It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.
the emcrit procedural sedation chapter has tons of references for all of this
Propofol
great propofol articles:
Ann Emerg Med 2008;52:392-398
Ann Emerg Med. 2007;50:182-187
Start with fentanyl 1-1.5 mcg/kg
Then give propofol 0.5-1 mg/kg
may need additional injections of 0.5 mg/kg
When patient is where you want them, begin the procedure
May need to give additional 20-30 mgs if the patient becomes too light
Burns on injection, you can precede with 20-40 mg of lidocaine to numb the vessels
Old people = 100 – age for initial propofol dose
Ketofol
read more here: (Ann Emerg Med. 2007;49:23-30)
1:1 mix of ketamine and propofol
In 20 ml syringe, place 10 ml of propofol (10 mg/ml)
And 10 ml of ketamine at a concentration of 10 mg/ml
Note: your ketamine may come in a different concentration, if so dilute down to 10 ml of 10 mg/ml
Shake like a martini
Dexmedetomidine
Precede with fentanyl 1 mcg/kg
Start with 0.5-1 mcg/kg over 10 minutes for loading dose
then use an infusion 0f 0.2-1 mcg/kg/hr
Beware in the bradycardic, hypotensive or patients with heart blocks
May need to supplement with 1-2 mg of midazolam
Procedural Sedation Checklist
Stay tuned for part III.
Additional New Information
More on EMCrit
Procedural Sedation – Part I(Opens in a new browser tab)
EMCrit 151 – Procedural Sedation Part 3 with Jim Miner(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Sent by email from a reader:
Hey
I enjoyed your sedation talk. A strategy that is used in our burns department for a dressing change is to mix 200 mg of ketamine with 10 mg of midazolam and made up to a volume of 20 ml in 1 syringe. It is then given as a PCA (usually as 1 ml with a lock out of 3 minutes). Seems to work well.
David
Scott
when using Ketofol, is it taking substantially longer for your patients to awaken and discharge as opposed to just Propofol and fentanyl?http://blog.emcrit.org/wp-content/plugins/wp-notcaptcha/lib/vertical_sign.png
It will take on average an additional 10 minutes of monitoring time in my experience. But this is time that the pt is not at risk of airway compromise.
Dr. Weingart, Love the podcast! I have only recently discovered it, and am part way through my catch-up. I believe it is in this podcast you discuss pain elicitation to increase ventilation rate in sedated patients (sorry if it was a different one, I listen to groups of them at a time). Regardless, you stated that pressing between the posterior mandible and the mastoid process can elicit a good pain response to increase ventilation rate without appearing harmful. However, I’m concerned about the fragility of the styloid process, which I believe is being compressed in this maneuver. Is there a… Read more »
Hi Scott,
Did you ever get to part III? I can’t find it. This is great. ER nurse…it’s annoyingly hard to find anyone in the nursing world to give you a straight but complete answer on anything. It’s awesome to get this all laid out in one place.
I’m going to go back and listen to both of these a couple of times and make my own notes. Thanks for all the info.
Paul
Hi Scott,
This may be a silly question, but is there a video of how you actually combine the propofol, ketamine, and normal saline (if you need to dilute ketamine) all in a single 20cc syringe? I’m a new Jr ER doc in a rural ED, and I’ve asked my senior colleagues what they do, but they don’t really use ketofol. Hope you can help with the hands-on part of how to actually make ketofol. Do you just squirt 10cc propofol, 10cc ketamine+saline into an open 20cc syringe?
Hope you can help!
Bill Hichs