Ketamine and Propofol (Ketofol) for Pediatric Sedation

Ketamine and Propofol (Ketofol)

Keeping children comfortable benefits everyone! Patients have less pain and psychological trauma. Their families think you are amazing and… your procedure is easier to do when not also performing professional wrestling maneuvers. Honestly, a successful procedural sedation is one of the best things to do in the ED. It satisfies everyone… which makes for some good job satisfaction while you are driving home. On the other hand… a less than successful sedation is… well, not satisfying at all. Recently, my stellar Pediatric EM Fellows and I were discussing sedation practices. We spoke of Ketamine for pain and sedation and how it can be given via the nostril route! Nitrous was also discussed and how it is almost the perfect tool for the job — yet, many are still unfamiliar with it. Then we discussed the nearly omnipresent topic of “Ketofol.” Even this old dog can learn a new trick I suppose… but do I need to? Let’s look briefly at Ketamine and Propofol (Ketofol) for Pediatric Procedural Sedation:

Ketamine and Propofol: A Complementary Pair

  • Risks and benefits are constantly being weighed in medicine.
  • Selecting the “best” medicine for procedural sedation is even more challenging as we need to consider appropriate:
    • Analgesia
    • Anxiolysis
    • Anesthesia
    • Airway Protection
    • Cardiovascular Stability
  • Every medicine has potential negative aspects that must be accounted for while hoping to augment the benefits.
  • While we all LOVE ketamine and propofol, neither Ketamine nor Propofol are perfect.
    • Ketamine:
      • Pros:
        • Has analgesic, amnestic, and dissociative properties!
        • Relatively fast onset
        • Airway reflexes are maintained
        • Supports (and even augments) cardiovascular status
      • Cons:
        • Laryngospasm risk
        • Nausea / Vomiting
        • Emergence Reactions
    • Propofol:
      • Pros:
        • Rapid onset and with
        • Predictable recovery time
        • Antiemetic effects
      • Cons:
        • Cardiovascular depression / hypotension
        • Pain at sight of injection
        • Poor analgesia over all
        • Longer term use of Propofol can lead to other issues too (not what we are talking about here).
  • In theory, the combination of the two has potential benefits:
    • Reduced vomiting.
    • Avoidance of hypotension.
    • Improved pain control.
    • Reduced dosage of both medicines.
  • In practice, the co-administration of ketamine and propofol has been found:
    • To be safe and effective. [Miller, 2019; Weisz, 2017; Scherer, 2015; Canpolat, 2012; Shah, 2011; Andolfatto, 2010]
    • To lead to less vomiting. [Shah, 2011]
    • To have slightly faster recovery times (although perhaps not clinically noticeable). [Shah, 2011]
    • To lead to good satisfaction. [Andolfatto, 2010]
    • To have similar adverse event rates with Ketamine alone. [Weisz, 2017]
    • To lead to less propofol use. [Chiaretti, 2011]
  • Whether the clinical differences between Ketamine alone and ketofol are substantial enough to warrant the advocacy of ketofol over ketamine is likely to be based on provider experience and preference.

Ketofol: How to…

  • Two separately administered medicines. [Miller, 2019]
    • Ketamine (0.5 mg/kg) given first to mitigate pain from propofol injection.
    • Followed by propofol (0.5 mg/kg).
    • Additional titrated doses of propofol as required.
  • Single mixture of both medicine administered concurrently. [Miller, 2019]
    • Commonly referred to as “ketofol.”
    • Mixture of ketamine and propofol within the same syringe.
    • Both ketamine and propofol have the same mg/ml concentration.
    • Typically used in a 1:1 ratio (same mg/kg dosage), although this is being investigated also.

Moral of the Morsel

  • Old dogs (like me) can learn new tricks. Sedation, though, shouldn’t be deemed a trick. Always be vigilant and careful!
  • Ketofol may be the best of both worlds. Yet, it is also not perfect.

References

Miller KA1, Andolfatto G2, Miner JR3, Burton JH4, Krauss BS5. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med. 2019 May;73(5):470-480. PMID: 30732981. [PubMed] [Read by QxMD]
Weisz K1, Bajaj L1, Deakyne SJ2, Brou L1, Brent A1, Wathen J1, Roosevelt GE3. Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department. J Emerg Med. 2017 Jul;53(1):1-9. PMID: 28433211. [PubMed] [Read by QxMD]
Scheier E1, Gadot C2, Leiba R3, Shavit I4. Sedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis. Am J Emerg Med. 2015 Jun;33(6):815-7. PMID: 25819203. [PubMed] [Read by QxMD]
Canpolat DG1, Esmaoglu A, Tosun Z, Akn A, Boyaci A, Coruh A. Ketamine-propofol vs ketamine-dexmedetomidine combinations in pediatric patients undergoing burn dressing changes. J Burn Care Res. 2012 Nov-Dec;33(6):718-22. PMID: 22878491. [PubMed] [Read by QxMD]
Shah A1, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33. PMID: 20947210. [PubMed] [Read by QxMD]
Mallory MD1, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011 May;57(5):462-8. PMID: 21513827. [PubMed] [Read by QxMD]
Chiaretti A1, Ruggiero A, Barbi E, Pierri F, Maurizi P, Fantacci C, Bersani G, Riccardi R. Comparison of propofol versus propofol-ketamine combination in pediatric oncologic procedures performed by non-anesthesiologists. Pediatr Blood Cancer. 2011 Dec 15;57(7):1163-7. PMID: 21584935. [PubMed] [Read by QxMD]
Andolfatto G1, Willman E. A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol). Acad Emerg Med. 2010 Feb;17(2):194-201. PMID: 20370749. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Sam Bawcum says:

    Thanks for this.
    Just to be clear, a 25kg child would receive a loading dose of 12.5mg ketamine AND 12.5mg propofol. May we confer this to adult patients? For example, a 75kg patient would receive a loading dose of 37.5mg ketamine and 37.5mg propofol?
    As to maintenance dosing, continue the 1:1 dosing of ketafol, or alternate between ketamine and propofol, or simply pick one? I would be inclined to maintain sedation (I’m a flight medic, so this would be in the flight transport) by picking one or the other. In my experience, and that shared with many in my field, patients often break through propofol sedation during the significantly increased stimuli during flight. As such, I much prefer ketamine (infusion or push dosing).

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