The Article: Ferguson I et al. Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine – The POKER Study: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2016, 68 (5): 574-582.
The Idea: A 1:1 mixture of propofol and ketamine (Ketofol) would decrease adverse effects compared to when propofol is used alone for deep sedation in the emergency department.
– Randomized, double-blind trial of adult patient requiring deep sedation in the emergency department at three Australian hospitals.
– 591 Patients (>18 years) requiring deep sedation in the opinion of the treating physician were randomized to either ketofol or propofol.
– Exclusion criteria included pregnancy, allergy to ketamine, soy or egg, uncontrolled hypertension (BP >160/90), known increased intracranial pressure or severe systemic or CV disease.
-Primary Outcome was the occurrence of a respiratory event defined as:
– Hypoxia (SpO2 < 93%)
– Hypoventilation (<8 bpm)
– Apnea (No capnography trace for >15 sec)
– Aspiration (persistent hypoxia + infiltrate on CXR)
– Occurrence of a rescue intervention (increased O2, repositioning, BVM, intubation)
– Hypotension (SBP <90)
– Patient satisfaction
– The occurrence of respiratory events were similar in both groups (9% in propofol group vs. 7% in ketofol group).
– There was a statistically significant increase in hypotension seen in the propofol group.
– Both groups had similar satisfaction ratings.
This is a well done study that shows both ketofol and propofol result in similar rates of respiratory events. This is in line with previous studies comparing the two agents. The author’s contend that the hypotension seen in the propofol group was not clinically significant because it was self-limited and only a few patients required a fluid bolus. This is likely true in a young, otherwise healthy person, however, many patient’s requiring sedation do not fit that description. It is also important to remember that propofol has no analgesic effect. Therefore, if using only propofol remember to provide adequate analgesia.
Bottom line (reinforcing what we all already know), both ketofol and propofol are effective agents for deep sedation. Keep your specific patient and clinical scenario in mind when choosing a sedative.