From the Guidelines
Ketamine and propofol continuous infusions are both viable options for sedation in intubated patients, but propofol is generally preferred due to its rapid onset, short duration, and predictable recovery, as evidenced by a recent study comparing dexmedetomidine and propofol sedation in patients with sepsis requiring mechanical ventilation, which found no difference in mortality at 90 days or in the primary endpoint of days alive without delirium or coma 1.
Key Considerations
- Propofol is typically preferred for most ICU sedation due to its pharmacokinetic profile, with dosing ranging from 5-80 mcg/kg/min, titrated to desired sedation level.
- Ketamine infusions (0.5-4 mg/kg/hr) may be beneficial in hemodynamically unstable patients, as it maintains or increases blood pressure, and provides analgesia, potentially reducing opioid requirements.
- However, ketamine may cause tachycardia, increased intracranial pressure, and emergence phenomena, making propofol a better choice for patients with traumatic brain injury or elevated ICP.
Clinical Implications
- A balanced approach using lower doses of both agents, along with analgesics, can minimize side effects while maintaining adequate sedation.
- Regular sedation assessment using validated tools like RASS or SAS should guide titration, with daily sedation interruptions when appropriate to assess neurological status and minimize total sedative exposure.
- The choice between ketamine and propofol should be based on individual patient needs and clinical scenarios, taking into account their unique profiles and potential side effects, as supported by the most recent and highest quality study available 1.
From the Research
Comparison of Ketamine and Propofol Infusion
- The comparison between ketamine and propofol infusion in intubated patients has been studied in various clinical trials 2, 3, 4, 5, 6.
- A study published in 2010 found that subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019) 2.
- Another study published in 1995 discussed the use of propofol for sedation in the intensive care unit, highlighting its rapid onset and offset of sedation, even after prolonged administration 3.
- A 2010 study compared propofol versus propofol/ketamine combination for procedural sedation using bispectral index monitoring and found that the combination of propofol and ketamine provides an attractive combination for procedural sedation in the emergency department 4.
- A 2016 study compared the safety and efficacy of propofol versus midazolam in oral fiberoptic endotracheal intubation and found that propofol provides better sedation for fiberoptic endotracheal intubation and better patient comfort and satisfaction 5.
- A 2019 systematic review and meta-analysis found that ketamine/propofol mixture (ketofol) has less respiratory adverse effects than propofol alone in ED procedural sedation 6.
Key Findings
- Propofol and ketamine have different effects on respiratory depression, with ketamine showing a higher rate of subclinical respiratory depression 2.
- The combination of propofol and ketamine may provide better sedation and patient comfort for procedural sedation in the emergency department 4.
- Propofol provides better sedation for fiberoptic endotracheal intubation and better patient comfort and satisfaction compared to midazolam 5.
- Ketofol has less respiratory adverse effects than propofol alone in ED procedural sedation 6.
Sedation and Patient Comfort
- The use of propofol and ketamine for procedural sedation has been shown to be effective in providing sedation and patient comfort 2, 4, 5.
- The combination of propofol and ketamine may provide better sedation and patient comfort for procedural sedation in the emergency department 4.
- Propofol provides better sedation for fiberoptic endotracheal intubation and better patient comfort and satisfaction compared to midazolam 5.