Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

Abstract

Case seriesPatient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61Final Diagnosis: —Symptoms: Hypotension • respiratory failureMedication: Ketamine • Propofol • EtomidateClinical Procedure: Endotracheal intubationSpecialty: Critical Care MedicineObjective:Educational Purpose (only if useful for a systematic review or synthesis)Background:Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation.Case Series:We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations.Conclusions:This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

“…decreased systemic vascular resistance). However, this risk is not universally recognized and there is substantial variance in best practices associated with safer ETI processes in the ICU [6,9,[10][11][12][13][14][15][16][17]. Further, despite the above cited associations, there is no currently available formal method that predicts the onset of hypotension when an airway is established in the ICU.…”

Period Prevalence of Ketamine-Propofol Admixture “Ketofol” in the Operating Room among Anesthesia Providers at an Academic Medical Center

“…The perception that the admixture was hemodynamically stable to very stable was detected in over 95% of the respondents. Hemodynamic stability may be more desirable than the worrisome consequence of emergence delirium, which seems to be less prevalent according to several studies [ 2 , 5 , 11 , 13 ].…”

Endotracheal Intubation Among the Critically Ill: Protocol for a Multicenter, Observational, Prospective Study

“…However, with mounting evidence for adrenal suppression and possible associations with mortality in septic patients, the clinician now struggles with the ideal sedative for endotracheal intubation [28-30]. Other agents and/or admixtures have shown promise [31,32]. Not only has the choice of induction medication changed in recent years, but current evidence suggests that the use of paralytics may help facilitate endotracheal intubation [33,34].…”