Title: Comparison of Ketamine Monotherapy versus Ketamine and Propofol for Procedural Sedation in the Pediatric Emergency Department and the Impact on Time to Discharge
Authors: Francesco Mottola; Andrea Gerwin; Maggie Raker; Sarah Sterner; Morgan Padron Background/Purpose: Optimizing sedation for procedures in the pediatric emergency department (PED) is essential for effective pain control and timely discharge. Ketamine is commonly used as monotherapy, but its associated adverse effects may delay recovery. Combining ketamine with propofol may reduce these effects, potentially shortening time to discharge. However, whether this combination leads to faster discharge compared to ketamine alone remains unclear within current literature. The purpose of this study is to compare discharge times between ketamine monotherapy versus ketamine and propofol when used for procedural sedation in the pediatric emergency department.
Methods: This study is a single-center, retrospective, chart review utilizing electronic health records of patients treated in the PED at the Children’s Hospital at Erlanger between January 1, 2023 and October 30, 2024. Patients were included if they were less than 18 years of age and received either ketamine or the combination of ketamine and propofol for procedural sedation with moderate depth sedation targets. Exclusion criteria included medically complex patients, patients with hypersensitivity to either ketamine or propofol, and patients admitted to the hospital after receiving procedural sedation in PED. The primary outcome is to evaluate whether the combination of ketamine and propofol leads to a quicker discharge time than the use of ketamine alone when used for procedural sedation in the PED. Secondary outcomes include the overall rate of adverse events, administration of pre‑sedation antiemetics, nausea, emesis, emergence reactions, and the mean sedation duration.
Results: Preliminary data included a total of 220 patients with 109 in the ketamine group and 111 in the combination of ketamine and propofol group, respectively. Preliminary results indicate that the mean dose of ketamine was 1.95 mg/kg ± 0.74 in the ketamine group compared to 1.21 mg/kg ± 0.43 in the ketamine and propofol group. The average dose of propofol was 2.38 mg/kg ± 1.12 when used in combination with ketamine. In the ketamine group, the mean duration of sedation was 23.08 minutes ± 16.4 with a mean discharge time of 155.7 minutes ± 105.6 (p< 0.001) compared to a mean sedation duration of 25.33 minutes ± 8.5 in the ketamine and propofol group with an average time to discharge of 112.40 minutes ± 39.57 (p< 0.001). In the ketamine group, 74 patients (67.3%) received pre‑sedation antiemetics, compared with 59 patients (53.2%) in the combination of ketamine and propofol group (p= 0.25). Overall adverse events were reported in 33 (30%) of patients in the ketamine group compared to 10 (9.1%) in the ketamine and propofol group (p < 0.0001). The most common adverse events reported in the ketamine group were emesis (33%) and nausea (45%). In the ketamine and propofol group, the adverse events reported were nausea (70%) and emesis (10%). No emergence reactions were observed between either group. Conclusions: The use of ketamine and propofol for procedural sedation within the pediatric emergency department may decrease the time to discharge when compared to ketamine alone. This is likely due to the lower incidence of adverse events seen with the combination of ketamine and propofol. When used in combination, lower doses of ketamine were more likely to be used, which may contribute to the lower reported rate of adverse effects. However, patients within the ketamine group were also more likely to receive pre-sedation antiemetics when compared to the ketamine and propofol combination group, which may also impact incidence of adverse effects.
