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Three Part Question

In [adult patients requiring procedural sedation in the emergency department] is [intravenous 'ketofol' (Ketamine/propfol)] an [effective combination to consider using for safe adequate sedation].

Clinical Scenario

A twenty-four year old man attends the emergency department with an anterior shoulder dislocation. You have heard of ketamine/propofol mixtures being used for sedation and wonder if you should consider using it for procedural sedation.

Search Strategy

Medline 1950 to April 2009 week 2 via NHS library interface. (ketofol OR (propofol AND ketamine) AND proc* AND sedation AND emergency AND department).ti,ab [Limit to: English Language]

Search Outcome

The search strategy returned 15 papers. One paper was directly relevant to the three part question. 14 papers were excluded as they were either not relevant or of insufficient quality (13) or looked at ketamine/propofol use in children (1).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Willman E.V.; Andolfatto G. January 2007 Canada	Convinience sample of 114 patients requiring procedural sedation at an Emergency Department were given ketofol (1:1 mixture of 1% Propofol and 1% Ketamine)	Prospective Case series	Dose required	Median Dose 0.75mg/kg popofol and 0.75mg/kg ketamine (Range 0.2 - 2.05mg/kg)	Potential selection bias. Emergence phenomenon not included as an adverse event.
			Sedation	110 (96.5%) required no adjunctive sedatives to perform procedure, 3 (2.6%) required extra propofol alone and in 1 case (0.9%) the intended procedure was unsuccessful.
			Adverse Events	No cardiovascular adverse events. 4 patients (3.5%; 95%CI 1-8%) required airway repositioning, there were 3 episodes (2.6%; 95%CI 0.6-7.5%) of low SaO2 readings, one of which required bag-valve-mask ventilation.
			Physician, Nurse and Patient Satisfaction	Median satisfcation scores were 10 on a 1-to-10 scale.

Comment(s)

It is thought that the opposing cardiovascular and respiratory effects of propofol and ketamine might be exploited to minimise overall adverse events when given together for sedation. Combined use has been reported for some time for sedation in the operating theatre environment (Frizelle et al. Anesth Analg. 1997;84:1318-1322). The paper reviewed in this BET suggests that this combination can indeed be used safely by emergency physicians for procedural sedation in the Emergency Department. No evidence yet exists comparing this combination to other emergency department sedation regimens. As with all sedation, the practitioner should be adequately trained and comfortable with the management of potential complications of sedation, including airway interventions.

Clinical Bottom Line

Ketamine in combination with propofol can provide an effective and safe alternative for procedural sedation in the emergency department.

References

1. Willman E.V.; Andolfatto G. A Prospective evaluation of "Ketofol" (Ketamine/Propofol Combination) for procedural sedation and analgesia in the Emergency Department Annals of Emergency Medicine January 2007, 49 (9): 23-30