Ketamine/Propofol Versus Midazolam/Fentanyl for Procedural Sedation and Analgesia in the Emergency Department: A Randomized, Prospective, Double-Blind Trial

Abstract

Objectives: The authors performed a prospective, double-blinded, randomized trial with emergency department (ED) patients requiring procedural sedation and analgesia (PSA) for repair of deep traumatic lacerations and reduction of bone fractures, to compare the ketamine ⁄ propofol (ketofol) combination with the midazolam ⁄ fentanyl (MF) combination.Methods: Sixty-two patients scheduled for PSA who presented between January 2009 and June 2009 were enrolled prospectively. Thirty-one were randomly assigned to the ketofol group, and 31 were assigned to the MF group.Results: The median starting doses were 0.75 mg ⁄ kg of both ketamine and propofol (interquartile range [IQR] = 0.75 to 1.5 mg ⁄ kg), 0.04 mg ⁄ kg midazolam (IQR = 0.04 to 0.06 mg ⁄ kg), and 2 lg ⁄ kg fentanyl (IQR = 2 to 3 lg ⁄ kg). There were no significant differences in sedation time between the groups. There were no differences in physician satisfaction (p = 0.065). Perceived pain in the ketofol group, as measured by the Visual Analog Scale (VAS), was significantly lower than in the MF group (median ketofol = 0, IQR = 0-1 vs. median MF = 3, IQR = 1-6; p < 0.001). Only one patient in each group required bag-mask ventilation, and neither of them were intubated. Conclusions:The ketamine ⁄ propofol combination provides adequate sedation and analgesia for painful procedures and appears to be a safe and useful technique in the ED.

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

“…It also has significant analgesic and hemodynamic stabilizing effects. A ketofol mixture provides greater quality sedation than does ketamine or propofol as sole agents at the same doses (14,15). Nevertheless, one study that compared ketofol and propofol indicated that hemodynamic and respiratory problems were significantly reduced in a ketofol group than in a propofol group, but both groups were similar regarding the need for intravenous fluid or vasopressor agent administration and oxygen support or assist ventilation (16).…”

Comparison of ketamine-propofol and remifentanil in terms of hemodynamic variables and patient satisfaction during monitored anaesthesia care

“…As the respiratory and hemodynamic effects of propofol and ketamine are antagonistic, combinations of these agents in low doses cause less dose-dependent adverse effects [9]. It has been shown that propofol and ketamine combinations in outpatient procedures are an effective and reliable method [9,10].…”

Alternative sedation regimens for upper gastrointestinal endoscopy proven to be safe. A retrospective comparative study

“…[22,23-25-28] It has been shown that the addition of ketamine to propofol allowed stable hemodynamics because of sympathomimetic effects of ketamine and reduced risk of hypoxemia even in pediatric patients with cardiac defects during procedural sedations. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]24] In a prospective randomized study by Nejati et al [25] , it was reported that hypotension and hypoxemia was not observed in two of 31 patients (6.45%) and apnea was observed in one of 31 patients (3.2%) during sedation for colonoscopy with a 1:1 mixture of ketamine and propofol. Tosun et al [12] found similar rate of hypoxemia (6.52%) and no hypotension with ketamine and propofol sedation in pediatric patients who underwent UGE.…”

“…[27] Even if combined with propofol, doses of ketamine >1 mg/kg were associated with 29% incidence of emergence reactions after procedural sedation. [25] The use 0.5 mg/kg of ketamine with or without propofol may eliminate emergence reactions. [28][29] We did not observe emergence reactions in any patient after the procedure because of low-dose ketamine combined with propofol.…”

“…[32] Previous studies have revealed that the use of larger initial bolus doses of propofol was associated with higher incidence of hypotension. [22][23][24][25][26][27][28][29][30] Hsieh et al [21] reported hypotension incidence as 23% for an initial bolus of 1 mg/kg propofol, which was then titrated in 10-20 mg increments plus 25 mg of meperidine (dose of propofol, 129.80±37.93 mg). In contrast, Sáenz-López et al [30] reported no hypotension for an initial bolus of 20 mg of propofol, followed by boluses of 10 mg every 30 s plus 25-50 mg of meperidine (dose of propofol, 66.93 mg).…”