HWN Suggests

Ketofol: Is this the “Game Changer” of Procedural Sedation and Analgesia?

Based on the studies reviewed, it is difficult to say if ketofol is the Holy Grail. Overall, it appears that ketofol could have a slightly better time to sedation, and length of sedation, but this is not statistically significant based on available evidence. However, it does appear that ketofol does have a more steady sedation depth not requiring as many subsequent doses.

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 Use Separate Syringes for Ketofol

Ketofol became popular as a procedural sedation cocktail, a mix of ketamine and propofol in a single syringe. Its pharmacological appeal was that you could avoid high doses of either agent through synergistic effects. Dose titration can be tricky, however, sometimes resulting in complications. Instead, use separate syringes—one for ketamine and one for propofol. A common regimen is to give IV ketamine initially and only once at 1 mg/kg IV. Follow that with an IV propofol bolus at 0.5-1 mg/kg. If the patient requires more sedation, an additional IV propofol bolus can be given at 0.5 mg/kg.

Articles of Interest

A Prospective Case Series of Pediatric Procedural Sedation and Analgesia in Emergency Department Using Single-Syringe Ketamine-Propofol Combination

The above mentioned article describes a prospective case series evaluating the effectiveness, recovery time and adverse events associated with intravenous (IV) ketofol (mixed 1:1 ketamine-propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children.

Ketamine and Propofol (Ketofol) for Pediatric Sedation

Ketofol may be the best of both worlds. Yet, it is also not perfect.

Propofol vs. Ketofol in PSA (The POKER Study)

While anecdotally Ketofol has been thought to be a safer alternative than propofol in the use of procedural sedation and analgesia in the ED, the results of this large multi-center study does not support this claim.

Should We Still Be Using Ketofol?

Ultimately, I’m not convinced that we need to be using ketofol. It’s not as advantageous as we thought, makes for an extra medication that needs to be drawn up with little added benefit, especially when it is possible to utilize propofol monotherapy with good outcomes.

The POKER Trial: Go All in on Ketofol?

Ketamine and Propofol are two agents commonly used for this and each agent has its own theoretical advantages and disadvantages. Due to this, it has been hypothesized that the combination of the two agents may result in fewer adverse events because of each agent counteracting the disadvantages of the other. Despite this, to date, no RCTs have really shown a reduction in adverse events with the combination of propofol and ketamine.