It’s Caturday night and you have a young, healthy male in your ED who dislocates his shoulder for the first time just 30 minutes prior to arrival. He seems like the purrfect candidate to perform a reduction without sedation, and you are paws-itive you can get the joint back in its place. You give some morphine and go for it right meow. Unfortunately, no luck. He states there is too much pain. Ultrasound guru Phil Andrus is your attending so you inject lidocaine into his shoulder joint via an ultrasound-guided spinal needle. Still no success. You think to yourself: you have got to be kitten me!
You decide to proceed with procedural sedation. Now what medication(s) do you use? There is quite a bit of practice variation, ranging from propofol to propofol/ketamine (“ketofol”) to ketamine with boluses of propofol throughout the sedation as published by our own Brad Shy and Reuben Strayer (1). The theory is that a mixture with ketamine will result in less respiratory depression than propofol alone. What’s a resident to choose other than agreeing with whatever your attending wants?
A recent RCT (2) comparing propofol vs 1:1 and 4:1 propofol to ketamine mixture shows that the latter two were not statistically significant better in reducing respiratory events compared to propofol alone. Furthermore, the 1:1 group had greater and longer recovery agitation. The author of the study talks more about his approach, and his preference for propofol only, in a recent EM Crit podcast (3).
The verdict: Propofol at (1.0-1.5mg/kg) is a safe medication for procedural sedation without the hassle of recovery agitation associated with ketamine. However, more studies on subdissociative dose ketamine and propofol are needed as there may be a benefit in its analgesic properties.
1) Independent Propofol and Ketamine Dosing (Shy/Strayer 2013)
2) Propofol vs Ketofol (Annals May 2015)
3) EM Crit Podcast with Jim Miner (PS guru)