Use of Ketamine, Propofol and Their Combination (KETOFOL) For Procedural Sedation in Emergency Department: A Review

Ketamine, Propofol and their combination (Ketofol) for Procedural Sedation


  • Huma Nasir Department of Emergency Medicine, Zia-ud-Din University Hospital, Karachi, Pakistan
  • Muhammad Arslan Zahid Department of Anesthesia, Agha Khan University Hospital, Karachi, Pakistan
  • Muhammad Saleh Department of Anesthesia, Jinnah Postgraduate Medical Center, Karachi, Pakistan
  • Shafique Ahmed Department of Anesthesia, The Indus Hospital and Health Network, Karachi, Pakistan ⁵
  • Reeba Wirk Department of Anesthesia, Jinnah Postgraduate Medical Center, Karachi, Pakistan
  • Bahram Khan Department of Anesthesia, The Indus Hospital and Health Network, Karachi, Pakistan



Emergency Department, Ketofol, Potential Anesthetic, Sedation


For Procedural Sedation, sedative and Analgesic agents are frequently used in Emergency Department but titration of anesthetic doses should be performed with care, and patients should be continuously monitored. The use of Ketamine, Propofol and their combination (Ketofol) is in common practice, but there is currently no intravenous anesthetic agent that is ideal. Therefore, this review was conducted to analyze the efficacy as well as the potential side effects of these anesthetic agents during procedural sedation. Method: For this purpose, Medline, EMBASE, CCRCT and CINAHL were searched and systematically analyzed and the meta-analysis included all English-language randomized control trials (RCTs) comparing K-P vs propofol for procedural sedation in ED. The study included the data of ED patients who received procedural sedation for non-elective unpleasant procedures. Results: As a result of the removal of duplicate citations and studies that did not fulfill eligibility requirements, a total of 06 RCTs involving 932 patients (412 in the propofol group and 520 in the K-P group). Very high levels of inter-rater reliability (j = 0.88; 95% CI = 0.68 to 1.0) were found in the final selection of included trials, with 95.2% agreement. Conclusion: Data revealed that the combination of Ketamine with propofol was the most effective anesthetic combination in the larger randomized, prospective studies carried out in the ED that had sufficient power to use the maintenance of vital signs and the success of the procedure as endpoints are still required


Corwell BN, Motov SM, Davis NL, Kim HK. Novel uses of ketamine in the emergency department. Expert Opinion on Drug Safety. 2022 Aug; 21(8): 1009-25. doi: 10.1080/14740338.2022.2100883.

Foo TY, Mohd Noor N, Yazid MB, Fauzi MH, Abdull Wahab SF, Ahmad MZ. Ketamine-propofol (Ketofol) for procedural sedation and analgesia in children: a systematic review and meta-analysis. BMC Emergency Medicine. 2020 Dec; 20(1): 1-4. doi: 10.1186/s12873-020-00373-4.

Symington L and Thakore S. A review of the use of propofol for procedural sedation in the emergency department. Emergency Medicine Journal. 2006 Feb; 23(2): 89-93. doi: 10.1136/emj.2005.023713.

Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Annals of Emergency Medicine. 2012 Jun; 59(6): 504-12. doi: 10.1016/j.annemergmed.2012.01.017.

Pemayun IG and Sudisma IG. Respons Fisiologis Babi Bali Terhadap Anestetik Ketamin dan Propofol. Jurnal Veteriner. 2022 Jul; 23(1): 70-9. doi: 10.19087/jveteriner.2022.23.1.70.

Akdeniz S, Ulu MB, Bakirtas M, Erdemir F. The renal protective efficacy of ketamine vs. propofol vs. ketofol against renal ischemia/reperfusion injury: An experimental rat study. Medicine. 2022; 11(3): 1317–21. doi: 10.5455/medscience.2022.04.097.

Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of laryngospasm during 276,832 episodes of pediatric procedural sedation. Annals of Emergency Medicine. 2022 Dec; 80(6): 485-96. doi: 10.1016/j.annemergmed.2022.05.002.

Pusp A, Kumari A, Tiwary R, Kumar R, Ansari MM, Deep A. Clinico-physiological effect of ketamine, propofol and Ketofol as constant rate infusion anaesthesia during elective ovariectomy in dogs. The Pharma Innovation Journal. 2022 Jan; 11(1): 1291–6.

Kayhan GE, Yucel A, Colak YZ, Ozgul U, Yologlu S, Karlidag R, et al. Ketofol (mixture of ketamine and propofol) administration in electroconvulsive therapy. Anaesthesia and Intensive Care. 2012 Mar; 40(2): 305-10. doi: 10.1177/0310057X1204000214.

Luna A, Gupta A, Aggarwal S. Comparison of a ketamine-propofol combination and etomidate for anaesthesia induction on haemodynamic parameters in patients undergoing coronary artery bypass grafting. Southern African Journal of Anaesthesia and Analgesia. 2022 Sep; 28(4): 151-5. doi: 10.36303/SAJAA.2022.28.4.2728.

Singh SA, Prakash K, Sharma S, Dhakate G, Bhatia V. Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography. Korean Journal of Anesthesiology. 2018 Feb; 71(1): 43-7. doi: 10.4097/kjae.2018.71.1.43.

Daele VA, Zeeuws D, Baeken C. Suicidality during neuromodulation in the elderly depressed: study design. European Psychiatry. 2022 Jun; 65(S1): S736-7. doi: 10.1192/j.eurpsy.2022.1902.

Kurdi MS, Theerth KA, Deva RS. Ketamine: current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014 Sep; 8(3): 283-90. doi: 10.4103/0259-1162.143110.

Marland S, Ellerton J, Andolfatto G, Strapazzon G, Thomassen O, Brandner B, et al. Ketamine: use in anesthesia. CNS Neuroscience & Therapeutics. 2013 Jun; 19(6): 381-9. doi:

Yan JW, McLeod SL, Iansavitchene A. Ketamine‐propofol versus propofol alone for procedural sedation in the emergency department: a systematic review and meta‐analysis. Academic Emergency Medicine. 2015 Sep; 22(9): 1003-13. doi: 10.1111/acem.12737.

Weisz K, Bajaj L, Deakyne SJ, Brou L, Brent A, Wathen J, et al. Adverse events during a randomized trial of ketamine versus co-administration of ketamine and propofol for procedural sedation in a pediatric emergency department. The Journal of Emergency Medicine. 2017 Jul; 53(1): 1-9. doi: 10.1016/j.jemermed.2017.03.024.

Schmitz A, Weiss M, Kellenberger C, OGorman Tuura R, Klaghofer R, Scheer I, et al. Sedation for magnetic resonance imaging using propofol with or without ketamine at induction in pediatrics—a prospective randomized double‐blinded study. Pediatric Anesthesia. 2018 Mar; 28(3): 264-74. doi: 10.1111/pan.13315.

Tewari K, Tewari VV, Datta SK. Dexmedetomidine–propofol vs ketamine–propofol anaesthesia in paediatric and young adult patients undergoing device closure procedures in cardiac catheterisation laboratory: An open label randomised trial. Indian Journal of Anaesthesia. 2018 Jul; 62(7): 531. doi: 10.4103/ija.IJA_692_17.

Ahmed SS, Hicks SR, Slaven JE, Nitu ME. Deep sedation for pediatric dental procedures: is this a safe and effective option? Journal of Clinical Pediatric Dentistry. 2016 Mar; 40(2): 156-60. doi: 10.17796/1053-4628-40.2.156.

Canpolat DG, Esmaoglu A, Tosun Z, Akın A, Boyaci A, Coruh A. Ketamine-propofol vs ketamine-dexmedetomidine combinations in pediatric patients undergoing burn dressing changes. Journal of Burn Care & Research. 2012 Nov; 33(6): 718-22. doi: 10.1097/BCR.0b013e3182504316.

Willman EV and Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 2007 Jan; 49(1): 23-30. doi: 10.1016/j.annemergmed.2006.08.002.

Andolfatto G and Willman E. A Prospective Case Series of Single‐syringe Ketamine–Propofol (Ketofol) for Emergency Department Procedural Sedation and Analgesia in Adults. Academic Emergency Medicine. 2011 Mar; 18(3): 237-45. doi: 10.1111/j.1553-2712.2011.01010.x.

Miner JR, Gray RO, Bahr J, Patel R, McGill JW. Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department. Academic Emergency Medicine. 2010 Jun; 17(6): 604-11. doi: 10.1111/j.1553-2712.2010.00776.x.

Green SM. Propofol in emergency medicine: further evidence of safety. Emergency Medicine Australasia. 2007 Oct; 19(5): 389-93. doi: 10.1111/j.1742-6723.2007.01016.x.

Akin A, Esmaoglu A, Tosun Z, Gulcu N, Aydogan H, Boyaci A. Comparison of propofol with propofol–ketamine combination in pediatric patients undergoing auditory brainstem response testing. International Journal of Pediatric Otorhinolaryngology. 2005 Nov; 69(11): 1541-5. doi: 10.1016/j.ijporl.2005.04.011.

Mourad M, El-Hamamsy M, Anwar M, Schwartz E. Low dose ketamine reduces sedative doses of propofol during ambulatory transoesophageal echocardiography. Egypt Journal of Anaesthology. 2004; 20(1): 41-6.

Aouad MT, Moussa AR, Dagher CM, Muwakkit SA, Jabbour‐Khoury SI, Zbeidy RA, et al. Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability. Acta Anaesthesiologica Scandinavica. 2008 Apr; 52(4): 561-5. doi: 10.1111/j.1399-6576.2008.01584.x.

Miner JR and Burton JH. Clinical practice advisory: emergency department procedural sedation with propofol. Annals of Emergency Medicine. 2007 Aug; 50(2): 182-7. doi: 10.1016/j.annemergmed.2006.12.017.

Miner JR, Biros MH, Seigel T, Ross K. The utility of the bispectral index in procedural sedation with propofol in the emergency department. Academic Emergency Medicine. 2005 Mar; 12(3): 190-6. doi: 10.1197/j.aem.2004.10.004.

Bell A, Treston G, Cardwell R, Schabort WJ, Chand D. Optimization of propofol dose shortens procedural sedation time, prevents resedation and removes the requirement for post‐procedure physiologic monitoring. Emergency Medicine Australasia. 2007 Oct; 19(5): 411-7. doi: 10.1111/j.1742-6723.2007.01009.x.

David H and Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Annals of Emergency Medicine. 2011 May; 57(5): 435-41. doi: 10.1016/j.annemergmed.2010.11.025.



DOI: 10.54393/pjhs.v4i02.539
Published: 2023-02-28

How to Cite

Nasir, H. ., Arslan Zahid, M., Saleh, M., Ahmed, S. ., Wirk, R., & Khan, B. . (2023). Use of Ketamine, Propofol and Their Combination (KETOFOL) For Procedural Sedation in Emergency Department: A Review: Ketamine, Propofol and their combination (Ketofol) for Procedural Sedation. Pakistan Journal of Health Sciences, 4(02), 05–11.



Review Article