Morning Report: 8/27/2013

Dr. Kong presents today’s Morning Report!

Ketofol

What is it?

A mixture of Ketamine and Propofol used for sedation

Why is it better than Ketamine or Propofol alone?

1. In theory, use of medications together produce rapid (Propofol), consistent (Ketamine) sedation with maintenance of blood pressure (Ketamine), less emesis (Propofol), and rapid termination (Propofol) of effect.

2. Characteristics of Ketamine:

– Phencyclidine derivative (PCP)

– Dissociative Sedative, Amnestic, analgesic

– Sympathomimetic, Vagolytic (Support BP)

– Preserve Airway Reflexes

– Onset: 30 sec, peak: 1-2min, duration 5-10min

– Emetogenic,Hypersalivation, Lyngospasm, Incs IOP, emergence

– Can be used IM

– Prolonged post procedure obs period (30-120min)

– Dose 1-2 mg/kg

3. Characteristics of Propofol:

– Lipophilic GABA potentiator (binds to GABAa receptor)

– Sedative – no amnesia or analgesia

– Rapid onset (10-15s) and peak (2min), short duration (2-5min)

– Short post procedure obs period (10-15min)

– antiemetic

– causes hypotension

– Dose 1-2 mg/kg

How do you mix it?

Most studies have looked at a 1mg:1mg ratio

In KCHC, Propofol comes 10mg/ml and Ketamine comes 50mg/ml.

To mix:

1. Draw up 10ml of Propofol (10ml of 10mg/ml = 100mg)

2. Get 10ml saline flush. Squirt out 2ml.

3. With the same flush, draw up 2ml Ketamine (2ml of 50mg/ml = 100mg)

–> this is now diluted to same concentration as Propofol (100mg/ 10ml = 10mg/ml)

4. Mix in 20-30ml Syringe

5. Every 1ml has 10mg ketofol

How do you dose it?

Dose: 0.5 -1mg/kg

Start with 0.3mg- 0.5mg/ kg

Give more as needed, to max dose

Are there alternative dosing methods?

Alternative mixture ratios

Dosing Ketamine and Propofol separately (e.g., starting with low dose ketamine and giving small propofol pushes)

Evidence?

These studies suggest dosing strategies, but do not reveal superiority of Ketafol to either Ketamine or Propofol.

Shah et al: Ketamines vs Ketofol

Blinded, randomized 136 peds pt (2-17) for Ortho procedure

1mg/kg ketofol vs 1mg/kg ketamine

Primary Outcome: sedation time. Secondary outcomes: time to recovery, AE, sedation efficacy, repeat dose, satisfaction

Bottom line: Ketofol has marginally better sedation and recovery times, but less vomiting compared to Ketamine. Provider/ parent satisfaction slightly better for ketofol

Andolfatto et al. Propofol vs Ketofol

Blinded randomized 284 pts >14yrs old

0.75mg/kg propofol vs 0.75 mg/kg ketofol

Primary outcome Adverse resp events (desat, central apnea, airway obstruct, spasm, aspiration), 2nd: sedation consistentcy, total dosage, sedation efficacy, induction procedure sedation and recovery times AE.

Bottom line: Sedation depth appeared to be better in ketofol. No diff in respiratory adverse reactions, induction time, efficacy or sedation time.

Resources:

1. Andolfatto et al. Ketamine-Propfol Combination (Ketofol) Versus Propofol Alone for Emergency Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial. Annals of Emergency Medicine. Volume 59, No. 6 June 2012.

2. Shah et al. A Blinded Randomized Controlled Trial to Evaluate Ketamine/Propofol Versus Ketamine Alone for Procedural Sedation in Children. Annals of Emergency Medicine. Vol 57, No. 5 May 2011

3. Shy, et al. Independent Dosing of Propofol and Ketamine May Improve Procedural Sedation Compared With the Combination “Ketofol” Annals of Emergency Medicine, Vol 6 Issue 2, Feb 2013

4. EM:rap March 2013

http://www.pemed.org/blog/2012/6/1/sedation-and-ketofol.html