Combinación de ketamina y propofol (Ketofol) para sedación y analgesia en procedimientos en el departamento de emergencias. Revisión
Combining ketamine and propofol ("ketofol") for emergency department procedural sedation and analgesia: a review. Arora S. West J Emerg Med. 2008 Jan;9(1):20-3. PDF
Comparación de ketamina-midazolam y ketofol para sedación en aspiración transbronquial guiada por ultrasonido. Estudio prospectivo, ciego y aleatorizado
A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study.
Dal T, Sazak H, Tunç M, Sahin S, Yılmaz A. J Thorac Dis. 2014 Jun;6(6):742-51. doi: 10.3978/j.issn.2072-1439.2014.04.10. Abstract OBJECTIVE: We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). METHODS: Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded. RESULTS: HR in the 10(th) min and RSS value in the 35(th) min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05). CONCLUSIONS:It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects. KEYWORDS:Transbronchial needle aspiration (TBNA); ketamine; midazolam; propofol; sedation PDF
Simulaciones Ketofol para dosificación en anestesia pediátrica.
Ketofol simulations for dosing in pediatric anesthesia. Coulter FL, Hannam JA, Anderson BJ. Paediatr Anaesth. 2014 Aug;24(8):806-12. doi: 10.1111/pan.12386. Epub 2014 Mar 26. Abstract BACKGROUND: Propofol mixed with racemic ketamine (or 'ketofol') is popular for short procedural sedation and analgesia. Use is creeping into anesthesia, yet neither the optimal combination nor infusion rate is known. The EC(50) of propofol's antiemetic effect is reported to be 0.343 mg*l(-1), while ketamine analgesia is thought to persist with concentrations above 0.2 mg*l(-1). We aimed to determine a ketofol dosing regimen for anesthesia 30-min and 1.5-h duration in a healthy child that did not unduly compromise recovery. METHODS: Pharmacokinetic-pharmacodynamic parameters were used to simulate drug concentration and effect profiles over time for different ratios of propofol to ketamine ratios (1 : 1 to 10 : 1) and rates. The target effect was the 95% probability of loss of response to a 5-s transcutaneous tetanus (P05). Combined effects were additive, with a propofol EC(50) of 3.1 mg*l(-1), ketamine EC(50) of 0.64 mg*l(-1), and slope of 5.4. The time to predicted 50% probability of return of this response after ceasing infusion (P(50)) was determined for a 5-year-old 20-kg healthy child. RESULTS: The addition of ketamine to propofol infused using a manual infusion regimen (loading dose 3 mg*kg(-1), then 15 mg*kg(-1) *h(-1) for 15 min, 13 mg*kg(-1) *h(-1) for 15 min, 11 mg*kg(-1) *h(-1) for 30 min, and 10 mg*kg(-1) *h(-1) for 1-2 h) caused prolonged postoperative sedation. The P(50) after a 1.5-h infusion using a 1 : 1 mixture was 4.5 h, 2 : 1 mixture was 3.25 h, 5 : 1 mixture was 1.6 h, and 10 : 1 mixture was 40 min. These P(50) estimates could be reduced by slowing administration infusion rates to 20%, 33%, 50%, 67%, 80%, and 90% for mixtures 1 : 1, 2 : 1, 3 : 1, 5 : 1, 6.7 : 1, and 10 : 1, respectively. These rates achieve a P(50) of approximately 20 min for 30-min duration anesthesia and 60 min for 1.5-h duration anesthesia. CONCLUSIONS: The addition of ketamine to propofol infusion will prolong recovery unless infusion rates are decreased. We suggest an optimal ratio of racemic ketamine to propofol of 1 : 5 for 30-min anesthesia and 1 : 6.7 for 90-min anesthesia. Delivery of these ratios achieves propofol concentrations above an antiemetic threshold for longer than the ketamine concentration above the analgesic threshold during, potentially reducing postoperative nausea incidence. KEYWORDS: anesthesia; ketamine; pediatric; pharmacodynamics; pharmacokinetics; propofol; sedation; target concentration PDF
Ketofol para la inducción del paciente grave versus etomidato (Ensayo KEEP PACE). Protocolo de estudio para un ensayo aleatorizado y controlado
Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial. Smischney NJ, Hoskote SS, Gallo de Moraes A, Racedo Africano CJ, Carrera PM, Tedja R, Pannu JK, Hassebroek EC, Reddy DR, Hinds RF,Thakur L. Trials. 2015 Apr 21;16(1):177. doi: 10.1186/s13063-015-0687-0. Abstract BACKGROUND: Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability. METHODS/DESIGN: A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients. DISCUSSION: The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population. PDF