Drug Choice for Procedural Sedation: Propofol vs. Ketamine

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Author: Randy Kring, MSIV
Tufts University School of Medicine

Procedural sedation is frequently performed in the emergency department, whether it is for electrical cardioversion, closed joint reduction or abscess incision and drainage. Although the focus in these cases is often on the procedure, smart preparation for procedural sedation and an understanding of the different strategies that can be used is vitally important.

The goal of procedural sedation is to provide moderate sedation and analgesia while preserving the patient’s protective airway reflexes, adequate ventilation and cardiovascular function. Relative contraindications for procedural sedation may include advanced age, significant medical comorbidities such as CHF or COPD or signs of a difficult airway.[1] Recent food intake is not a contraindication for procedural sedation, but aspiration risk should be assessed and minimized whenever possible.[2] Many drugs can be used for procedural sedation, including midazolam, etomidate, propofol and ketamine. Which drug is “the best?”

Propofol, a sedative and amnestic, has onset in about 40 seconds and duration of action of about six minutes. Common side effects include pain at the injection site, hypotension and respiratory depression.[3] Ketamine, a dissociative anesthetic that provides sedation, amnesia and analgesia, has onset in about 30 seconds and duration of action of about 10 to 20 minutes. Common side effects include agitation on emergence, nausea and (rarely) tachycardia and hypertension.[4]

Resident Journal Review: Procedural Sedation

Originally Published: Common Sense, Mar/Apr 2013

Original Authors: Authors: Kami Hu, MD; Michael Allison, MD; Michael Scott, MD; Phillip Magidson, MD MPH; David Wacker, MD PhD; David Bostick, MD MPH

Editors: Michael C. Bond, MD FAAEM; Jay Khadpe, MD FAAEM

Introduction
The ability to administer procedural sedation and analgesia (PSA) is a necessity for today’s emergency physician (EP), and the list of indications for its use have grown over the years. The quest to determine the safest, most efficacious method continues, producing ongoing research on sedation techniques both old and new. This edition of Resident Journal Review focuses on selected updates on familiar agents and investigations into novel regimens over the past two years.