What is the recommended dosage for ketofol (ketamine and propofol)?

Ketofol Dosing for Procedural Sedation

For adult emergency department procedural sedation, use a 1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL at an initial dose of 0.5-0.7 mg/kg of each agent, with supplemental boluses of 0.25-0.5 mg/kg every 3 minutes as needed. 1

Adult Dosing Regimens

Standard 1:1 Ratio (Most Evidence-Based)

• Initial bolus: 0.5-0.7 mg/kg of each agent (ketamine and propofol) 2, 1
• Supplemental doses: 0.25-0.5 mg/kg every 3 minutes as needed 2, 3
• Preparation: Mix as single-syringe combination of 10 mg/mL ketamine + 10 mg/mL propofol 1
• Expected recovery time: 14 minutes (median, range 3-50 minutes) 1

Alternative Ratios

• 1:3 ketamine-to-propofol ratio may be optimal for intermittent dosing in procedures lasting 5-20 minutes, achieving rapid onset within 1 minute and emergence in 9-19 minutes 4
• Higher ketamine ratios (1:2): Propofol 0.5 mg/kg + ketamine 0.5 mg/kg reduces rescue propofol requirements and oversedation compared to lower ketamine doses 2

Pediatric Dosing (Ages 2-20 Years)

Children (2-11 years)

• Initial dose: 0.1 mL/kg of 1:3 ketofol mixture 4
• Second dose at 2 minutes: 0.05 mL/kg 4
• Subsequent doses: 0.025 mL/kg as needed 4

Adolescents/Young Adults (12-20 years)

• Initial dose: 0.05 mL/kg of 1:3 ketofol mixture 4
• Subsequent doses: 0.025 mL/kg as needed 4

Safety and Efficacy Profile

Effectiveness

• Success rate: 98% for procedural completion 1
• Patient satisfaction: 97% would choose same method again 1
• Staff satisfaction: Median score 10/10 1

Adverse Events

• Bag-mask ventilation required: 2.1% of cases 1
• Recovery agitation: 3.6% overall, with only 1.8% requiring treatment 1
• Respiratory depression: Ketamine alone shows higher subclinical respiratory depression (64%) compared to propofol alone (40%), but clinical interventions are similar 3
• Vomiting: Rare (<1%) 1

Recovery Characteristics

• Faster recovery with ketofol: Propofol combinations show median recovery of 5 minutes versus 14 minutes with ketamine alone 3
• Propofol antiemesis maintained: 30-40 minutes after last dose with 1:3 ratio 4

Critical Monitoring Requirements

All patients receiving ketofol must have:

• Continuous pulse oximetry 5
• Vascular access maintained throughout procedure until no longer at risk for cardiorespiratory depression 6
• Capability to rescue from unintended deep sedation or general anesthesia 6
• Supplemental oxygen and positive pressure ventilation immediately available 6

Contraindications

Avoid ketofol in patients with:

• Uncontrolled cardiovascular disease 6, 7
• Pregnancy 7
• Active psychosis (relative contraindication; can be mitigated with benzodiazepines) 7
• Severe liver dysfunction 6

Key Clinical Pearls

• Titrate slowly: Rapid administration increases risk of hypotension and respiratory depression 5
• Pre-treat pain: Patients with pain before the procedure should receive IV morphine at least 20 minutes before starting sedation 3
• Emergence reactions: Occur in 10-30% of adults with ketamine; minimize by co-administering benzodiazepines 7
• Avoid higher ratios for longer procedures: Ketamine-to-propofol ratios greater than 1:3 result in delayed recovery after 20 minutes 4