Authors: Ferguson I et al., Ann Emerg Med 2016 Jul 22;
A large high-quality randomized trial finds these regimens to be equivalent.
Investigators randomized 573 adults from three emergency departments (EDs) in Australia to receive ketofol (a 1:1 mixture of ketamine and propofol) or propofol prior to a painful procedure. The main outcome was occurrence of a respiratory adverse event requiring intervention.
The study drug was packaged as 20 mL of solution in a syringe; this contained either 100 mg ketamine + 100 mg propofol, or 200 mg propofol. Patients were treated with an initial dose of 0.05 mL/kg and additional as-needed doses of 0.025 mL/kg.
There was no difference in the main outcome between the ketofol and propofol groups (3% and 5%). Patient satisfaction was high in both groups. Severe emergence delirium was uncommon but slightly more likely to occur in the ketofol group (5% vs. 2%). Mild agitation was more common with propofol (12% with ketofol vs. 20% with propofol) but patient interference with the procedure was uncommon and similar in the two groups (2% and 4%, respectively). Transient hypotension was more common in the propofol group (1% with ketofol vs. 8% with propofol). Recovery was shorter with propofol, by a median of 9 minutes.
Propofol and ketofol are both good options for procedural sedation of adults. A prior meta-analysis (NEJM JW Emerg Med Feb 2016 and Am J Emerg Med 2016; 34:558) suggested that ketofol was safer. I think the totality of evidence technically points to ketofol as a better choice, but not enough to influence a change. Both options are appropriate and reasonable.