Ketofol for Procedural Sedation? Pro and Con

Procedural sedation in pediatric dentistry: a narrative review

Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.

Inducción Anestésica: Propofol, Ketamina o Ketofol ¿Cuándo utilizarlos?

Introducción: La anestesia general se subdivide en diferentes etapas donde una de las más importantes es la etapa de la inducción anestésica y los fármacos que se utilizan en ella, siendo el Propofol y la Ketamina los más nombrados Objetivo: Realizar una revisión de las propiedades farmacocinéticas y farmacodinámicas de estos dos medicamentos, para la toma de decisiones sobre en qué situaciones debería usarse cada uno de ellos o de forma concomitante Materiales y métodos: Se realizaron 4 búsquedas separadas en la base de datos de PUBMED, obteniendo un total de 27 bibliografías utilizadas para la revisión. Resultados: El propofol es un agente hipnótico útil para procedimientos cortos, en pacientes estables hemodinámicamente. La ketamina tiene un perfil farmacodinámico ideal para pacientes con inestabilidad hemodinámica. El ketofol es una alternativa que logra adecuado sinergismo permitiendo mantener los beneficios de cada uno de estos medicamentos y disminuyendo la probabilidad de efectos adversos. Conclusión: Dependiendo de la cirugía que se vaya a realizar y de la estabilidad hemodinámica de cada paciente se puede preferir un medicamento sobre otro.

Sedative and analgesic effects of propofol–ketamine versus propofol–fentanyl for emergency department procedures

Background:

To manage and reduce painful procedures in the emergency wards, procedural sedation as well as analgesia can be used. Propofol combinations are the most common short-acting intravenous sedative drugs in the field of emergency medicine.

Objectives:

This research aimed to compare the effectiveness, safety, and complications of intravenous infusion of ketofol with fentofol in painful emergency procedures.

Methods:

This study was a randomized, double-blind clinical trial. Sampling was simple and used random assignment; 196 participants were randomly assigned to two groups of 98 patients each. In each group, injection was done with fentanyl–propofol or ketamine–propofol. For data gathering, pre-procedure, and procedure, modified Aldrete’s scoring checklist was used. In order to determine the levels of sedation, we used the Ramsay Sedation Scale. Data analysis was performed via SPSS Version 20 using statistical tests such as mean ± standard division, t-test, chi-square test, and analysis of variance.

Results:

Among the participants in this study, shoulder procedure was performed more than other procedures (56.6%). The mean of recovery time was significantly different in the two groups (ketofol: 5.65 ± 0.35 vs fentofol: 9.33 ± 0.78); the recovery time in group B (fentofol) was longer than that in group A (ketofol) (p = 0.001). Drug complications were statistically significant in the two groups, and complications by ketofol were less than those by fentofol (p = 0.001). “Hypotension and bradycardia” were observed with fentofol and “tachycardia” was observed with ketofol. The performance of these two drugs was not the same when subject to various procedures.

Conclusion:

Results of this study revealed that ketofol provided better analgesia and sedation, faster recovery time, lesser complications and adverse events, and reduced bradycardia and hypotension.

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

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.

Ketamine-propofol (Ketofol) for procedural sedation and analgesia in children: a systematic review and meta-analysis

Objectives

The aim of this review is to elucidate the efficacy and side effects of ketofol in comparison to other anaesthetic agents during procedural sedation and analgesia.

Method

The Cochrane Central Register of Controlled Trials (1996 to Feb 2019) and MEDLINE (1966 to Feb 2019) were searched, including the related randomised control trials and reviewed articles to find unpublished trials or trials not obtained via electronic searches. Inclusion criteria for the studies included comparing recovery time, recording clinician satisfaction, and assessing the adverse effects of ketofol.

Results

Eleven trials consisting of a total of 1274 patients met our criteria and were included in this meta-analysis. Five trials compared ketofol with a single agent, while six trials compared ketofol with combined agents. While comparing between ketofol and a single agent (either ketamine or propofol), ketofol showed significant effect on recovery time (MD: -9.88, 95% CI: − 14.30 to − 5.46; P = 0.0003; I² = 92%). However, no significant difference was observed while comparing ketofol with combined agents (RR: 0.75, 95% CI: − 6.24 to 7.74; P < 0.001; I² = 98%). During single-agent comparison, ketofol showed no significant differences in terms of clinician satisfaction (RR: 2.86, 95% CI: 0.64 to 12.69; P = 0.001; I² = 90%), airway obstruction (RR: 0.72, 95% CI: 0.35 to 11.48; P = 0.81; I² = 0%), apnoea (RR: 0.9, 95% CI: 0.33 to 2.44; P = 0.88; I² = 0%), desaturation (RR: 1.11, 95% CI: 0.64 to 1.94; P = 0.28; I² = 21%), nausea (RR: 0.52, 95% CI: 0.91 to 1.41; P = 0.2; I² = 38%), and vomiting (RR: 0.63, 95% CI: 0.25 to 1.61; P = 0.18; I² = 42%). During comparison with combined agents, ketofol was more effective in reducing hypotension (RR: 4.2, 95% CI: 0.2 to 0.85; P = 0.76; I² = 0%), but no differences were observed in terms of bradycardia (RR: 0.70, 95% CI: 0.14 to 03.63; P = 0.09; I² = 53%), desaturation (RR: 1.9, 95% CI: 0.15 to 23.6; P = 0.11; I² = 61%), and respiratory depression (RR: 1.98, 95% CI: 0.18 to 21.94; P = 0.12; I² = 59%).

Conclusion

There is low certainty of evidence that ketofol improves recovery time and moderate certainty of evidence that it reduces the frequency of hypotension. There was no significant difference in terms of other adverse effects when compared to other either single or combined agents.

Trial registration

PROSPERO CRD42019127278.

Effects of ketamine in electroconvulsive therapy for major depressive disorder: meta-analysis of randomised controlled trials

Background

The use of ketamine in electroconvulsive therapy (ECT) has been examined in the treatment of major depressive disorder (MDD); however, there has been no systematic review and meta-analysis of related randomised controlled trials (RCTs).

Aim

To examine the efficacy and safety of ketamine augmentation of ECT in MDD treatment.

Methods

Two reviewers searched Chinese (China National Knowledge Infrastructure and Wanfang) and English (PubMed, PsycINFO, Embase and Cochrane Library) databases from their inception to 23 July 2019. The included studies' bias risk was evaluated using the Cochrane risk of bias assessment tool. The primary outcome of this meta-analysis was improved depressive symptoms at day 1 after a single ECT treatment session. Data were pooled to calculate the standardised mean difference and risk ratio with their 95% CIs using RevMan V.5.3. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess the whole quality of evidence.

Results

Four RCTs (n = 239) compared ketamine alone or ketamine plus propofol (n = 149) versus propofol alone (n = 90) in patients with MDD who underwent a single ECT session. Three RCTs were considered as unclear risk with respect to random sequence generation using the Cochrane risk of bias. Compared with propofol alone, ketamine alone and the combination of ketamine and propofol had greater efficacy in the treatment of depressive symptoms at days 1, 3 and 7 after a single ECT session. Moreover, compared with propofol alone, ketamine alone and the combination of ketamine and propofol were significantly associated with increased seizure duration and seizure energy index. Compared with propofol, ketamine alone was significantly associated with increased opening-eye time. Based on the GRADE approach, the evidence level of primary and secondary outcomes ranged from very low (26.7%, 4/15) to ‘low’ (73.3%, 11/15).

Conclusion

Compared with propofol, there were very low or low evidence levels showing that ketamine alone and the combination of ketamine and propofol appeared to rapidly improve depressive symptoms of patients with MDD undergoing a single ECT session. There is a need for high-quality RCTs.

Procedural Sedation Using a Propofol-Ketamine Combination (Ketofol) vs. Propofol Alone in the Loop Electrosurgical Excision Procedure (LEEP): A Randomized Controlled Trial

Background: Although the loop electrosurgical excision procedure (LEEP) is a brief procedure, it can cause severe pain and discomfort to patients in the absence of adequate sedation. An admixture of ketamine with propofol (ketofol), may reduce patient movement due to insufficient sedation while providing hemodynamic and respiratory stability. This study evaluated the ability of two ratios of a propofol–ketamine combination, compared with propofol alone, to reduce patient movement during procedural sedation for LEEPs. Methods: One hundred and twenty women scheduled for a LEEP were randomly assigned to three groups. Anesthesia was induced with 1 mg/kg propofol (group P), 1 mg/kg propofol and 0.33 mg/kg ketamine (group K1), or 1 mg/kg propofol and 0.66 mg/kg ketamine (group K2). The primary outcome was the incidence of adduction motion in the lower extremities during the procedure. The requirements for respiratory interventions, changes in vital signs, sedation score, additional anesthetic usage, and surgeon and patient satisfaction were also evaluated. Results: The incidence of adduction motion was significantly lower in groups K1 and K2 than in group P (overall p-value <0.001) but did not differ significantly in groups K1 and K2. Group K2 needed more jaw thrust maneuvers than group K1. Additional propofol usage was lower and surgeon satisfaction scores higher in groups K1 and K2 than in group P. Conclusion: A propofol–ketamine combination is more effective than propofol alone in reducing procedural interference during LEEPs. However, increasing the dose of ketamine showed no additional benefit.

Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

IMPORTANCE

Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.

OBJECTIVE

To examine the incidence and risk factors associated with sedation-related SAEs.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.

EXPOSURES

The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type.

MAIN OUTCOMES AND MEASURES

Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting.

RESULTS

Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions.

CONCLUSIONS AND RELEVANCE

The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.

Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium

OBJECTIVE

Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events.

DESIGN

Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium.

SETTING

Sedation services from academic, community, free-standing children's hospitals and pediatric wards within general hospitals.

PATIENTS

Children from birth to 21 years old or younger.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92-7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60-1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm.

CONCLUSIONS

This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.

Ketamine use in current clinical practice

After nearly half a century on the market, ketamine still occupies a unique corner in the medical armamentarium of anesthesiologists or clinicians treating pain. Over the last two decades, much research has been conducted highlighting the drug's mechanisms of action, specifically those of its enantiomers. Nowadays, ketamine is also being utilized for pediatric pain control in emergency department, with its anti-hyperalgesic and anti-inflammatory effects being revealed in acute and chronic pain management. Recently, new insights have been gained on ketamine's potential anti-depressive and antisuicidal effects. This article provides an overview of the drug's pharmacokinetics and pharmacodynamics while also discussing the potential benefits and risks of ketamine administration in various clinical settings.

Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis

OBJECTIVE AND DESIGN

We conducted a systematic review and meta-analysis to evaluate the incidence of adverse events in the emergency department (ED) during procedural sedation in the paediatric population. Randomised controlled trials and observational studies from the past 10 years were included. We adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

SETTING

ED.

PARTICIPANTS

Children.

INTERVENTIONS

Procedural sedation.

OUTCOMES

Adverse events like vomiting, agitation, hypoxia and apnoea. Meta-analysis was performed with random-effects model and reported as incidence rates with 95% CIs.

RESULTS

A total of 1177 studies were retrieved for screening and 258 were selected for full-text review. 41 studies reporting on 13 883 procedural sedations in 13 876 children (≤18 years) were included. The most common adverse events (all reported per 1000 sedations) were: vomiting 55.5 (CI 45.2 to 65.8), agitation 17.9 (CI 12.2 to 23.7), hypoxia 14.8 (CI 10.2 to 19.3) and apnoea 7.1 (CI 3.2 to 11.0). The need to intervene with either bag valve mask, oral airway or positive pressure ventilation occurred in 5.0 per 1000 sedations (CI 2.3 to 7.6). The incidences of severe respiratory events were: 34 cases of laryngospasm among 8687 sedations (2.9 per 1000 sedations, CI 1.1 to 4.7; absolute rate 3.9 per 1000 sedations), 4 intubations among 9136 sedations and 0 cases of aspiration among 3326 sedations. 33 of the 34 cases of laryngospasm occurred in patients who received ketamine.

CONCLUSIONS

Serious adverse respiratory events are very rare in paediatric procedural sedation in the ED. Emesis and agitation are the most frequent adverse events. Hypoxia, a late indicator of respiratory depression, occurs in 1.5% of sedations. Laryngospasm, though rare, happens most frequently with ketamine. The results of this study provide quantitative risk estimates to facilitate shared decision-making, risk communication, informed consent and resource allocation in children undergoing procedural sedation in the ED.

What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews

BACKGROUND

Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings.

METHODS

We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED.

RESULTS

Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention).

CONCLUSIONS

This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.

The Comparison of Infusion of Two Different Sedation Regimens with Propofol and Ketamine Combination During Plastic and Reconstructive Surgery

OBJECTIVE

Anesthetic agents are often combined to enhance their therapeutic effects while minimizing adverse events. The aim of this study was to evaluate the effects of two different sedation regimens of ketamine and propofol combination via infusion on perioperative variables in patients who underwent plastic and reconstructive surgery.

METHODS

This randomized double-blind clinical trial was done on 80 patients who were randomized to two groups; group 1 (n = 40) received a 2:1 mixture of 9 mg/ml propofol and 4.5 mg/ml ketamine, and group 2 (n = 40) received a 4:1 mixture of 9 mg/ml propofol and 2.25 mg/ml ketamine. After premedication and before local anesthetic injection, the infusion of mixtures was adjusted to attain the Ramsay sedation scores of 5 in both groups. We recorded induction time, sedation efficacy, cardiovascular and respiratory events, recovery time, and incidence of adverse events during and after the procedure.

RESULTS

The mean of volume infusion of mixtures in the beginning of the procedure was higher in group 2 (3.2 ± 1. 2 ml) than in group 1 (2.4 ± 0.8 ml) (p < 0.001). The induction time for sedation was 2.8 ± 0.8 min and 2.6 ± 0.4 min in group 1 and group 2, respectively (p = 0. 92). The number of oversedated patients was greater in group 2 compared to group 1 but not statistically significant (p = 0. 80). The sedation efficacy was similar between the two groups. The hemodynamic changes during the procedure were greater in group 2 compared to group 1 (p = 0. 001). The recovery time was not significantly different between the two groups (p = 0.43). The mean pain score in the recovery room was lower in group 1 than group 2 (1.2 ± 0.8 vs 2.8 ± 1.8, p = 0. 01). Moreover, 4 (10 %) patients in group 1 and 10 (25 %) patients in group 2 needed opioid administration (p = 0. 02). Other postoperative adverse events were similar between the two groups.

CONCLUSION

We recommend the use of a 2:1 combination of propofol-ketamine, because it reduced the rescue propofol requirement and consequently produced lower cardiovascular and respiratory depression effects and also less postoperative pain.

Managing moderate and severe pain in mountain rescue

AIMS

We aimed to describe evidence-based options for prehospital analgesia, and to offer practical advice to physicians and nonphysicians working in mountain rescue.

METHODS

A literature search was performed; the results and recommendations were discussed among the authors. Four authors considered a scenario. The final article was discussed and approved by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) in October 2013.

RESULTS AND RECOMMENDATIONS

Many health care providers fail to recognize, assess, and treat pain adequately. Assessment scales and treatment protocols should be implemented in mountain rescue services to encourage better management of pain. Specific training in assessing and managing pain is essential for all mountain rescuers. Persons administrating analgesics should receive appropriate detailed training. There is no ideal analgesic that will accomplish all that is expected in every situation. A range of drugs and delivery methods will be needed. Thus, an 'analgesic module' reflecting its users and the environment should be developed. The number of drugs carried should be reduced to a minimum by careful selection and, where possible, utilizing drugs with multiple delivery options. A strong opioid is recommended as the core drug for managing moderate or severe pain; a multimodal approach may provide additional benefits.

An update on pediatric hospital-based sedation

PURPOSE OF REVIEW

The need for sedation for procedures performed outside the operating room has increased dramatically, and pediatric procedural sedation (PPS) is increasingly performed by practitioners who are not anesthesiologists. With 'sedationists' emerging from various specialties, there are differences in practice and guidelines with regards to presedation assessment, targeted depths of sedation, monitoring requirements, and the training required. Our aim is to identify some of the recent advances in PPS and to describe progress towards greater standardization of practice.

RECENT FINDINGS

Several studies report attempts to optimize the efficacy of specific pharmaceuticals used in PPS. Ketamine, a dissociative agent, functions uniquely and requires its own sedation practice guidelines. Utilizing less invasive administration of sedation via transmucosal and inhaled routes is gaining popularity. Additionally, replacing subjective measurement of depths of the sedation continuum and the nonstandardized definitions of adverse events with alternatives based on physiological parameters and/or required rescue interventions is underway. Finally, the use of presedation family-centered counseling and adjuncts that provide visual and auditory distraction are enhancing pharmaceutical methods.

SUMMARY

Further multispecialty collaboration and formation of greater consensus with regards to sedation practice are essential to the development of universal guidelines that optimize patient care.

Evaluation of a ketamine-propofol drug combination with or without dexmedetomidine for intravenous anesthesia in cats undergoing ovariectomy

OBJECTIVE

To evaluate the use of a ketamine-propofol combination, with or without dexmedetomidine, in cats undergoing ovariectomy and to assess Heinz body formation following administration of these drugs.

DESIGN

Randomized clinical trial.

ANIMALS

15 client-owned female cats.

PROCEDURES

Anesthesia was induced with a ketamine (2.0 mg/kg [0.91 mg/lb])-propofol (2.0 mg/kg) combination with (n = 7) or without (8) dexmedetomidine (0.003 mg/kg [0.0013 mg/lb]) and was maintained via continuous IV infusion of a 1:1 ketamine-propofol combination (administration rate for each drug, 10.0 mg/kg/h [4.54 mg/lb/h]). Cats underwent ovariectomy; duration of infusion was 25 minutes. Physiologic variables were measured at predetermined time points. Heinz bodies were quantified via examination of blood smears. Numeric scales were used to assess quality of recovery, degree of sedation, and signs of pain after surgery.

RESULTS

The ketamine-propofol group had a significantly higher mean heart rate at several time points during drug infusion, a significantly shorter time from the end of infusion to extubation (7 vs 29 minutes), and significantly lower sedation scores for the first hour after surgery than did the ketamine-propofol-dexmedetomidine group. Other variables were similar between groups; recovery was smooth, and anesthesia and postoperative analgesia were deemed adequate for all cats. The number of RBCs with Heinz bodies was not increased after surgery, compared with values immediately after anesthetic induction.

CONCLUSIONS AND CLINICAL RELEVANCE

Total IV anesthesia with a ketamine-propofol combination, with or without dexmedetomidine, appeared to be effective in healthy cats. These short-term infusions produced smooth recovery and adequate analgesia during the postoperative period.

Ketamine: use in anesthesia

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

Sedation and analgesia for the pediatric trauma patients

The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Comparison of effects of propofol and ketamine-propofol mixture (ketofol) on laryngeal mask airway insertion conditions and hemodynamics in elderly patients: a randomized, prospective, double-blind trial

PURPOSE

The objective of this study was to compare the effects of ketamine-propofol mixture (ketofol) and propofol on ProSeal laryngeal mask airway (PLMA) insertion conditions and hemodynamics in elderly patients.

METHODS

Eighty elderly patients, American Society of Anesthesiologists (ASA) physical status I and II, were randomly divided into two groups to receive either propofol 0.15 ml/kg (n = 40), or ketofol (using a 1:1 single-syringe mixture of 5 mg/ml ketamine and 5 mg/ml propofol) (n = 40) before induction of anesthesia. Sixty seconds after induction, the PLMA was inserted. Heart rate and arterial blood pressure (systolic [S] BP) were recorded prior to the induction of anesthesia, immediately following induction, immediately after PLMA insertion, and 5 and 10 min after PLMA insertion. PLMA insertion conditions were scored according to mouth opening, swallowing, coughing, head and body motion, laryngospasm, and ease of PLMA insertion by the same experienced anesthesiologist, who did not know which agents were used.

RESULTS

There were no differences in PLMA insertion conditions between the groups. The number of patients in need of ephedrine (P = 0.043) and the total dose of ephedrine (P = 0.022) were significantly lower, and apnea duration (P < 0.001) was significantly higher in the ketofol group compared with the propofol group. SBP was significantly higher in the ketofol group than in the propofol group immediately after PLMA insertion and 5 min after PLMA insertion.

CONCLUSIONS

The same PLMA insertion conditions were found with ketofol and propofol. The number of patients in need of ephedrine and the total ephedrine dose were lower and apnea duration was increased in the ketofol group.

Ketofol in electroconvulsive therapy anesthesia: two stones for one bird

PURPOSE

Propofol and ketamine have become progressively popular in electroconvulsive therapy (ECT) anesthesia, although propofol shortened seizure duration and ketamine might cause cardiotoxicity, psychotic episodes, and delayed recovery. Ketofol is a combination of ketamine and propofol, and the current study was designed to evaluate the effect of ketamine, propofol, and ketofol on hemodynamic profile, duration of seizure activity, and recovery times in patients undergoing ECT.

METHODS

Ninety patients (44 women, mean age 27.8 ± 7.2 years) in one ECT session were enrolled and randomized to the propofol, ketamine, or ketofol group. Hemodynamic profile duration of seizure activity and recovery times were recorded.

RESULTS

Motor seizure duration in the propofol group was significantly decreased compared to other groups (p < 0.001), whereas spontaneous breathing time in the ketamine group statistically increased compared to the propofol group (p = 0.001), and also eye-opening time (p < 0.001) and obeying-command time (p < 0.001) was significantly increased in the ketamine group compared to other groups. Heart rate (HR) at induction (ketamine 91.2 ± 13.6 vs. propofol 77 ± 13.4 and ketofol 79.9 ± 15.6; p < 0.013; p < 0.08, respectively) was statistically significantly increased in the ketamine group compared to other groups, and HR at the third minute (ketamine 92 ± 12.9 vs. propofol 79.4 ± 9.3 and ketofol 81.5 ± 14.2; p < 0.012, p < 0.048) was also statistically significantly increased in ketamine group compared to other groups.

CONCLUSION

The ketofol 1:1 mixture is associated with longer mean seizure time than propofol, and shorter mean recovery times than ketamine, with better hemodynamic stability, without any important side effects in ECT anesthesia.

Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial

STUDY OBJECTIVE

We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone.

METHODS

Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events.

RESULTS

A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval -9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents.

CONCLUSION

Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.

Pharmacokinetics of ketamine and propofol combination administered as ketofol via continuous infusion in cats

The pharmacokinetics of the extemporaneous combination of low doses of ketamine and propofol, known as 'ketofol', frequently used for emergency procedures in humans to achieve safe sedation and analgesia was studied in cats. The study was performed to assess propofol, ketamine and norketamine kinetics in six female cats that received ketamine and propofol (1:1 ratio) as a loading dose (2 mg/kg each, IV) followed by a continuous infusion (10 mg/kg/h each, IV, 25 min of length). Blood samples were collected during the infusion period and up to 24 h afterwards. Drug quantification was achieved by HPLC analysis using UV-visible detection for ketamine and fluorimetric detection for propofol. The pharmacokinetic parameters were deduced by a two-compartment bolus plus infusion model for propofol and ketamine and a monocompartmental model for norketamine. Additional data were derived by a noncompartmental analysis. Propofol and ketamine were quantifiable in most animals until 24 and 8 h after the end of infusion, respectively. Propofol showed a long elimination half-life (t(1/2λ2) 7.55 ± 9.86 h), whereas ketamine was characterized by shorter half-life (t(1/2λ2) 4 ± 3.4 h) owing to its rapid biotransformation into norketamine. The clinical significance of propofol's long elimination half-life and low clearance is negligible when the drug is administered as short-term and low-dosage infusion. The concurrent administration of ketamine and propofol in cats did not produce adverse effects although it was not possible to exclude interference in the metabolism.