Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department

Abstract

OBJECTIVE: To evaluate the efficacy and safety of low-dose intravenous ketamine in addition to intravenous propofol for procedural sedation and analgesia in the emergency department (ED). DATA SOURCES: Articles were identified using PubMed (1949-February 2007), MEDLINE (1966-February 2007), EMBASE (1980-February 2007), BioMed Central (to February 2007), the Cochrane Library (to February 2007), International Pharmaceutical Abstracts, and Google Scholar (until February 2007). Reference citations from retrieved publications were also reviewed. Search terms included ketamine, propofol, ketamine-propofol, ketofol, combination, sedation, procedural sedation, conscious sedation, and emergency department. STUDY SELECTION AND DATA EXTRACTION: All articles on prospective procedural sedation that were published or translated into English and that compared combination ketamine-propofol with an appropriate comparator group were included. Clinically relevant safety endpoints included the frequency of significant hemodynamic and respiratory compromise warranting medical intervention, nausea, vomiting, and emergence reactions. Time until hospital discharge criteria were met and patient satisfaction scores were efficacy endpoints of interest. DATA SYNTHESIS: Of the 11 trials included in this review, most had small sample sizes and were conducted in non-ED settings. The ketamine-propofol combination demonstrated no additional efficacy over propofol in terms of time to discharge. Although fewer patients given the ketamine-propofol combination experienced significant hemodymamic and respiratory compromise, need for active interventions, including fluid or vasopressor administration, supplemental oxygen, or assisted ventilation did not differ between groups. Patients who received higher doses of adjuvant ketamine reported an increased incidence of nausea, vomiting, and emergence reactions following the procedure. Few studies reported patient satisfaction scores postprocedure, and effect of ketamine-propofol on time-to-discharge criteria met was inconclusive. CONCLUSIONS: At this time, insufficient clinical evidence exists to recommend the routine use of low-dose ketamine with propofol for procedural sedation in the ED setting.