International Journal of Clinical Obstetrics and Gynaecology

Background: Procedural sedation and analgesia (PSA) is routinely performed in the emergency department (ED) to facilitate painful procedures while ensuring patient safety and rapid recovery. Propofol is widely used because of its rapid onset and short duration of action but lacks intrinsic analgesia and is associated with dose-dependent respiratory and hemodynamic depression. Ketamine provides effective analgesia and cardiovascular stability but may cause psychomimetic adverse effects. Combining ketamine with propofol (ketofol) has been proposed to exploit the complementary pharmacological properties of both agents.

Objectives: To compare the efficacy, safety, and satisfaction outcomes of ketofol versus propofol alone for procedural sedation and analgesia in adult emergency department patients.

Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Randomized and quasi-randomized controlled trials published between 1999 and August 2024 were identified through searches of PubMed, CENTRAL, Google Scholar, and clinical trial registries. Studies enrolling adults (?18 years) undergoing ED PSA and comparing ketofol with propofol alone were included. Primary outcomes were significant respiratory or hemodynamic compromise requiring intervention, nausea and vomiting, and emergence reactions. Secondary outcomes included sedation efficacy, provider satisfaction, and total propofol dose. A random-effects model was used for data synthesis.

Results: Ten studies met inclusion criteria, with four randomized trials included in quantitative analysis. Ketofol was associated with a lower incidence of respiratory depression compared with propofol alone, demonstrating a 6% relative risk reduction; however, this did not reach statistical significance (pooled RR 0.64; 95% CI 0.41-1.00; P = 0.05). Sedation efficacy was high in both groups, with ketofol showing a consistent but non-significant trend toward more reliable and adequate sedation. Across multiple trials, ketofol significantly reduced total propofol requirements, indicating a propofol-sparing effect. Provider satisfaction scores consistently favored ketofol, reflecting smoother procedural conditions and fewer interruptions. Importantly, ketofol did not increase the incidence of nausea, vomiting, or emergence reactions compared with propofol alone.

Conclusions: Ketofol provides comparable sedation efficacy to propofol alone with favorable trends toward improved respiratory safety, reduced propofol dosage, and higher provider satisfaction, supporting its use for procedural sedation in the emergency department.