What is the recommended dosing for pediatric ketofol (ketamine and propofol) sedation?

Pediatric Ketofol Dosing for Procedural Sedation

For pediatric procedural sedation, the optimal ketamine-to-propofol (ketofol) ratio is 1:3, with initial dosing of 0.1 mL/kg for children 2-11 years and 0.05 mL/kg for adolescents 12-20 years. 1

Ketofol Composition and Rationale

Ketofol combines the benefits of both medications while minimizing their individual side effects:

• Ketamine: Provides analgesia and dissociative sedation
• Propofol: Provides rapid sedation with quick recovery
• Combined benefits: Hemodynamic stability, reduced respiratory depression, less emesis, and shorter recovery time

Age-Specific Dosing Recommendations

Children (2-11 years):

• Initial dose: 0.1 mL/kg of 1:3 ketofol mixture
• Subsequent doses: 0.05 mL/kg at 2 minutes, then 0.025 mL/kg for additional doses as needed 1

Adolescents (12-20 years):

• Initial dose: 0.05 mL/kg of 1:3 ketofol mixture
• Subsequent doses: 0.025 mL/kg for additional doses as needed 1

Preparation of 1:3 Ketofol Mixture

1. Mix 1 part ketamine (10 mg/mL) with 3 parts propofol (10 mg/mL)
2. Final concentration: ketamine 2.5 mg/mL and propofol 7.5 mg/mL

Alternative Approaches

Single-Agent Ketamine Option

If propofol is unavailable or contraindicated:

• IV ketamine: 1-1.5 mg/kg initial dose 2, 3
• Lower doses (0.5-1.0 mg/kg) may be effective in many pediatric patients 4
• Consider adding midazolam 0.05 mg/kg IV to reduce emergence reactions 3

Infusion Option

For longer procedures (5-20 minutes):

• Initial bolus: 0.25-0.35 mg/kg ketamine (age-dependent)
• Infusion rate: 2.5-3.5 mg/kg/hr (age-dependent) 5
• A 1:4 ketamine-to-propofol ratio is suitable for short infusions 1

Monitoring and Safety Considerations

• Continuous monitoring: Pulse oximetry, blood pressure, and capnography
• Personnel: Staff trained in airway management must be present
• Equipment: Emergency airway equipment must be immediately available 3
• Recovery time: Expect approximately 9-19 minutes to emergence after a 10-minute sedation with ketofol 1

Cautions and Contraindications

• Respiratory depression: While ketofol doesn't significantly reduce respiratory depression compared to propofol alone (22% vs 28%), it allows for less total propofol administration 6
• Emergence reactions: More common in patients over 10 years; consider midazolam 3
• Emesis: More common with increasing age 3
• Cardiovascular effects: Ketamine produces dose-dependent increases in heart rate, blood pressure, and cardiac output; avoid in patients with ischemic heart disease, cerebrovascular disease, or hypertension 2

Practical Advantages of Ketofol

1. Rapid onset (within 1 minute)
2. Shorter recovery time than ketamine alone
3. Maintained propofol antiemesis for 30-40 minutes after the last dose
4. Greater provider satisfaction compared to propofol alone 6
5. Less total propofol required 6

The 1:3 ketamine-to-propofol ratio represents the optimal balance between sedation efficacy and recovery time for pediatric procedural sedation, with dosing adjusted by age to account for pharmacokinetic differences in children versus adolescents.