on the Management of Pain Associated with Procedures in Children with Cancer. Pediatrics 1990; 86 (5, Pt 2): 826-831
  PubMedGoogle Scholar
• 15 Hui TW, Short TG, Hong W, Suen T, Gin T, Plummer J. Additive interactions between propofol and ketamine when used for anesthesia induction in female patients. Anesthesiology 1995; 82 (3) 641-648
  CrossrefPubMedGoogle Scholar
• 16 Morse Z, Sano K, Kanri T. Effects of a propofol—ketamine admixture in human volunteers. Pac Health Dialog 2003; 10 (1) 51-54
  PubMedGoogle Scholar
• 17 Akin A, Esmaoglu A, Guler G, Demircioglu R, Narin N, Boyaci A. Propofol and propofol-ketamine in pediatric patients undergoing cardiac catheterization. Pediatr Cardiol 2005; 26 (5) 553-557
  CrossrefPubMedGoogle Scholar
• 18 Akin A, Esmaoglu A, Tosun Z, Gulcu N, Aydogan H, Boyaci A. Comparison of propofol with propofol-ketamine combination in pediatric patients undergoing auditory brainstem response testing. Int J Pediatr Otorhinolaryngol 2005; 69 (11) 1541-1545
  CrossrefPubMedGoogle Scholar
• 19 Tomatir E, Atalay H, Gurses E, Erbay H, Bozkurt P. Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging. Paediatr Anaesth 2004; 14 (10) 845-850
  CrossrefPubMedGoogle Scholar
• 20 Suzuki M, Tsueda K, Lansing PS , et al. Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery. Anesth Analg 1999; 89 (1) 98-103
  PubMedGoogle Scholar
• 21 Tverskoy M, Oz Y, Isakson A, Finger J, Bradley Jr EL, Kissin I. Preemptive effect of fentanyl and ketamine on postoperative pain and wound hyperalgesia. Anesth Analg 1994; 78 (2) 205-209
  CrossrefPubMedGoogle Scholar
• 22 Choe H, Choi YS, Kim YH , et al. Epidural morphine plus ketamine for upper abdominal surgery: improved analgesia from preincisional versus postincisional administration. Anesth Analg 1997; 84 (3) 560-563
  PubMedGoogle Scholar
• 23 Wong CS, Liaw WJ, Tung CS, Su YF, Ho ST. Ketamine potentiates analgesic effect of morphine in postoperative epidural pain control. Reg Anesth 1996; 21 (6) 534-541
  PubMedGoogle Scholar
• 24 David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 2011; 57 (5) 435-441
  CrossrefPubMedGoogle Scholar
• 25 Short SM, Aun CS. Haemodynamic effects of propofol in children. Anaesthesia 1991; 46 (9) 783-785
  CrossrefPubMedGoogle Scholar
• 26 Newson C, Joshi GP, Victory R, White PF. Comparison of propofol administration techniques for sedation during monitored anesthesia care. Anesth Analg 1995; 81 (3) 486-491
  PubMedGoogle Scholar
• 27 Hasan RA, Shayevitz JR, Patel V. Deep sedation with propofol for children undergoing ambulatory magnetic resonance imaging of the brain: experience from a pediatric intensive care unit. Pediatr Crit Care Med 2003; 4 (4) 454-458
  CrossrefPubMedGoogle Scholar
• 28 Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?. Acad Emerg Med 2006; 13 (5) 500-504
  CrossrefPubMedGoogle Scholar
• 29 Bryson HM, Fulton BR, Faulds D. Propofol. An update of its use in anaesthesia and conscious sedation. Drugs 1995; 50 (3) 513-559
  CrossrefPubMedGoogle Scholar
• 30 Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994; 81 (4) 1005-1043
  CrossrefPubMedGoogle Scholar
• 31 Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med 2007; 49 (1) 1-8
  CrossrefPubMedGoogle Scholar
• 32 Burton JH, Bock AJ, Strout TD, Marcolini EG. Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial. Ann Emerg Med 2002; 40 (5) 496-504
  CrossrefPubMedGoogle Scholar
• 33 Messenger DW, Sivilotti ML, van Vlymen J, Dungey PE, Murray HE. Which alarms first during procedural sedation: the pulse oximeter or the capnograph?. Can J Emerg Med 2007; 9: 186
  PubMedGoogle Scholar
• 34 Willman EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med 2007; 49 (1) 23-30
  CrossrefPubMedGoogle Scholar
• 35 Cravero JP, Blike GT, Beach M , et al; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118 (3) 1087-1096
  CrossrefPubMedGoogle Scholar