One of the benefits of being a generalist, a doc who tries to do a bit of everything is that from time to time I find that a trick, concept or idea from one area of practice jumps and screams to be used in another area of practice.
So I thought I might throw out a few examples of generalist cross-pollination – ideas that are not new, but work well in another area where they make life a little easier. If you know of any examples of clinical cross-pollination then let me know, I am keen to hear your pearls.
Todays concept is a simple one. I am going to look at ketofol from the perspective of a Paeds Anaesthetist. If you have read any of the popular EM blogs in the last few years you will know that Ketofolf ( ketamine + propofol ) is pretty sexy. I have used it lots and like the combo – smooth sedation on average.
However there are papers out there that suggest propofol of ketamine alone are just as good. A lot of ED docs shy away from ketamine as it is reported to cause laryngeal spasm, vomiting, hallucinations etc. Propofol is often seen as an Anaesthesia only drug, though getting more popular in ED. So, how would a Paeds Anaesthetist think about it?
Well, I do a bit of kids gas and a lot of ED sedations. And I have noticed that my thinking has changed as I have started splitting may ketamine and propofol into 2 syringes and using it the way I might in an OR. Let us deconstruct ketofol, break it down as a gas guy might do.
Wander into any kids operating theatre and the Anaesthetic doc will have the “emergency drugs” drawn up on the trolley. Ask them what the commonest problem that they see- the child is too light, hyperreflexic and prone to all the complications listed above. Then ask them what they reach for if the kid starts creaking, reacting to stimuli and becoming difficult to bag….. the trusty bonus of propofol, guaranteed.
Ok, now back to the ED where thou are planning to reduce a fracture, drain an abscess, sew up a laceration etc on a grumpy kid. What to use? ketofol? Nasal ketamine, brutacaine or something really expensive like Precedex? Let’s say thou have been FOAMed and like the sound of ketofol. Here is how I would use it if I were channelling my part-time inner, Paeds Anaesthetist.
- IV access,
- monitoring, including waveform capnography
- Oxygen, only if you have CO2 monitor
- Draw up ketamine and propofol in separate syringes
- ensure the “surgeon” is all set up and ready at the bedside, scalpel etc poised
- Give a sedative dose of K eg. 1 mg/ kg IV
- wait for the kid to nod off, but be aware – they are too light to inflict pain upon – in Anaesthesia they call this “stage 2” – this is a bad time to do anything painful
- Now, ask the surgeon to wait. Not yet…. 30 seconds more than you think
- inject some propofol ( 0.5 – 1 mg/kg) – just enough to cover the painful bit- the cut, the pull, the squeeze
- As the HR and RR drop give your team mate the nod – GO, inflict the pain. And watch the kid for any flinch, gasp, apnoea etc.
- If they react say: “Wait”, and inject a little more propofol, wait 30 secs and try again.
- Once the painful part is over, you can put the propofol down and use the ketamine tail to do the dressing, plaster, sew up post infiltration with local etc
- now make the room quiet, turn the lights down and get mum in to stay and reassure the kid as they rouse.
Ok, that is my recipe for smooth sedation using the combination of ketamine and propofol. The K is the sedative, but it is too little in small doses for a smooth ride. The propofol is your iron to smooth out the bumpy bits. Used together in a premeditated, team-work and coordinated way they work well, and you end up using less drug in total. The kids wake up sooner, you use less nurse hours and we all go home happy!
Let me know if this helps. I want to hear your cross-pollination ideas.
Coming up soon will be me trying to marry Obstetric partogram action lines with Airway decision-making. It is a long bow, but might work for you as it does for me!