Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children

Sheikh Sohail Ahmed; Mara Nitu; Shawn Hicks; Lauren Hedlund; James E. Slaven; Mark R. Rigby

doi:10.1055/s-0035-1568152

Journal of Pediatric Intensive Care, Table of Contents

J Pediatr Intensive Care 2016; 05(01): 001-006
DOI: 10.1055/s-0035-1568152

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children

Sheikh Sohail Ahmed

¹Department of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, United States

,

Mara Nitu

¹Department of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, United States

,

Shawn Hicks

¹Department of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, United States

,

Lauren Hedlund

¹Department of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, United States

,

James E. Slaven

²Department of Biostatistics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, United States

,

Mark R. Rigby

¹Department of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, United States

› Author Affiliations

Abstract

Objective Examine comparative dosing, efficacy, and safety of propofol alone or with an initial, subdissociative dose of ketamine approach for deep sedation.

Background Propofol is a sedative-hypnotic agent used increasingly in children for deep sedation. As a nonanalgesic agent, use in procedures (e.g., bone marrow biopsies/aspirations, renal biopsies) is debated. Our intensivist procedural sedation team sedates using one of two protocols: propofol-only (P-O) approach or age-adjusted dose of 0.25 or 0.5 mg/kg intravenous ketamine (K + P) prior to propofol. With either approach, an initial induction dose of 1 mg/kg propofol is recommended and then intermittent dosing throughout the procedure to achieve adequate sedation to safely and effectively perform the procedure. Approach: Retrospective evaluation of 754 patients receiving either the P-O or K + P approach to sedation.

Results A total of 372 P-O group patients and 382 K + P group. Mean age (7.3 ± 5.5 years for P-O; 7.3 ± 5.4 years for K + P) and weight (30.09 ± 23.18 kg for P-O; 30.14 ± 24.45 kg for K + P) were similar in both groups (p = NS). All patients successfully completed procedures with a 16% combined incidence of hypoxia (SPO2 < 90%). Procedure time was 3 minutes longer for K + P group than P-O group (18.68 ± 15.13 minutes for K + P; 15.11 ± 12.77 minutes for P-O; p < 0.01), yet recovery times were 5 minutes shorter (17.04 ± 9.36 minutes for K + P; 22.17 ± 12.84 minutes for P-O; p < 0.01). Mean total dose of propofol was significantly greater in P-O than in K + P group (0.28 ± 0.20 mg/kg/min for K + P; 0.40 ± 0.26 mg/kg/min for P-O; p < 0.0001), and might explain the shorter recovery time.

Conclusion Both sedation approaches proved to be well tolerated and equally effective. Addition of ketamine was associated with reduction in the recovery time, probably explained by the statistically significant decrease in the propofol dose.

Keywords

propofol - ketamine - painful procedure

Full Text

References

References
1 Miner JR, Biros M, Krieg S, Johnson C, Heegaard W, Plummer D. Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department. Acad Emerg Med 2003; 10 (9) 931-937
2 Burton JH, Miner JR, Shipley ER, Strout TD, Becker C, Thode Jr HC. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med 2006; 13 (1) 24-30
3 Frazee BW, Park RS, Lowery D, Baire M. Propofol for deep procedural sedation in the ED. Am J Emerg Med 2005; 23 (2) 190-195
4 Miner JR, Danahy M, Moch A, Biros M. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 2007; 49 (1) 15-22
5 Zed PJ, Abu-Laban RB, Chan WW, Harrison DW. Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study. CJEM 2007; 9 (6) 421-427
6 Godambe SA, Elliot V, Matheny D, Pershad J. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department. Pediatrics 2003; 112 (1, Pt 1): 116-123
7 Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 2007; 41 (3) 485-492
8 Campbell SG, Magee KD, Kovacs GJ , et al. Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series. CJEM 2006; 8 (2) 85-93
9 Innes G, Murphy M, Nijssen-Jordan C, Ducharme J, Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. J Emerg Med 1999; 17 (1) 145-156
10 Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 367 (9512) 766-780
11 Guldner GT, Petinaux B, Clemens P, Foster S, Antoine S. Ketamine for procedural sedation and analgesia by nonanesthesiologists in the field: a review for military health care providers. Mil Med 2006; 171 (6) 484-490
12 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologistss. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96 (4) 1004-1017
13 Coté CJ, Wilson S ; American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118 (6) 2587-2602
14 Zeltzer LK, Altman A, Cohen D, LeBaron S, Munuksela EL, Schechter NL. American Academy of Pediatrics Report of the Subcommittee on the Management of Pain Associated with Procedures in Children with Cancer. Pediatrics 1990; 86 (5, Pt 2): 826-831
15 Hui TW, Short TG, Hong W, Suen T, Gin T, Plummer J. Additive interactions between propofol and ketamine when used for anesthesia induction in female patients. Anesthesiology 1995; 82 (3) 641-648
16 Morse Z, Sano K, Kanri T. Effects of a propofol—ketamine admixture in human volunteers. Pac Health Dialog 2003; 10 (1) 51-54
17 Akin A, Esmaoglu A, Guler G, Demircioglu R, Narin N, Boyaci A. Propofol and propofol-ketamine in pediatric patients undergoing cardiac catheterization. Pediatr Cardiol 2005; 26 (5) 553-557
18 Akin A, Esmaoglu A, Tosun Z, Gulcu N, Aydogan H, Boyaci A. Comparison of propofol with propofol-ketamine combination in pediatric patients undergoing auditory brainstem response testing. Int J Pediatr Otorhinolaryngol 2005; 69 (11) 1541-1545
19 Tomatir E, Atalay H, Gurses E, Erbay H, Bozkurt P. Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging. Paediatr Anaesth 2004; 14 (10) 845-850
20 Suzuki M, Tsueda K, Lansing PS , et al. Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery. Anesth Analg 1999; 89 (1) 98-103
21 Tverskoy M, Oz Y, Isakson A, Finger J, Bradley Jr EL, Kissin I. Preemptive effect of fentanyl and ketamine on postoperative pain and wound hyperalgesia. Anesth Analg 1994; 78 (2) 205-209
22 Choe H, Choi YS, Kim YH , et al. Epidural morphine plus ketamine for upper abdominal surgery: improved analgesia from preincisional versus postincisional administration. Anesth Analg 1997; 84 (3) 560-563
23 Wong CS, Liaw WJ, Tung CS, Su YF, Ho ST. Ketamine potentiates analgesic effect of morphine in postoperative epidural pain control. Reg Anesth 1996; 21 (6) 534-541
24 David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 2011; 57 (5) 435-441
25 Short SM, Aun CS. Haemodynamic effects of propofol in children. Anaesthesia 1991; 46 (9) 783-785
26 Newson C, Joshi GP, Victory R, White PF. Comparison of propofol administration techniques for sedation during monitored anesthesia care. Anesth Analg 1995; 81 (3) 486-491
27 Hasan RA, Shayevitz JR, Patel V. Deep sedation with propofol for children undergoing ambulatory magnetic resonance imaging of the brain: experience from a pediatric intensive care unit. Pediatr Crit Care Med 2003; 4 (4) 454-458
28 Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?. Acad Emerg Med 2006; 13 (5) 500-504
29 Bryson HM, Fulton BR, Faulds D. Propofol. An update of its use in anaesthesia and conscious sedation. Drugs 1995; 50 (3) 513-559
30 Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994; 81 (4) 1005-1043
31 Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med 2007; 49 (1) 1-8
32 Burton JH, Bock AJ, Strout TD, Marcolini EG. Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial. Ann Emerg Med 2002; 40 (5) 496-504
33 Messenger DW, Sivilotti ML, van Vlymen J, Dungey PE, Murray HE. Which alarms first during procedural sedation: the pulse oximeter or the capnograph?. Can J Emerg Med 2007; 9: 186
34 Willman EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med 2007; 49 (1) 23-30
35 Cravero JP, Blike GT, Beach M , et al; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118 (3) 1087-1096