UCONN Emergency Medicine Interest Group

Posts Tagged ‘Sarah de Loizaga’

Journal Article Synopsis: Ketamine vs. Ketofol, an RCT

In JOURNAL CLUB on May 1, 2011 at 4:15 PM

Summary for “A Blinded, Randomized Controlled Trial to Evaluate Ketamine/Propofol Versus Ketamine Alone for Procedural Sedation in Children” by Amit Shah et al. in Annals of Emergency Medicine Vol 57 (5); pp 425 -433

What is already known on this topic:
Ketamine is a well-established agent used for procedural sedation of children in the Emergency Department.   However, ketamine recovery times can be lengthy and have been shown to range from 25-108 minutes.  Recently, the use of propofol for procedural sedation has become more popular given its favorable pharmokinetics and adverse events profile.  The disadvantage of propofol is the risk of dose-dependent respiratory depression.

Recent studies have demonstrated the safety of administering ketamine and propofol together.  The premise behind administering both medications together, is that it allows for a dose reduction in each medication and thus decreases the risk of respiratory depression.  In addition, ketamine and propofol exhibit several opposite qualities, which may complement each other for a more favorable side effect profile (i.e.  ketamine is emetogenic while propofol has antiemetic properties; ketamine often produces post procedural agitation, while propofol has anxiolytic properties; ketamine maintains respiratory drive, while propofol depresses repiratory drive; ketamine provides an element of analgesia which propofol is lacking)

What question this study addressed:
Is there a clinically significant decrease in total sedation time (10 minutes or more) when using ketamine plus propofol compared to the use of ketamine alone for pediatric procedural sedation?

Secondarily, is there a significant difference in time to recovery, adverse events, efficacy, or satisfaction scores between ketamine plus propofol or ketamine alone?

What was the study design:
Blinded, randomized, controlled trial including 136 pediatric patients requiring procedural sedation for an isolated orthopedic injury.

What this study adds to our knowledge:
The use of ketamine plus propofol compared to the use of ketamine alone reduced the total sedation time by 3 minutes (p=0.04).  In addition, ketamine plus propofol demonstrated a 10% reduction in vomiting compared to ketamine alone (95% CI  -18% to -2%).  Finally, satisfication scores were higher with the ketamine/propofol group (p<0.05).  There was no statistical difference between the two groups with respect to efficacy or airway complications.

How this is relevant to clinical practice:
The combination of ketamine plus propofol for procedural sedation only minimally reduces total sedation time (3 minutes) making it questionable as to whether or not this is clinically significant.  However, ketamine plus propofol does decrease the incidence of vomiting and has a higher rate of satisfaction among patients, nurses, and physicians.

Other considerations:
It would be interesting to compare ketamine plus propofol to propofol alone for pediatric procedural sedation.

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