Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis

Abstract

BACKGROUND: Drugs such as propofol and ketamine are used alone or in combination to provide sedation for medical procedures in children. The purpose of this systematic review was to compare the safety and effectiveness of propofol and ketamine to other drug regimens. METHODS: We searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Web of Science, and the grey literature (meta-Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar) for randomized controlled studies comparing intravenous propofol and ketamine to any other single or combination drug regimen administered to children undergoing diagnostic or therapeutic procedures. Meta-analyses were performed for primary (hemodynamic and respiratory adverse events) and secondary outcomes using RevMan 5.3. We assessed the risk of bias and the certainty (quality) evidence for all outcomes using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: Twenty-nine studies were included for analysis. Based on low-to-moderate quality evidence, we concluded that the use of propofol and ketamine may result in a slight-to-small reduction in the risk of hypotension, bradycardia, and apnea, and a slight increase in the risk of tachycardia, hypertension, and other respiratory adverse events, such as cough or laryngospasm. The ratio of propofol to ketamine and comparator drug regimen subgroups effects were important for desaturation and some secondary outcomes. CONCLUSIONS: The use of propofol and ketamine had a minimal effect on the incidence of adverse events and other secondary outcomes. Large-scale studies are required to more accurately estimate adverse event rates and the effects of propofol and ketamine on patient-important outcomes.

Ketofol: is it the best sedoanalgesic for pediatric procedures outside the operating room?

“…In conclusion, even with a few articles mentioned in this study, ketofol has a short pathway to become the best pediatric procedure sedative outside the operating room, with data from Hayes et al 1 being confirmed by other good-quality articles. This article is extremely well-written and clear and concludes that using propofol with ketamine is safe, since you have in your hands appropriate resuscitation tools and are prepared to conduct the side effects, albeit rare, when you need to do this.…”

“…To the Editor, It was with great interest that I read the article by Hayes JA et al 1 , entitled "Safety and efficacy of the combination of propofol and ketamine for procedural sedation/anesthesia in the pediatric population: a systematic review and meta-analysis" in the present issue of Anesthesia & Analgesia.…”

“…El Mourad et al 3 studied the effects of ketofol, propofol, and dexmedetomidine (DEX) for transesophageal echocardiography (TEE). The time onset and offset of sedation, duration of TEE procedure, and the need for rescue propofol were significantly less in the propofol and ketamine groups compared with the group using DEX.…”

“…Rayes et al 1 found that other combination of drugs (e.g., chloral hydrate and fentanyl), compared with ketofol (administered either together or in separate bolus), had no statistical difference in providing tachycardia (OR 1.27; 95%CI 0.89-1.8) but was safer in the bradycardia group, with a tendency of protection (OR 0.61, 95%CI 0.38-0.98). Light hypotension without the need for intervention was also more associated with ketofol (OR 0.52; 95%CI 0.37-0.73).…”

Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis

“…This may explained that propofol had effect on airway smooth muscle reflexes [ 31 ]. Previous researches in the pediatric did not demonstrate the relationship between side effects and propofol/ketamine [ 32 – 37 ]. Pain with intravenous administration is an adverse effect of propofol [ 38 – 41 ].…”