Tuesday, 16 August 2016

Propofol vs. Ketofol for deep procedural sedation in the ED; which is better?

Ketofol exploded on the scene with great enthusiasm over the past decade. But is all the hype worth it?

No.

Most anaesthetists are loath to combine fixed strength drugs in the same syringe. This is akin to combining salt and pepper in the same shaker. (Don’t think about it… I’ve already got the patent.)

Ketofol, a fixed mixture of ketamine and propofol, is theoretically meant to have the advantage of mitigating the side effects of either drug when used alone. So why not.

This Australian double blind randomized controlled trial went far to try to answer the question. They included adults requiring deep procedural sedation supervised by a FACEM.

The primary outcome looking for “respiratory events” was arguably a bit irrelevant. To be fair, researchers try to come up with a feasible question to study. Sometimes the primary outcome is a compromise. But fortunately, they did look at secondary outcomes that are more important.

Results? 573 patients were randomized to propofol or ketofol. 5% in the propofol group and 3% in the ketofol group met the primary outcome. So, no statistical difference.

More patients had self-limited hypotension with propofol. But recovery times were shorter by about 9 minutes.

However, there was a 5% incidence of “severe emergence delirium” in the ketofol group vs. 2% in those that got propofol. 1 in 20 seems concerning to me and probably enough for me to abandon ketofol. 

In the end, I wonder what we are trying to accomplish with ketofol. Either drug works fine when used alone. Procedural sedation is incredibly safe when properly administered. There are times when we should use propofol and times we should use ketamine.

So keep the salt out of the pepper shaker and use either drug alone.  



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