Use of ketofol for procedural sedation and analgesia in children with hematological diseases

Effects of propofol, ketamine-propofol mixture in pediatric dental patients undergoing intravenous sedation: a clinical study

This study aimed to evaluate the clinical effects, complications (peri- and postoperative), depth of sedation, recovery times, and changes in anxiety levels in paediatric dental patients receiving intravenous sedation with propofol and ketamine-propofol mixtures. This prospective clinical study included 69 healthy children (ASA 1) aged 3-7 years. The patients were assigned randomly to propofol group (n = 23), which received propofol; 1:3 ketofol group (n = 23), which received 1:3 ketofol; or 1:4 ketofol group (n = 23), which received 1:4 ketofol. The bispectral index (BIS) and Ramsay Sedation Scale (RSS) score were recorded at intervals of 5 min to measure the depth of sedation, and vital signs were evaluated. Peri- and postoperative complications and recovery times were recorded. Anxiety levels were also evaluated using the Facial Image Scale (FIS) and changes in saliva cortisol levels (SCLs) before and after the intravenous sedation procedure. The Kruskal‒Wallis test and Wilcoxon signed-rank test were used to determine pre- and posttreatment parameters. Dunn's test for post hoc analysis was used to determine the differences among groups. Children's pre- and posttreatment anxiety levels did not differ significantly according to FIS scores, and increases in SCLs were detected in 1:3 ketofol and 1:4 ketofol groups after dental treatment was completed. Compared with those in the other groups, the BIS values of the patients in 1:4 ketofol indicated a slightly lower depth of sedation. The recovery time of the patients in 1:3 ketofol was longer than that of patients in propofol and 1:4 ketofol. The incidence of postoperative complications (agitation, hypersalivation, nausea/vomiting, and diplopia) did not differ among the groups. Ketamine-propofol combinations provided effective sedation similar to that of propofol infusion without any serious complications during dental treatment performed under intravenous sedation. The ketofol infusion increased the anxiety level of paediatric dental patients to a greater extent than the propofol infusion.

Prospective observational study on the use of continuous intravenous ketamine and propofol infusion for prolonged sedation in critical care

INTRODUCTION

Analgesia and sedation are a priority in paediatric intensive care. The combination of ketamine and propofol is a possible option in patients requiring prolonged or difficult sedation and to reduce the use of benzodiazepines and opiates. The aim of this study was to assess the efficacy and safety of combination ketamine and propofol in continuous infusion for prolonged analgesia/sedation in the paediatric intensive care setting.

PATIENTS AND METHODS

Prospective, observational single-group cohort study in patients aged 1 month to 16 years admitted to the paediatric intensive care unit in 2016-2018 that received ketamine and propofol in continuous infusion for analgesia and sedation. We collected data on demographic and clinical characteristics, analgesia and sedation scores (MAPS, COMFORT-B and SOPHIA), haemodynamic parameters and adverse events.

RESULTS

The study included 32 patients. The maximum dose of ketamine was 1.5 mg/kg/h (interquartile range [IQR], 1-2 mg/kg/h) and the infusion duration was 5 days (IQR, 3-5 days). The maximum dose of propofol was 3.2 mg/kg/h (IQR, 2.5-3.6 mg/kg/h) and the infusion duration, 5 days (IQR, 3-5 days). Thirty (93.7%) patients had previously received midazolam and 29 (90.6%) fentanyl. Analgesia scores did not change after initiation of the ketamine and propofol infusion. There was a statistically significant increase in the COMFORT-B score, but the score remained in the adequate sedation range (12-17). There were small but statistically significant decreases in the mean arterial pressure (from 64 mmHg to 60 mmHg; P = .006) and the diastolic blood pressure (from 50.5 to 48 mmHg; P = .023) 1 h after the initiation of the ketamine and propofol infusion, but this difference was not observed 12 h later and did not require administration of vasoactive drugs. No other major adverse events were detected during the infusion.

CONCLUSIONS

The combination of ketamine and propofol in continuous infusion is a safe treatment in critically ill children that makes it possible to achieve an appropriate level of analgesia and sedation without relevant haemodynamic repercussions.

An Analytical Comparison Between Ketamine Alone and a Combination of Ketamine and Propofol (Ketofol) for Procedural Sedation and Analgesia From an Emergency Perspective: A Systematic Review and Meta-Analysis

Procedural sedation and analgesia (PSA) is a treatment approach involving treating patients with agents with dissociative, sedative, or analgesic properties to suppress their consciousness to variable levels. Ketamine and propofol have been used historically for PSA. Because they each have their demerits, it was postulated that combining both drugs (ketofol) would result in a mixture with additive properties and lessen or eliminate the demerits attributed to each drug. The primary objective of this systematic review and meta-analysis is to compare ketamine alone and a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia from an emergency perspective.

A systematic search was conducted on published studies from the databases of Scopus, ScienceDirect, PubMed, Google Scholar, APA PsycInfo, and the Cochrane Central Register of Controlled Trial (CENTRAL) until July 2022. The articles that were published on the online databases were authored between January 2007 and 2018. The selected papers were scanned and examined to check whether they met the eligibility criteria for the study.

The search produced six articles that were included in the systematic review and meta-analysis. All six articles that passed the eligibility criteria were viable for the analysis. All the trials focused on the effectiveness of ketofol versus ketamine for PSA from an emergency perspective.

Ketofol was found to be safe and more effective in comparison to ketamine for PTA.

Ketofol for Procedural Sedation and Analgesia in the Pediatric Population

ABSTRACT

The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol.

[Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments]

OBJECTIVES

To offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents.

METHODS

A multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016.

RESULTS

A total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95%CI: 72.7-79.4%), partial in 138 (21.7%; 95%CI: 18.5-24.9%), and poor in 14 (2.2%; 95%CI: 1.1-3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95%CI: 1.10-8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95%CI: 1.68-3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95%CI: 1.09-1.28 and OR: 1.86; 95%CI: 1.22-2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95%CI: 11.78-50.76). The perceived satisfaction level (0-10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70).

CONCLUSIONS

The sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.

Bone marrow aspirations in oncological patients: experience from an in-house standard in paediatrics

BACKGROUND

Nearly all paediatric patients require deep sedation when undergoing bone marrow aspiration (BMA). We analyzed the data from our protocols documented in a standardised procedure for bone marrow puncture over a period of 2 years.

METHODS

Our standard included the documentation of personal data as well as vital parameters. In addition, we documented all medications administered, potential complications and required intervention measures, as necessary.

RESULTS

A total of 107 protocols were available for the evaluation. Our standard covered the usage of midazolam and S‑ketamine and resulted in complications in just 9 patients, which could be remedied using simple measures. For both active substances, the dosage necessary to reach sufficient deep analgosedation was significantly higher for patients under 24 months of age.

CONCLUSIONS

Our standard for BMA provides a practical and feasible procedure. In addition to good examination conditions, our standard also helps ensure the safety of our patients.

The Effectiveness of Distraction as Procedural Pain Management Technique in Pediatric Oncology Patients: A Meta-analysis and Systematic Review

CONTEXT

Diagnostic tests and treatment regimens for pediatric cancers involve invasive and painful procedures. Effective management of such pain has been shown to be suboptimal in many parts of the world, often because of the cost and limited availability of appropriate medications. Current evidence suggests that distraction (a relatively low-cost technique) is a promising intervention for procedural pain management. There is, however, limited evidence demonstrating its effectiveness in pediatric oncology patients.

OBJECTIVES

A systematic review was conducted to ascertain the effectiveness of distraction as a procedural pain management technique in pediatric oncology patients.

METHODS

Using a comprehensive search strategy, MEDLINE, PsycINFO, Cochrane Library, AMED, CINAHL, Web of Science, and EMBASE electronic databases were searched for studies comparing distraction techniques to standard care/any intervention. Using the selected studies, a systematic review and meta-analysis of randomized controlled trials was conducted.

RESULTS

Two hundred ninety-nine studies were identified, with seven randomized control trials identified as eligible for inclusion. Pain was assessed using self-report, observer-report, and physiological measures. A meta-analysis of four studies showed distraction as effective in reducing procedural pain, based on self-reported pain. A meta-analysis of three studies, based on pulse rates, demonstrated similar results. For observer-reported pain, limited evidence supported the effectiveness of distraction.

CONCLUSION

This systematic review demonstrates that distraction is a promising intervention for procedural pain. Future research should assess effectiveness of distraction in varied populations, to explore evidence of cultural influences on pain expression, measurement, and management approaches.

Hemodynamic Responses to Two Different Anesthesia Regimens in Compromised Left Ventricular Function Patients Undergoing Coronary Artery Bypass Graft Surgery: Etomidate-Midazolam Versus Propofol-Ketamine

Background:

Various methods have been suggested to prevent hemodynamic instability caused by propofol and adverse effects caused by etomidate induction. The current study evaluated hemodynamic effects of propofol-ketamine mixture in comparison to etomidate-midazolam mixture during anesthesia induction.

Objectives:

The aim of this study was to evaluate the hemodynamic effects of etomidate-midazolam by comparing it with propofol-ketamine for the induction of anesthesia in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery.

Patients and Methods:

One-hundred patients aged between 40 and 65 with coronary artery disease and low ejection fraction scheduled for elective coronary artery bypass surgery participated in this study. The patients were randomly allotted to one of the two groups to receive either propofol-ketamine or etomidate-midazolam combination. Two groups were compared for pain on injection and myoclonus, Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Cardiac Index (CI) and Systemic Vascular Resistance (SVR), before and one minute after induction of anesthesia, and one, three and five minutes after intubation.

Results:

Incidence of pain on injection (2 - 4%) and myoclonus (10%) was less in both groups. The hemodynamic response was similar in the two groups for all variables over the time interval, except for CI at one and three minutes after intubation (P = 0.024 and P = 0.048, respectively), and SVR in five minutes after intubation (P = 0.009), with differences being statistically significant.

Conclusions:

Both anesthetic regimens were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction undergoing coronary artery bypass graft surgery.

[Ketamine-propofol sedation in circumcision]

BACKGROUND AND OBJECTIVE

to compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation.

METHODS

60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II.

RESULTS

in the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050).

CONCLUSION

propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.

Ketofol dosing simulations for procedural sedation

BACKGROUND

Propofol mixed with racemic ketamine (or "ketofol") is popular for short procedural sedation and analgesia, yet the optimal combination is unknown. We aimed to determine a ketofol dosing regimen for short procedural sedation and analgesia of 5- to 20-minute duration in healthy patients (2-20 y).

METHODS

Pharmacokinetic-pharmacodynamic parameters were used to simulate drug concentration and effect profiles over time for different ketamine-to-propofol ratios (1:1-1:10). The target effect was a Children's Hospital of Wisconsin Sedation Scale score of less than 2. Combined effects were additive, with a propofol EC50 of 1.54 μg/mL (concentration required to produce hypnosis in 50% of patients), a ketamine EC50 of 0.44 μg/mL, and a slope of 5.3. Emergence threshold concentrations for propofol were 2.0 μg/mL in children and 1.8 μg/mL in adults as well as 0.5 μg/mL for ketamine (children and adults). The EC50 for propofol antiemesis was 0.343 μg/mL.

RESULTS

A ketamine-to-propofol ratio of 1:3 was the best combination for intermittent dosing, achieving a rapid onset of a Children's Hospital of Wisconsin Sedation Scale score of less than 2 within 1 minute and a time to emergence of 9 to 19 minutes in all ages after a 10-minute sedation. The optimal ketofol dosing in children (2-11 y) was 0.1 mL/kg initially followed by 0.05 mL/kg at 2 minutes and then 0.025 mL/kg for the subsequent doses. The adults (12-20 y) received 0.05 mL/kg of ketofol initially followed by 0.025 mL/kg for the subsequent doses. These regimens maintain a propofol antiemesis for 30 to 40 minutes after the last dose.

CONCLUSIONS

We suggest an optimal ratio of racemic ketamine to propofol of 1:3 for boluses during short procedures (5-20 minutes). A short ketofol infusion, ratio 1:4, is a suitable alternative to intermittent boluses. Ratios greater than 1:3 result in delayed recovery after 20 minutes.

Ketamine-propofol sedation in circumcision

BACKGROUND AND OBJECTIVE

To compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation.

METHODS

60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II.

RESULTS

In the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050).

CONCLUSION

Propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.

Ketamine, propofol, and ketofol use for pediatric sedation

The use of a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia in the emergency department setting shows promise as an agent that may minimize adverse effects of ketamine or propofol as single agents. This article provides a summary of current literature regarding ketofol. It also reviews the comparative pharmacokinetics, adverse effects, and dosing of ketamine, propofol, and ketofol as agents for procedural sedation and analgesia.

The current status of procedural sedation for pediatric patients in out-of-operating room locations

PURPOSE OF REVIEW

To illustrate the changes that are occurring in the rapidly growing field of pediatric sedation. In the USA and throughout the world, children receive sedation from a multitude of specialists with varying levels of training. The current pediatric sedation literature reflects a growing body of sedation literature by medical specialists other than anesthesiologists. This article will review the controversial use of propofol by nonanesthesiologists and the manner in which this varied group of providers along with government entities, regulatory agencies, and national organizations contribute to the continuing evolution of sedation practices.

RECENT FINDINGS

The number of diagnostic and therapeutic procedures performed on children outside of the operating room continues to increase. The growing body of pediatric sedation literature suggests anesthesiologists are no longer at the forefront of pediatric sedation training, education, and research. Articles published by nonanesthesiologists describe pediatric sedation services, safety, and quality initiatives, drugs, and original sedation research. Medications that were considered under the realm of anesthesiologists are utilized by nonanesthesiologists to provide sedation to children. Regulating and government agencies, including the Joint Commission and the Center for Medicaid and Medicare Services have recently issued statements on the oversight and practice of sedation.

SUMMARY

The direction of pediatric sedation is no longer solely under the leadership of anesthesiologists. The use of anesthetic agents, including propofol, have been administered by nonanesthesiologists and reported as safe and effective agents. Nonanesthesiologists and governmental and regulatory agencies influence the delivery of sedation services. The future direction of pediatric sedation will ultimately depend upon the ability of anesthesiologists to collaborate with specialists, hospital administrators, credentialing committees, and oversight agencies in order to provide high-quality efficient sedation services to children.

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.

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.

Ketofol (Mixture of Ketamine and Propofol) Administration in Electroconvulsive Therapy

The aim of this study was to evaluate the effect of a ketamine:propofol combination (‘ketofol’) for electroconvulsive therapy on seizure activity, haemodynamic response and recovery parameters, and to compare with these with the effects of propofol alone. Twenty-four patients underwent a total of 144 electro-convulsive therapy sessions, allocated in this prospective, double-blind, crossover study. Patients were randomly assigned to receive 1 mg/kg ketofol (0.5 mg/kg propofol plus 0.5 mg/kg ketamine) or 1 mg/kg propofol 1% for anaesthesia induction. Seizure duration and quality, haemodynamic data, recovery parameters and side-effects were recorded and analysed between groups. Both motor and electroencephalography seizure durations in the ketofol group (29±17 and 41±17 seconds, respectively) were similar to that in the propofol group (28±13 and 38±16 seconds, respectively). Postictal suppression index was higher in the ketofol group (89.63±7.88) than in the propofol group (79.74±14.6) (P P <0.05). There were no untoward psychological reactions following ketofol. Although no superiority to propofol in terms of seizure duration, haemodynamic or recovery parameters was found, the ketofol mixture selected in our study provided better seizure quality than propofol. We conclude that ketofol can be an alternative strategy to enhance the seizure quality and clinical efficiency of electroconvulsive therapy.