Ketofol for procedural sedation? Pro and con.

In an old Reese’s Peanut Butter Cups television commercial, 2 snacking pedestrians collide and their respective treats—peanut butter and chocolate—inadvertently mix. Both parties sample the blend with unexpected pleasure, and the narrator then pitches the slogan, “Two great tastes that taste great together.” Ketamine and propofol are 2 extremely common agents used for emergency department (ED) procedural sedation, with each having well-documented safety and efficacy. But do these 2 drugs work better together? The combination of ketamine and propofol, referred to by the portmanteau “ketofol,” is currently all the rage. According to Internet and physician buzz, a large number of EDs in North America have adopted this combination as their primary sedation regimen. Much of this popularity has been fueled by anecdote rather than solid research. This is reminiscent of the dramatic entry of propofol a decade ago into emergency medicine, in which clinical application surged far ahead of the science. Ultimately, the original enthusiasm for propofol was properly validated, but will ketofol enjoy the same outcome? Other popular anecdotal therapies were later discredited, eg, aminophylline for asthma, antishock trousers for traumatic hypotension, highdose epinephrine in cardiac arrest. The concept of ketofol has immediate allure because of its intriguing synergistic premise. These 2 completely different sedatives exhibit clinical features that appear to balance each other’s deficits. Propofol is a superb sedative but lacks the analgesia that ketamine can amply provide. Respiratory depression and hypotension are the principal adverse events of propofol; perhaps the sympathomimetic ketamine mitigates them. Vomiting and hallucinatory recovery reactions are the principal adverse events of ketamine; perhaps the antiemetic and hypnotic properties of propofol mitigate them. In this editorial, we debate the pros and cons of ketofol, with our preexisting biases against (S.M.G.), for (G.A.), and neutral (B.K.). Summary arguments are show in the Figure. h