Advantages of Ketofol Over Ketamine

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Ketofol vs ketamine alone had the advantage of fewer unpleasant emergence reactions and less post-procedural vomiting.

Why does this matter?
Many like the combination of ketamine plus propofol, as it allows them to use less of each drug.  The propofol is sedating; ketamine is both sedating and an analgesic.  But the POKER study noted more hypotension when patients receive propofol.  And the combination was associated with increased adverse events in children.  Personally, I use ketofol when muscle relaxation is important, such as a hip reduction or difficult shoulder reduction.  Ketamine alone may result in increased muscle tone.  It also has the nasty effect of causing extreme dysphoria upon awakening occasionally.  Is this blunted with the addition of propofol?

Ketofol vs ketamine RCT
This was a RCT with 152 patients who received either ketamine 1mg/kg plus intralipid (to mimic propofol) or 0.5mg/kg ketamine + 0.5mg.kg propofol.  Use of intralipid to mimic propofol allowed for effective blinding.  The primary outcome was unpleasant recovery reaction: "confusion, anxiety, unpleasant dreams or hallucinations, agitation, and aggressiveness."  The power calculation was based on an incidence of recovery reaction in 20% of the ketamine arm.  Instead, they found the incidence of unpleasant recovery was present in 44.7% in the ketamine-only arm and 22.3% in the ketofol arm.  I am surprised by the high incidence of emergence reaction in both groups and wonder if the definition was a bit broad.  I can't recall a sedation with ketamine or propofol in which the patient didn't have "confusion" upon awakening, but I haven't considered this an unpleasant recovery reaction.  Either way, there was more of it in the ketamine-only group.  They also found less emesis in the group that received ketofol at 5%, vs 18% with ketamine-only.  Both provided adequate sedation and were otherwise safe.

Source
Adverse Events With Ketamine Versus Ketofol for Procedural Sedation on Adults: A Double-blind, Randomized Controlled Trial. Acad Emerg Med. 2017 Dec;24(12):1441-1449. doi: 10.1111/acem.13226. Epub 2017 Jul 14.

Peer reviewed by Thomas Davis, MD.  

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