Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department

Abstract

Objectives: The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED).Methods: This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg ⁄ kg IV followed by 0.5 mg ⁄ kg every 3 minutes as needed or ketamine 1.0 mg ⁄ kg IV followed by 0.5 mg ⁄ kg every 3 minutes as needed. Doses, vital signs, nasal end-tidal CO 2 (ETCO 2 ), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO 2 of >10 mm Hg, an oxygen saturation of <92% at any time, or an absent ETCO 2 waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation.Results: One-hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = )13.7%; 95% CI = )33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p < 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = )3.9%, 95% confidence interval [CI] = )11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = )7.6% to 17.1%). Forty-eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = )7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect siz...

Dexmedetomedine-Ketamine versus Propofol-Ketamine as anaesthetic agents in paediatric cardiac catheterization

“…However, because of its adverse psychological effects and the availability of other induction agents, its use diminished rapidly. Emergence reactions in children are less intense, so it can be used for both sedation and general anaesthesia in procedures such as cardiac catheterization (with caution in patients with raised pulmonary vascular resistance) 12 higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group 18 . There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups.…”

Ketamine use in current clinical practice

“…Accordingly, a retrospective case analysis suggested that sedation with the combination of ketamine and propofol can be safely performed in the pediatric ED by a skilled emergency physician [54] . The use of ketamine, 1.0 mg/kg iv followed by 0.5 mg/kg every 3 min as needed, was safe and effective for procedural sedation [55] . Additionally, propofol in conjunction with 0.5 mg/kg ketamine, compared with propofol alone, may result in less hemodynamic depression, which may be advantageous in patients with unstable hemodynamics in the ED [56] .…”

Randomized, Double-Blinded, Clinical Trial of Propofol, 1:1 Propofol/Ketamine, and 4:1 Propofol/Ketamine for Deep Procedural Sedation in the Emergency Department

“…Our primary outcome was the relative number and proportion of subjects experiencing airway or respiratory adverse events leading to an intervention, defined as the composite of 1 or more predefined airway or respiratory events and 1 or more associated predefined clinical interventions [5][6][7]36,37 (Figure 1). Research assistants continuously assessed for evidence of either one, recording monitoring values and asking treating physicians to clarify if there was any doubt.…”

“…[1][2][3][4][5][6][7] The dissociative agent ketamine maintains cardiopulmonary stability [8][9][10] but can result in extended recovery, emesis, hypersalivation, and hallucinations. 6,8,[10][11][12][13] The popular combination of propofol and ketamine ("ketofol") is purported to reduce respiratory depression, emesis, and recovery time by counteracting the negative effects of one drug with the positive effects of the other, 11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] although the best evidence thus far does not indicate a reduction in airway and respiratory adverse events relative to propofol alone. 16,32 Ketofol has been described in 1:1 and 4:1 propofol:ketamine mixtures 14,33 ; however, the optimal formulation is not known.…”