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Three Part Question

In [Adults needing procedural sedation in the emergency department], is [ketamine as good as propofol] at [providing adequate level of sedation] ?

Clinical Scenario

A 34 years old man presents to your emergency department with a dislocated shoulder. You want to use procedural sedation for the reduction of his shoulder. You have used ketamine successfully for sedation in children before and you wonder if it would be as effective as propofol in an adult population requiring procedural sedation.

Search Strategy

No BestBET was found on this topic.
Medline on March 29th 2012, all years, via PubMed.
Embase on March 29th 2012, all years.
Cochrane library on March 29th 2012.
Clnicaltrial.gov on March 15th 2012 : no ongoing trial found

Medline search :
1. propofol OR \\\"propofol\\\"[Mesh] 14123
2. ketamine OR “ketamine”[Mesh] 12377
3. #1 AND #2 99
4. Sedation OR “conscious sedation”[Mesh] 25750
5. #3 AND #4 257
6. (emergency room) OR (emergency department) OR \\\"Emergency Service,
Hospital\\\"[Mesh] 120554
7. #5 AND #6 54

Embase search :
1. \\\'propofol\\\'/exp 28402
2. \\\'ketamine\\\'/exp 21257
3. #1 AND #2 3469
4. \\\'sedation\\\'/exp OR \\\'conscious sedation\\\'/exp 41218
5. #3 AND #4 1065
6. \\\'emergency health service\\\'/exp OR \\\'emergency ward\\\'/exp OR \\\'emergency room\\\' OR \\\'emergency department\\\' 58 819
7. #5 AND #6 107
8. #7 AND [humans]/lim AND [controlled clinical trial]/lim OR [meta analysis]/lim OR [randomized
controlled trial]/lim OR [systematic review]/lim 13

Cochrane Search :
1. propofol AND ketamine AND sedation 22

Search Outcome

Medline search : 54 articles found, 3 were relevant to the subject, 2 of them were randomized controlled trials which were included. One was a non randomized observational study of much lower level of evidence and was therefore excluded.

Embase search : 13 articles found, 2 relevant randomized controlled trials, the same as in the Medline search

Cochrane Search : No relevant article found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Miner J. R June 2010 United State	Adults needing moderate procedural sedation in ER, ASA 1-2 50 patients : Propofol 1mg/kg + 0,5 mg/kg every 3 minutes as needed 47 patients : Ketamine 1mg/kg + 0,5 mg/kg every 3 minutes as needed IV Morphine for analgesia 20 min before procedure in both groups	Randomized non-blinded prospective clinical trial	Subclinical respiratory depression (Primary)	63,8% for Ketamine vs 40%, for Propofol (p=0,02)	Not blinded Unclear significance of subclinical respiratory dépression Groups not comparable at baseline: supplemental oxygen before procedure used more often in propofol group - this is not accounted for in the statistical analysis No benzodiazepine used before Ketamine Powered to detect a 25% difference in subclinical respiratory depression, therefore answers our clinical question mainly in secondary outcomes not used for power calculation Higher than usual dose of Propofol for sedation
			Clinical intervention for respiratory depression (Primary)	40.4% for Ketamine vs 52% for Propofol (p=NS)
			Perceived pain, Level of sedation (OOAS scale ), Recall of procedure, Success of procedure, Patient satisfaction (Secondary)	No statistically significant difference
			Time to return to baseline level of consciousness (Secondary)	Increased with Ketamine 14 min vs 5 min (9,38 min difference; Confidence interval ; 5,28 to 13,48 min)
Uri O December 2011 Israel	Adult with orthopedic injuries requiring painful manipulation 18-65 years old ASA 1-2 30 patients : Midazolam 0,1 mg/kg until eye closure then ketamine 1mg/kg 30 patients : Propofol 10mg / 10 seconds until desired sedation level + 10mg/10sec as needed	Randomizedpatient-blinded prospective clinical trial	Recovery time (Primary)	Increased with Ketamine : 30,7min vs 7,8 min (p<0,001)	Convenience sample based on avalability of the authors : possible selection bias Analgesia not included in protocol Use of midazolam as a confounding factor, and high dose of midazolam used Small number of patients
			Total sedation time (Primary)	Increased with Ketamine : 41,6 min vs 16,2 min (p<0,001)
			Secondary : Effectiveness of sedation (Procedure success, physician satisfaction, patient obseved distress, patient satisfaction)	No statistically significant difference

Comment(s)

The studies above are the only randomized trials that we found comparing ketamine to propofol in adults. The question regarding the adequacy of the level of sedation achieved was a secondary outcome for both of the studies.. The measure of adequate level of sedation is not standardized in both studies and the authors used different data to assess the effectiveness of the sedation. No statistically significant difference was found regardless of the measure used. However, the studies might not be powered enough to detect a difference in their secondary outcome. Of note, both studies found that ketamine was associated with longer time before return to baseline level of consciousness. This may influence the overall efficiency of the sedation

Clinical Bottom Line

Ketamine seems to be as effective as Propofol for achieving adequate level of sedation. However, in a busy emergency department, concerns about longer time to recovery with ketamine and consequently longer time for monitoring would favour the use of Propofol

References

1. Miner, J. R., R. O. Gray, J. Bahr, R. Patel, and J. W. McGill Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department Acad Emerg Med 2010;p. 604-611
2. Uri, O., E. Behrbalk, A. Haim, E. Kaufman, and P. Halpern Procedural Sedation with Propofol for Painful Orthopaedic Manipulation in the Emergency Department Expedites Patient Management Compared with a Midazolam/Ketamine Regimen: A Randomized Prospective Stu J Bone Joint Surg 2011 ; p. 2255-2262