Combining propofol, a beloved agent for procedural sedation for its rapid onset, quick recovery times, and titratable levels of sedation with ketamine, the world’s safest agent for unmonitored anesthesia, has been shown in case series to be as safe and effective as expected.
This small, randomized trial is a direct comparison between ketofol and propofol, with the primary outcome measure being the proportion of patients experiencing an adverse respiratory event using the standardized Quebec Criteria. The authors are testing the hypothesis that use of ketofol will result in fewer adverse respiratory events, which they believe to be one of the weaknesses of propofol, and one of the strengths of ketamine.
With ~120 patients in each group, there is essentially no clinical or statistical difference between outcomes of the two groups. Clinicians provided transient assisted ventilation for three ketofol patients and one propofol patient – which is not statistically different. Secondary outcomes were similar, although a handful of ketofol patients experienced recovery agitation, some of which required treatment.
It seems odd to me that the authors would be testing the respiratory adverse events of ketofol – both ketamine and propofol are so profoundly safe, with already extremely low rates of assisted ventilation, and unplanned intubation rates of ~1 in 5,000 or more. Ketofol has been similarly already shown to be extremely safe in terms of respiratory events, primarily in retrospective case series. They’ve essentially set themselves up to test something that’s almost already conclusively expected to generate insignificant differences. What is more interesting to clinicians now, when considering agents for sedation, is the secondary effects – hypotension, hypersalivation, vomiting, myoclonus, agitation – and how that affects procedural success and time to disposition. Ketofol is a great combination – but its value seems to be in the mitigation of the non-airway adverse events.
“Ketamine-Propofol Combination (Ketofol) Versus Propofol Alone for Emergency Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial”
http://www.ncbi.nlm.nih.gov/pubmed/22401952