A Comparison of Ketofol (Ketamine and Propofol Admixture) Versus Propofol as Induction Agents on Hemodynamic Parameters

This is a pilot study to compare the hemodynamic changes that occur during induction with a
novel drug combination known as ketofol with that of propofol. Propofol and ketamine are
widely used as induction agents and their effects on patient hemodynamics are well known.
Many of these drug-induced changes are undesirable and when used alone sometimes lead to
hemodynamic effects on opposite ends of the spectrum, ie. hypotension (propofol) and
hypertension (ketamine). We will investigate the hemodynamic changes associated with this
drug combination referred to as "ketofol" (ketamine/propofol admixture) during induction
compared with propofol as the gold standard induction agent used widely in anesthetic
practice. If we validate that the changes produced by the ketofol admixture are favorable,
we will then test its use in a wider setting of patient populations including emergency
department intubations and the trauma setting.

Background: Propofol is a non-opioid, non-barbiturate, sedative-hypnotic agent with rapid
onset and short duration of action. It possesses many favorable effects such as an
antiemetic effect and reliably produces sedation and amnesia (Felfernig Jour of Royal Naval
Medical Service, '06; White International Anesth Clinics, '88; Willman Ann of Emer Med,
'07). However, there are several undesirable side effects such as cardiovascular and
respiratory depression. In addition, Propofol as a sole agent has no analgesic properties.
These drug-induced side effects have led to alternative drugs being used with the hopes of
a more favorable side effect profile. Ketamine is an example of one such drug. Ketamine is
a phencyclidine derivative commonly classified as a dissociative sedative with fairly rapid
onset and short duration of action (Felfernig Jour of Royal Naval Medical Service, '06;
White International Anesth Clinics, '88; Willman Ann of Emer Med, '07). It causes little or
no respiratory and cardiovascular depression and unlike propofol, has pain relieving
properties. Ketamine as a single induction agent, however, is limited by emergence
phenomena including postoperative dreaming and hallucinations, however these are attenuated
by the administration of benzodiazepines. Also ketamine in induction doses 1-4.5 mg/kg can
have some undesirable effects on hemodynamics (opposite of propofol) in certain patient
populations including ischemic heart disease (IHD), and patients with increases in
intracranial hypertension and intracranial pressure (ICP). Effectiveness of the two agents
in combination has been recently demonstrated and this new combination could allow a novel
induction agent with favorable effects on hemodynamics (Felfernig Jour of Royal Naval
Medical Service, '06; Hui Jour of Amer Soc of Anesth, '95; Willman Ann of Emer Med, '07).
To date, this combination known as ketofol has been used most extensively for procedural
sedation in the Emergency Department but has not yet been standardized as an induction
agent. We are obtaining funding for a pilot study to validate the use of ketofol as an
induction agent.