Written by Clay Smith
Ketamine + propofol (ketofol) in children was associated with reduced hypotension and bradycardia when compared with other single agents or combinations.
Why does this matter?
I’m not a big fan of propofol in children. It has no analgesic properties and often requires a large dose to deeply sedate them. It seems patients are pushed right to the edge of apnea (or over it). And then it’s time to redose. I’m never sure what I will get with a certain sedation dose in any given child (or adult). Hypotension is also common. On the other hand, I have only personally seen apnea with ketamine when it was rapidly pushed IV. Ketamine provides excellent pain relief and dissociation, and I know exactly what I’ll get with 1-2 mg/kg. But ketamine increases risk of nausea and delirium upon recovery. It often increases muscle tone, which is not ideal for some joint reductions or if you need to open the mouth. What about the safety and efficacy of ketofol in children?
Ketofol for kids!
This was a systematic review and meta-analysis of 29 RCTs on the use of ketofol in children for various painful and non-painful procedures in a variety of settings. Evidence quality was deemed low to moderate. The upside was that ketofol resulted in significantly less hypotension and bradycardia than other single agents or different drug combinations and had a nonsignificantly lower risk for apneic events. The downside is that those who received ketofol had increased risk for hypertension, tachycardia, and possibly cough or laryngospasm. However, all the downside outcomes were not statistically significantly greater. There was substantial heterogeneity in the dosage and ratio of ketofol used, but most gave more propofol than ketamine; 8 studies had a >3:1 ratio. Given this, the effect on reducing the risk of apnea may have been blunted.
Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis. Anesth Analg. 2021 Apr 1;132(4):979-992. doi: 10.1213/ANE.0000000000004967.