Propofol/Ketafol

TXmed

TXmed

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Does anyone have experience using propofol or Ketafol as an induction agent for RSI? either pre-hospital or in the critically ill?

if so.

what dosage range do you use for the critically ill ? outside of the standard OR usage dose.

Is there anything you can tell me about using these 2 medications as an induction that a google search or a book wont tell me? IE: personal experiences, things you've noticed, tips & tricks on usage.

I have plenty of experience using both as a sedation drip with the occasional small push-dose to maintain sedation.
 
There is absolutely no reason to mix ketamine and propofol in the same syringe, for induction or otherwise. It's an unnecessary step, which is the last thing you need during an induction sequence. If you feel the need to give both for some reason, just give the ketamine during pre-ox, then give the propofol when you are ready to induce.

In anesthesia, the most common reason that the drugs are mixed is to lower propofol requirements during sedation cases in patients who have OSA or otherwise are expected to be difficult to keep ventilating effectively. The mixtures generally contain too little ketamine to provide a potent analgesic effect.

My opinion as someone who uses both drugs on a daily basis - and I realize there are plenty who would disagree with me - is that mixing them is a silly waste of time. Why ever take the time to mix them? It is less work to simply start your propofol and then give small boluses of ketamine as needed. Once you mix the two you are committed to a fixed ratio of the two drugs. Why do that?

Doses depend on the situation.
 
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@Remi good point about being stuck to the fixed ratio's. Ive listened to rich duttons lectures about using 1/10th of the dose of any drug for induction in the hemodynamically unstable trauma patient and he encourages his fellows to use prop or theo. But what about hemodynamically unstable cardiac patients?
 
Propofol is highly bound to plasma proteins and there was a study done a while ago that showed that in patients with massive hypoproteinemia from burns, that as little as 10% of a normal induction dose may be required to reach the same free plasma concentration of propofol. The same may be true of non-burn patients who have received massive crystalloid resuscitation or hypoproteinemia from other reasons, such as hepatic failure or some types of renal disease. This probably doesn't apply to *most* critically ill or injured patents that we encounter in EMS.

The problem with using that information clinically is that plasma protein levels aren't the only factor that affects pharmacodynamics. You can't calculate a dose based on plasma protein levels, even if you know what they are. There are lots of sick patients who you might give 10% of a normal dose to, and they will be looking at you and asking "shouldn't I be feeling something by now?".

Fortunately, propofol (and most other induction drugs) is fast-enough acting that all you really need to do is give it slowly until the desired clinical effect is produced, and not worry about the dose.

In a really unstable patient, it is perfectly acceptable to give a very small (amnestic) dose and proceed. That's a scenario where premedicating with a small dose of ketamine is really helpful.
 
I don't see the point? Is there a clinically high enough utility in mixing them to make it worthwhile in the "average" patient in whom we would want to induce general anaesthesia? Would also be concerned with the problem of getting the ratios wrong ... reminds me of having to mix insulin!
 
Im really not the biggest fan of mixing induction meds. Some providers here in texas will mix there induction and paralytic. Or their etomidate w/ versed or fent in the same syringe i hate that.

Especially when you open the ambulance and they hand you a random syringe and say "here we were about to put him down" then get upset when you dont use their meds psssshhh get that **** outta here.

In 2 of the ketafol studies i read they mixed it in the induction syringe 1:1. I figured it was to ensure that both drugs counteracted the hemodynamic profile of the other as both the studies were measuring the MAP. So prior to Remi's point i thought that was standard among anesthesia to do it. Now im happy i asked.
 
Disclaimer: I don't do inductions... but to me it just seems that mixing ketamine and propofol (for instance) is an unnecessary step that doesn't give you any advantage. Frankly I'd rather give a dose of ketamine during pre-ox and even if it ends up being too big of a dose, that's OK because the patient will usually resume breathing on their own. If that ends up being enough to correct a problem, fine. Then once it's time to really put 'em under, then push the propofol but be ready for either more push doses of the stuff to keep 'em under OR be ready with a drip on a pump.

The other thing is that unless I *know* what's in a syringe, I'm not going to use it. I've been handed syringes and have watched them draw the med so I know what it is and I've pushed it. If I don't know, I won't push it. I'll tell the person, "you drew it, you push it because I don't know what that is and I didn't see you draw it."
 
TXmed said:
Im really not the biggest fan of mixing induction meds. Some providers here in texas will mix there induction and paralytic. Or their etomidate w/ versed or fent in the same syringe i hate that.
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That is just a bad idea. If nothing else, it's just extra steps and more work. Probably something some folks heard about in a podcast or saw done in the OR somewhere and they thought it was hardcore so they started doing it themselves.

A large dose of roc or sux will start to take noticeable effect before the induction agent has taken full effect. I'm not talking about good intubating conditions, but people do start to feel themselves getting weak all over - generally starting with the respiratory and pharyngeal muscles - and it doesn't last long but it can be very anxiety inducing for those last few seconds before falling asleep. I've even seen people get anxious after receiving a tiny priming dose very shortly before the induction agent was given.
 
Getting in the habit of mixing different drugs in the same syringe will inevitably one day lead to not knowing exactly what is and what is not in the syringe.
 
So for the anestesia people here. What are some other ways to use propofol in the critical patient? Or ways you pair it with other meds ?
 
I get the appeal of Ketafol however I am not convinced that the benefits warrant it's addition to prehospital RSI over Ketamine only. Most of the research seems to be geared towards procedural sedation rather than RSI where the decrease in vomiting and emergence reactions really aren't a huge concern. I don't always follow the adage "Keep it Simple" but I rather have a sole induction agent and focus on solid RSI fundamentals.
 
TXmed said:
So for the anestesia people here. What are some other ways to use propofol in the critical patient? Or ways you pair it with other meds ?
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Depends on the critical patient. I shy away from it as my "critical" patients are at the edge of or beyond their compensation envelope by the time I get to them. In those cases lidocaine and some ketamine are all they'll tolerate for intubation, and even with those, it can be pretty labor intensive to keep them from arresting altogether sometimes.

All that aside, small dose if any, is pretty key with "critical" patients and propofol IME.
 
TXmed said:
@E tank why even the lidocain in the critical patient just wondering ?
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Because it is pretty effective at blunting sympathetic response to laryngoscopy and has a modest CNS depressant effect. It is not uncommonly the sole agent used for in-hospital intubations in very, very ill patients. I've used it (about 2/kg) for a stun dose without any muscle relaxant at all in a patient with spontaneous eye opening or opening to voice.
 
The only benefit to mixing Ketamine and Propofol is to balance the pros and cons of each. The Ketamine would provide analgesia (none for Propofol) and catecholamine release (to counteract the hypotension associated with Propofol). That would, in theory, balance-out the hemodynamic effects of one or the other, but If that's your primary concern then just go with Etomidate. I just don't think it's a worthwhile trade-off to avoid the catecholamine side of Ketamine. Moreover, the only pt's you're really going to need to consider the hemodynamic effects of Ketamine are those whose stores may almost be depleted, in which case you can provide that via a drip (epi, Levo, dopamine, etc.).
 
CWATT said:
I just don't think it's a worthwhile trade-off to avoid the catecholamine side of Ketamine. Moreover, the only pt's you're really going to need to consider the hemodynamic effects of Ketamine are those whose stores may almost be depleted, in which case you can provide that via a drip (epi, Levo, dopamine, etc.).
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I agree. Use a lower dose of Ketamine, ~1mg/kg, and resuscitate before induction. Push dose pressors if you have them or low dose drip.
 
My question wasnt centered around IF to use propofol or ketofol for induction, but more tips on how (working knowledge i cant learn in a book). As my service is considerimg using it for a study (primarily propofol). Sorry for the confusion.
 
TXmed said:
My question wasnt centered around IF to use propofol or ketofol for induction, but more tips on how (working knowledge i cant learn in a book). As my service is considerimg using it for a study (primarily propofol). Sorry for the confusion.
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Got it...I wouldn't use propofol for any intubations in the field in anyone that was critical. Even in very experienced hands and healthy, hydrated patients, the hypotension that occurs is expected, let alone in the critical patient population. Not saying we don't use it in these patients in the hospital, but it is a very nuanced, gentle and patience driven exercise. My 0.02$
 
E tank said:
Got it...I wouldn't use propofol for any intubations in the field in anyone that was critical. Even in very experienced hands and healthy, hydrated patients, the hypotension that occurs is expected, let alone in the critical patient population. Not saying we don't use it in these patients in the hospital, but it is a very nuanced, gentle and patience driven exercise. My 0.02$
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Add on top of it the balance between using a drug first known as a "vet med" Vs. a drug that has a plain bad reputation in the popular media. Lest we not forget the Michael Jackson affair.
 
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