Propofol Versus Propofol/Ketamine for Brief Painful Procedures in the Emergency Department: Clinical and Bispectral Index Scale Comparison

Abstract

The ideal procedural sedation drug for emergency department (ED) use would be easily titrated, rapid in onset, brief in duration, and provide sedation and analgesia without respiratory or hemodynamic compromise. Although many agents have been tried, no single drug fits this profile. The authors evaluated the comparative effectiveness and safety of propofol versus propofol/ketamine combination for procedural sedation using bispectral index monitoring for measuring depth of sedation. A prospective, randomized case series of patients undergoing procedural sedation for fracture manipulation was studied in a Level 1 trauma center emergency department. Patients were randomized to a propofol (P) group with a target dose of 0.5 to 1.5 mg/kg or a propofol/ketamine (P/K) group with a target dose of both ketamine and propofol of 0.75 mg/kg. Procedural success, bispectral index (BIS) score, adverse effects, recovery time, and vital signs were measured. Twenty-eight patients were enrolled. The P/K group experienced a smaller decline in systolic blood pressure (1.6% versus 12.5%) and BIS score at goal sedation (77 versus 61), a smaller difference between baseline and goal sedation BIS score (18.78 ± 10 versus 34.64 ± 11) and a lower mean propofol dose (92.5 ± 58 versus 177.27 ± 11 mg). No patient in either group experienced respiratory depression or required any intervention. The combination of propofol and ketamine provides an attractive combination for procedural sedation in the emergency department. Compared to propofol alone, "ketofol" results in less hypotension, better sedation, and enhanced patient comfort and safety.

Ketamine‐Propofol Versus Propofol Alone for Procedural Sedation in the Emergency Department: A Systematic Review and Meta‐analysis

“…1,[18][19][20][21][22] Percent agreement for final selection of included trials was 95.2%, with very good inter-rater agreement (j = 0.88; 95% CI = 0.68 to 1.0).…”

“…Two of the studies included only adult patients, 1,18 and two included both adult and pediatric patients (one excluded age < 14 years and one included age ≥ 2 years). 19,20 The trial by Del Pizzo et al 21 included pediatric patients aged 3 to 18 years, and the patient population was unclear in one trial.…”

“…Four of the studies were published journal articles, 1,[18][19][20] and two were peer-reviewed abstracts selected for presentation at national and international conferences. 21,22 Two of the included studies were randomized, blinded, three-arm clinical trials of patients undergoing procedural sedation in the ED.…”

“…However, propofol may cause dose-dependent adverse events such as respiratory depression and hemodynamic compromise. 1 Although propofol has amnestic and antiemetic properties, it is not an analgesic, so opioids and other agents are often used to provide pain control. 2 It has been suggested that the combination of ketamine and propofol (K-P), or "ketofol" if the two agents are mixed in a single syringe, for procedural sedation allows for a reduction in the required dose of each individual agent, potentially mitigating the risk of adverse respiratory events compared to propofol alone or in combination with opioids.…”

Ketamine versus alfentanil combined with propofol for sedation in colonoscopy procedures: A randomized prospective study

“…At present, no sole agent has all of these characteristics. For this reason, various doses of different drug combinations are used to achieve most of these desired effects (4,5).…”