A Prospective Randomized Double Blind Evaluation of Ketamine/Propofol vs Ketamine Alone for Pediatric Extremity Fracture Reduction

Purpose: Procedural sedation has become an essential skill for emergency physicians, allowing for completion of painful procedures in a safe, comfortable and efficient manner. The ideal sedative agent would allow for an effective level of sedation, rapid onset and offset, absence of hemodynamic or respiratory compromise, and lack of post procedural side effects. A variety of agents have been studied for paediatric procedural sedation, however no currently used agent meets all of these criteria (1).

Background: Ketamine and Propofol are two agents that have been well studied and are commonly utilized as single agents for sedation. Ketamine is a dissociative agent that has amnestic and analgesic qualities. It has the unique property of allowing for deep sedation with minimal effects on the patient's respiratory drive. Ketamine use does not cause hypotension and in fact can have a positive effect on blood pressure. Ketamine has been extensively studied in paediatric sedation and has been found to be a safe and effective (2,3,4). Side effects associated with Ketamine use include post procedural nausea and vomiting, and unpleasant emergence phenomena such as agitation or hallucinations. Ketamine sedation can result in prolonged recovery times compared to other sedative agents and has a low rate of respiratory depression, apnea and laryngospasm (1).

Propofol is a sedative-hypnotic agent that has been popular for use in adult and paediatric procedural sedation for over a decade. The agent's rapid onset of effect and short duration of action allow for efficient sedation and recovery. Propofol has antiemetic properties and post-procedural side effects are rare. Caution must be used with Propofol, as it can be associated with significant respiratory depression and/or hypotension (1). The prolonged use of Propofol in children can produce acidosis, but this is not a problem for single use for an acute painful procedure.

A number of studies have demonstrated that the combination of Ketamine and Propofol for sedation is safe and effective, with most of the data in adults or in adult-child studies with small number of children (5,6). The combination of the two agents appears to reduce side effects of each medication used alone, and allows for a rapid recovery time. A prospective case series of Canadian emergency department patients given Ketamine-Propofol for procedural sedation has recently been published (5). In this study, 22% of the patients were children. However, to date there has been no targeted research published comparing Ketamine-Propofol head to head with any other presently utilized sedation regimen in a paediatric emergency department setting.

Objective & Hypothesis: The objective of this study is to compare Ketamine-Propofol with Ketamine-only in a double-blind, randomised, controlled trial in a paediatric emergency department. We believe that the combination of these two agents will provide a novel and more efficacious option for procedural sedation in paediatric emergency department patients. The hypothesis of the study is paediatric emergency department patients requiring procedural sedation for an isolated orthopaedic injury with Ketamine-Propofol will have reduced total sedation time, time to recovery, complications and improved satisfaction scores compared to patients receiving Ketamine alone.