Sedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis

doi:10.1016/j.ajem.2015.03.033

The American Journal of Emergency Medicine

Volume 33, Issue 6, June 2015, Pages 815-817

https://doi.org/10.1016/j.ajem.2015.03.033 Get rights and content

Abstract

Background

Literature to date has suggested advantages of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. However, there is a paucity of data regarding sedation with the combination of ketamine and propofol in pediatric emergency medicine.

Methods

A retrospective case series analysis of children who underwent sedation with the combination of ketamine and propofol in a pediatric emergency department was conducted. Study covariates were extracted from the emergency department medical records.

Results

Four hundred twenty-nine patients, 297 males and 132 females, with a median age of 6.8 years (interquartile range, 3.9-10.9 years), underwent sedation by pediatric emergency physicians. Serious adverse events during sedation (SAEDS) were recorded in 52 procedures (12.1%), which included 39 hypoxic events (9.1%), 12 apneic events (2.8%), and 1 laryngospasm (0.2%). All SAEDS were managed successfully, and no child underwent intubation because of an adverse reaction or required hospitalization. Multivariate logistic regression analysis did not reveal any association between age, weight, fasting time, analgesic medication provided before sedation, length of procedure, capnography use, dosages of medications, and the presence of SAEDS.

Conclusions

This is the largest reported series of sedation with the combination of ketamine and propofol in pediatric emergency medicine. Findings suggest that sedation with the combination of ketamine and propofol can be safely performed by a skilled emergency physician.

Introduction

Procedural sedation and analgesia (PSA) administered by pediatric emergency physicians for pain control and anxiolysis is well established [1], [2]. The combination of ketamine and propofol has gained popularity in recent years because the drugs are thought to complement one another [2], [3], [4], [5], [6], [7]. Theoretically, the antiemetic and anxiolytic properties of propofol can mitigate the vomiting and emergence reactions induced by ketamine, whereas the sympathomimetic effect of ketamine can mitigate the hypotension induced by propofol [3].

The 2014 American College of Emergency Physicians clinical policy on PSA regards the use of a ketamine and propofol combination as a level B recommendation, reflecting “moderate clinical certainty” [2]. However, there is a limited number of studies on the use of this combination in pediatric emergency medicine [2].

In the pediatric emergency department (ED) of Rambam Health Care Campus (RHCC) in Haifa, Israel, children are treated with PSA regularly [8]. According to ED protocol, if the child is older than 12 months, has an American Society of Anesthesiologists physical status classification of 2 or less, and has been fasting for 2 hours or more, she/he can be managed with deep sedation [9], [10]. Department protocol recommends using propofol and ketamine in separate doses, with ketamine given first to decrease the risk of injection site pain with propofol.

The objective of this study was to retrospectively evaluate the safety of sedation with the combination of ketamine and propofol in this pediatric ED.

Section snippets

Study design, data collection, and processing

A retrospective case series analysis of all patients who underwent sedation with the combination of ketamine and propofol between August 1, 2013, and July 31, 2014, was conducted. The medical records of the children were extracted by the principal investigator (E.S.) from the ED electronic medical records system (“Prometheus”, RHCC integrated computer system). This computerized system was developed by the hospital's department of information technology and is a mandatory working tool for

Data analysis

Data were analyzed using SPSS program, version 21 (SPSS, Chicago, IL). The normal distribution of the data was tested by Kolmogorov-Smirnov tests. As most of the quantitative parameters were not normally distributed, Mann-Whitney U tests were used for differences between groups. Otherwise, t tests were used. Fisher exact test was used for differences between categorical parameters. Univariate and multivariate logistic regression analyses were used for assessment of the relation between study

Demographic data and procedures characteristics

Four hundred twenty-nine children, 297 males and 132 females, with a median age of 6.8 years (range, 3.9-10.9 years), underwent sedation using the combination of ketamine and propofol. All 429 procedures were successfully completed. The procedure most commonly performed was fracture reduction of the forearm (38.7%), followed by repair of a large or multiple lacerations (33.1%). Types of procedures and procedure-related covariates are presented in Figure and Table 1.

Serious adverse events during sedation

Serious adverse events during

Discussion

This is the largest reported series of sedation with the combination of ketamine and propofol in pediatric emergency medicine. The combination of propofol and ketamine was used in a wide spectrum of emergency procedures (Figure), and although potentially serious airway complications occurred in 12.1% of the procedures, all the events were transient, quickly identified, and effectively managed by the emergency physicians. Our findings are consistent with previous studies that examined the safety

Conclusions

Our findings suggest that pediatric ED patients can be safely sedated with the combination of ketamine and propofol when sedation is performed by a skilled emergency physician.

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Ketamine, propofol, and ketofol use for pediatric sedation
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Citation Excerpt :
However, in this second meta-analysis, the incidence of respiratory adverse events was similar (approximately 12% vs 11.7%) in PROP-KET and KET groups [43]. In the present meta-analysis, we have observed the incidence of hypoxic desaturation events at a rate of 13% in the PROP-KET group and 12% in the KET group which is comparable to studies outside this meta-analysis as well [44]. There are some limitations of the present study.
To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication.
Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events.
15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (−3.5 beats per minute (BPM) [95% CI: −5.1, −1.9]) through midpoint (−7.2 BPM [95% CI: −12.1, −2.3]) and at end of sedation (−8.7 BPM [95% CI: −13.1, −4.4]). Decrease in HR after DEX administration at start was −11.6 BPM [95% CI: −16.0, −7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by −6.9 [95% CI: −10.4, −3.3] at start, −7.8 [95% CI: −11.4, −4.2] at middle, and by −6.6 [95% CI: −14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia.
DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.
Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update
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Despite the unique oxygenation considerations for pediatric patients, the frequency of hypoxia and apnea is the same or lower in children undergoing ED propofol sedation compared with adults. Hypoxia occurs in 1% to 9% of pediatric propofol sedations, with apnea reported in 1% to 6% of them.20,54,104,105 When such events occur in either adult or pediatric patients, most resolve without incident.
We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.
Emergency Physician–Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series
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The sedation recording tool was initiated to collect real-time procedural sedation data in pediatric emergency medicine and was developed by the information technology department to record directly into the electronic patient data management system of the hospital (Prometheus integrated computer system; Fort Lee, NJ) (11,15). This system is a mandatory tool for all clinical staff (11). The sedation recording tool records each phase of sedation care, from the preprocedural assessment to recovery and discharge.
Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.
The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI).
We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse.
Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6–20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79–104 min), 10.5 min (IQR, 9–12 min), 21 min (IQR, 20–30 min), 25 min (IQR, 23–30 min), and 108 min (IQR, 82–161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation.
The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician–administered sedation for PRI.
Propofol administration for procedural sedation in the ED
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To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios.
A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles.
Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk.
Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.
Determinar as principais indicações e examinar os eventos adversos mais comuns com uso do hipnótico propofol na maioria dos cenários clínicos pediátricos.
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^☆: Competing interest: All authors declare that they have no competing interests.

^☆☆: Funding sources: None declared.

^★: Conflict of interest: None declared.

^★★: Authors contribution information: E.S. conceived the idea for the study, extracted the data and carried out the initial analysis, drafted the manuscript, and reviewed the literature; C.G. abstracted the data and reviewed the literature; R.L. performed the statistical analysis and carried out the initial analysis; I.S. designed the study, abstracted and analyzed the data, drafted the manuscript, and reviewed the literature. I.S. has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Brief ReportSedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis☆,☆☆,★,★★

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study design, data collection, and processing

Data analysis

Demographic data and procedures characteristics

Serious adverse events during sedation

Discussion

Conclusions

Emerg Med Clin North Am

Ann Emerg Med

Ann Emerg Med

Clinical Policy: Procedural sedation and analgesia in the emergency department

Ann Emerg Med

Ketamine, propofol, and ketofol use for pediatric sedation

Pediatr Emerg Care

Brief Report
Sedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis☆,☆☆,★,★★