Journal of Emergency Medicine Trauma & Surgical Care Category: Medical Type: Research Article

Single-Shot Sub-Dissociative Dose Ketofol versus Ketamine Alone for Emergency Department Procedural Sedation and Analgesia in Adult

Shihab AL Sheikh1*, Mohammad Javad Ahmad1, Zafar Mahmood Tariq Sadar Khan1, Majed Rafik Mohammadiih1, Mohsen Al Tabatabai1, Ghulam Yasin Naroo1 and Tariq AL Janabi1
1 Emergency Department, Rashid Hospital Trauma Center, Dubai Health Authority, United Arab Emirates

*Corresponding Author(s):
Shihab AL Sheikh
Emergency Department, Rashid Hospital Trauma Center, Dubai Health Authority, United Arab Emirates
Tel:+971 4 219 1000,
Email:shamahdi@dha.gov.ae

Received Date: Jan 05, 2021
Accepted Date: Feb 15, 2021
Published Date: Feb 22, 2021

Abstract

Study Objective: To compare the recovery time, effectiveness, adverse events and patient satisfaction between I/V mixed 0.5:1 Ketofol (Ketamine and Propofol) and Ketamine alone for adult Procedural sedation and Analgesia (PSA) in Emergency Department. 

Methods: Prospective randomized data were collected in 100 patients above 14 years of age over six months, the patients presented with various types of injuries which needed PSA. Half of them (50%) were given Ketofol and other half Ketamine. Head injury patients, pregnant women, hemodynamically unstable patients and history of allergy to the drugs used were excluded from the study. All the procedures were carried out in ED with all facilities of resuscitation. Informed consent was taken from each patient. We mixed 10ml Propofol (10mg/ml) plus 1ml Ketamine (50mg/ml) plus 9ml of normal saline in 20 ml syringe so for each ml of this mixture contains 2.5mg Propofol plus 5mg Ketamine. Ketofol was given in a dose of 1ml per 5Kg of patient body weight and Ketamine given in a dose of 1mg per Kg. The total calculated dose of Ketofol or Ketamine must be given with a one minute. All the required parameters were recorded in the prescribed forms, and results were tabulated and compared. 

Results: 50% of patients received Ketofol, and 50% received Ketamine. The most commonly performed procedures were orthopaedic, comprising 95% of both groups and mostly shoulder dislocation 49% secondly elbow dislocation 22 % and thirdly Colles` fracture. Seven patients (14%) of Ketamine and three patients (6%) Ketofol required additional doses to complete the procedure.80% of Ketofol group patients and 66% of the ketamine group patients did not exhibit hypoxia signs. In Ketofol group, 92% of patients had no complications while in the Ketamine group, 48% did not show any complications. Recovery time was less than 30 minutes in 92% of Ketofol group and 62% in the Ketamine group. 82% of the Ketofol group and 72% in the Ketamine group with zero visual analog scales. Patient satisfaction was 10/10 in 90% of the patient from Ketofol group while 56% in the Ketamine group. 

Conclusion: When compared with Ketamine alone for PSA in ED settings, the Ketofol with rapid onset of action, faster recovery time, cardio respiratory stability, less adverse events, and high patient satisfaction level make it a better option.

Keywords

Ketamine; Ketofol; Procedural sedation and Analgesia; Sub-dissociative dose

Introduction

Background

Procedural sedation and analgesia is a crucial component in the emergency department for a painful procedure. Many studies recently proved that the combination of Ketamine and Propofol is safe and effective for procedural sedation and analgesia (PSA) [1-4]. 

Propofol has a rapid onset of sedation and short duration of action. This nonbarbiturate, non opioid, sedative-hypnotic agent has amnestic but no analgesic properties [5]. Propofol is associated with a dose-depended risk of respiratory depression, and this risk appears to be heightened with concomitant opioid use [6]. Ketamine is a unique sedative agent that causes dissociation between the thalamic and limbic systems of the brain. At doses commonly used for procedural sedation (1 to 1.5 mg/kg), Ketamine produces a trance-like cataleptic state [7], whereas at sub dissociative doses (0.1 to 0.6 mg/kg; most commonly 0.3 mg/kg) it maintains potent analgesic and amnestic effects that are accompanied by preservation of protective airway reflexes, spontaneous respiration, and cardiopulmonary stability [8-10]. 

Many studies reveal that mixing Ketamine and Propofol will synergy the effect and balanced the side effect of each other [11-13]. Propofol can be associated with dose-dependent hypotension and respiratory depression [14]. Ketamine is known to preserve respiratory drive, and its sympathomimetic properties increase blood pressure [15]. Ketamine is emetogenic, and Propofol has intrinsic antiemetic properties [16]. Post procedural agitation is a common complication of ketamine sedation, where Propofol is known to be an anxiolytic [17]. Furthermore, the addition of Ketamine provides an analgesic effect that is lacking in a propofol-only procedural sedation and analgesia regimen [18]. 

The Mixture of Ketamine and Propofol at 50:50 and 30:70 ratios were physically compatible and chemically stable for up to 3 hours when stored in capped polypropylene syringes at room temperature with exposure to light [19].

Importance

If the combination of Ketamine/Propofol is safer or more effective than Ketamine alone, it would be preferred for procedural sedation and analgesia in ED.

Goals of this study

We want to compare the total sedation and full physiological recovery time (SRT) of Ketofol and Ketamine alone in ED for procedural sedation and analgesia according to the Quebec guideline (end of induction phase to end of physiologic recovery phase), (Figure 1) [20].

The secondary outcomes were the time of onset, hypoxia incidence, cardiovascular changes, adverse events, Visual analog pain scale, and patients' satisfaction scores.

 Figure 1: Sedation Time Interval.

Materials and Methods

Study design

This is a prospective randomized controlled trial of adults receiving procedural sedation and analgesia from April 2019 until September 2019 in the ED of a 700beds trauma center Rashid hospital with an annual census of 160,000 patient visits. The study was approved by the medical research committee of Dubai health authority, and informed consent was obtained from all participants or first-degree relative.

Selection of participants

Eligible patients were identified by the treating emergency physicians according to inclusion criteria. The inclusion criteria include patients aged 14 years old or older, and the American Society of Anaesthesiology class 1 to 2 status and patients of any country of origin. Exclusion criteria consisted of hemodynamic instability; pregnancy; head injury; intoxication; an allergy to egg, soy and study medicine; and other traditional ketamine contraindication.

Intervention

A hundred patients were randomized to either Ketamine/Propofol or Ketamine alone using a fixed 1:1 allocation ratio determined by a computer-based random number generator. Small, random block sizes of 4 were used to ensure equal allocation to each treatment arm.  All procedural sedation and analgesia events required the attendance of one certified emergency physician (treating doctor), two registered nurses and whenever possible, a second certified emergency physician (sedating doctor) assigned to the administration of the PSA medication was also present. Ketofol was prepared as a 0.5:1 mixture of 1ml of 50mg/ml Ketamine plus 10ml of 10mg/ml propofol plus 9ml normal saline into a single 20ml polypropylene syringe. Thus, each one milliliter of Ketofol solution contained 2.5mg ketamine and 5mg Propofol and the dosage given to the patients was 1ml of Ketofol solution per 5kg of patient body weight. 

Ketamine prepared as a mixture of 2ml of 50mg/ml Ketamine plus 18ml intra-lipid solution in 20 ml polypropylene syringe. Thus, each milliliter of ketamine solution contained 5mg Ketamine also the dosage given to the patients was 1ml of Ketamine solution per 5kg of patient body weight. The total calculated dose of Ketofol or Ketamine must be given with a one minute. All procedures were performed in the ED in an area equipped with continuous Oxygen saturation, cardiac monitoring and complete airway and resuscitation cart. 

Preprocedural analgesia was administered by the emergency doctor according to the clinical judgment to control the patient's pain when arrival to the ED but a minimum 30-minute washout period between administering any opioid analgesic and the commencement of the procedural sedation and analgesia procedure was mandated. Patients were given supplemental oxygen if pulse oximetry value less than 90% and do not improve by vigorous tactile stimulation and airway repositioning.

Data collection and processing

The standardized procedural and analgesia datasheet was used for all procedures conducted and was completed by the registered nurse and supervised and signed by attended emergency physician. The information collected included three stages.

The first stage: include presedation documentation like ID number, chief complaint, fasting time for liquid and food, vital signs cardio respiratory examination. 

Second stage: include sedation documentation type of procedure performed, any pre procedural medication, weight, the total dose of procedural medication, time of onset, vital sign( pulse rate, respiratory rate, oxygen saturation, systolic, diastolic and mean blood pressure) recorded by the cardio respiratory monitor (NIHON KOHDEN TEC -8300 series), modified Ramsay sedation scale (Table 1), available online at http://www.annemergmed.com) and visual analogue scale every 5 minutes and any adjunctive medication was given. 

Third stage: post sedation documentation or recovery time (recovery time was define as the time when the procedure is completed till a cumulative score of 9, with minimum scores of 2 for the respiratory and oxygen saturation parameters according to the modified Aldrete Recovery Scale (Table 2), available online at http://www.annemergmed.com), patient satisfaction, recall of procedure and agreement about the sedation, lastly the fate of the patient. 

All adverse events are reported according to the Quebec guidelines 14 and documented by the attending physician on standardized datasheet with specific events checkboxes and free-text area for any other events could be recorded. 

Score

Patient Response

1

Anxious or restless or both

2

Cooperative, orientated and tranquil

3

Asleep - responds quickly to normal voice commands

4

Asleep - no response to normal voice - brisk response to loud voice, or light forehead tap

5

Asleep-no response to above - shows sluggish response to loud voice or light forehead tap

6

Asleep - no response to loud voice or  forehead tap - sluggish purposeful response to pain only

7

Reflex withdrawal (not purposeful) to pain only

8

No response, even to pain

Table 1: Ramsay Sedation Scale. 

Parameter

0

1

2

 

Level of consciousness/sedation

Nonresponsive, or responsive only to painful stimuli

Responds to verbal stimuli but falls asleep readily

Awake and orientated (child oriented to parent), or equivalent to preoperative status

 

Circulation

Systolic BP <100 mm Hg

Systolic BP >100 mm Hg

Systolic BP within normal limits for patient

 

Respiration

Apneic: requires airway support

Shallow, irregular breathing

Able to breathe deeply and cough on command or equivalent to preoperative status

 

Oxygen saturation

SpO2 ≤92% on oxygen

SpO2>92% on oxygen

SpO2≥94% on room air or equivalent to preoperative status

 

Activity level

Unable to lift head or move extremities voluntarily or on command

Lifts head or moves extremities on command

Lifts head and moves all extremities spontaneously. Is able to ambulate consistent with surgical procedure or equivalent to preoperative status.

 

SP02, Oxygen saturation; BP, blood pressure.

*Recovery criteria: minimum score of 8, with a minimum of 2 in respiratory and oxygen saturation.

 
 

Table 2:  Modified Aldrete Recovery Scale*.

Primary data analysis

Data are reported using descriptive statistics (IBM SPSS STATISTICS19). Continuous variables are expressed as mean ± SD. Differences in the average (SRT) in minutes between the two groups of patients were tested using t-test.  The results were considered to be significant if p < .05 and are presented with 95% CIs. 

Since the results of the F test (Levene’s test) for evaluating the equality of variance has a p-value of 0.002, which indicates that the variances are significantly different, The independent samples t-test assuming unequal variances was performed to test the hypothesis that the average SRT time in minutes of the two groups of patients given Ketamine and Ketofol was equal.”

Results

Characteristics of the study subjects

This study was conducted during six months, in which 100 patients were enrolled for procedural sedation and analgesia with Ketofol and Ketamine for a painful procedure in the ED. The two groups were similar in demographics and baseline characteristics (Table 3). 

Characteristics

Ketofol

( n = 50 )

Ketamine

( n = 50 )

Total

( n = 100 )

Age, years ( mean ± SD )

31.1 ± 8.4

30.4 ± 11.9

30.7 ± 10.2

Gender ( % )

·                     Female

·                     Male

 

6 ( 12 )

44 ( 88 )

 

2 ( 4 )

48 ( 96 )

 

8 ( 8 )

92 ( 92 )

Weight, Kg ( mean ± SD )

76.8 ± 15.2

67.7 ± 17.3

72.2 ± 16.8

Baseline vital signs  ( mean ± SD )

·                     Pulse rate (Br/min)

·                     Systolic blood pressure (mm Hg)

·                     Diastolic blood pressure (mm Hg)

·                     Mean arterial pressure (mm Hg)

·                     Respiratory rate (Br/min)

·                     A pulse oximeter (% of oxygen saturation)

 

87.2 ± 17.1

136.9 ± 22.1

84.5 ± 15.8

98.8 ± 15.7

19.3 ± 3.2

99.3 ± 1.3

 

89.5 ± 16.4

134.0 ± 16.5

82.6 ± 11.9

97.8 ± 12.3

18.7 ± 3.0

99.2 ± 1.5

 

88.4 ± 16.7

135.5 ± 19.5

83.5 ± 13.9

98.3 ± 14.1

19.0 ± 3.1

99.2 ± 1.4

Time since last meal, hours

( mean ± SD )

 

5.9 ± 3.0

 

5.4 ± 2.5

 

5.7 ± 2.7

Time since last drink, hours

( mean ± SD )

 

3.8 ± 2.6

 

3.3 ± 2.6

 

3.5 ± 2.6

The preprocedural dose of Morphine

( mean ± SD )

2.5± 3.9

2.0± 3.2

2.2± 3.5

Ketamine dosage, mg

( mean ± SD )

 

37.3 ± 7.5

 

68.3 ± 17.5

 

52.8 ± 20.5

Propofol dosage, mg

( mean ± SD )

75.7±14.9

0000

75.7±14.9

Total sedation and Recovery time, min

( mean ± SD )

19.7 ± 5.0

27.4 ± 9.1

23.6 ± 8.3

Table 3: Baseline characteristics of study subjects. 

The most commonly performed procedures were orthopedic, comprising 95% of both groups and mostly shoulder dislocation 49% secondly elbow dislocation 22 % and thirdly Colles` fracture, (Table 4). 57% of the study patients were from South Asia country, and 13% were from UAE (Table 5). 

Diagnosis (group)

Frequency

Percent

Shoulder dislocation

49

49

Elbow dislocation

22

22

Colles fracture

11

11

Hip dislocation

3

3

Patella dislocation

3

3

Lock jaw

2

2

Bilateral fracture of femur shafts

2

2

Ankle dislocation

2

2

Knee joint dislocation

1

1

Suturing & removing FB

1

1

Lacerated wound in the scalp

1

1

Right pneumothorax

1

1

Left gluteal abscess

1

1

Burn on the lower limb

1

1

Total

100

100

Table 4: Diagnosis. 

Nationality (grouped)

Frequency

Percent

South Asia

57

57

UAE

13

13

Arab countries

12

12

Rest of Asia

6

6

West

5

5

Unclassified

4

4

Others

3

3

Total

100

100

Table 5: Nationality. 

Three patients with epilepsy, two with diabetic mellitus, two asthmatic and 88% without any prior medical history, and (Table 6). 32% of the patients are given narcotics, and 19% were given Voltaren as preprocedural pain management. 8% of the patients were given Maxolon as post procedural treatment. Only three patients required an additional dosage of Ketofol to complete the intended procedure, and seven patients required an additional dosage of Ketamine only. 

Present illness

Frequency

Percent

Nil

88

88

Epilepsy

3

3

 Asthmatic

2

2

 Diabetes mellitus

2

2

Hypertension

1

1

Depression

1

1

 Thyroid disease

1

1

 Myasthenia gravis

1

1

 Duodenal ulcer

1

1

Total

100

100

Table 6: Present illness. 

For our primary outcome, “The average SRT ( minutes ) of the group of patients given Ketamine ( M = 27.4 min , SD = 9.1, N = 50 ) is significantly different from the group of patients given Ketofol ( M = 19.7 min, SD = 5.0, N = 50 ), t ( 76 ) = 5.24, p < 0.0001, 95% confidence Interval is ( 4.78, 10.63 ), (Figure 2). The number of patients discharged over time is more in the Ketofol group than the ketamine group, and patients are discharged sooner in the Ketofol group (20 min) compared to the Ketofol group (30min), (Figure 3).

 Figure 2: RST time (mins) by treatment group for 100 procedural sedations. Circles indicate outliers. 

Figure 3: Number of discharges over time. 

For our secondary outcome, The average time of onset (sec) of the group of patients given Ketamine ( M = 47.8 sec, SD = 23.4, N = 50 ) is significantly different from the group given Ketofol ( M = 35.5 sec, SD  = 13.6, N = 50 ), t ( 98 ) = 3.202, p = 0.002, 95% confidence Interval is ( 4.6, 19.9 ), (Figure 4).

 Figure 4: Time of onset (sec) by treatment group for 100 procedural sedations. Asterisks indicate extreme cases. 

The hypoxia incidence was 21.6% in Ketofol group compared to 34% in the Ketamine group but patient in either group not required bag-valve ventilation, tracheal intubation, or any airway intervention other than airway repositioning or increased oxygen supplement. The average percentage of oxygen saturation of the patients' given Ketamine is lower than the average for the Ketofol patients, except at 5 minutes (Figure 5). However, the patients' average respiratory rate given Ketamine is more or less the same as the Ketofol patients' a (Figure 6).

 Figure 5: The average percentage of oxygen saturation of the patients given Ketamine is lower than the average for the Ketafol patients, except at 5 minutes. 

Figure 6: The average Respiratory rate of the patients given Ketamine is more or less the same as the average for the Ketafol patients. 

Cardiovascular changes are compared between two groups during procedural sedation and analgesia and summarized as the average pulse rate of the patients given Ketamine is consistently more than the average for the Ketofol patients, except at 30 minutes after treatment (Figure 7).

 Figure 7: The average pulse rate of the patient given Ketamine is consistently more than the average for the Ketafol patients, except at 30 minutes after treatment. 

The average SBP of the patients given Ketamine is more than the average for the Ketofol patients up to 25 minutes, and the average is lower than the Ketofol group after 25 minutes after treatment (Figure 8).The average diastolic BP of the patients given Ketamine is more than the average for the Ketofol patients up to 30 minutes, and the average is lower than the Ketofol group from 40 minutes after treatment (Figure 9). The average MAP of the patients given Ketamine is more than the average for the Ketofol patients up to 30 minutes, and the average is lower than the Ketofol group from 40 minutes after treatment (Figure 10).

Figure 8: The average SBP of the patients given Ketamine is more than the average for the Ketafol patient’s up to 25 minutes and the average is lower than the Ketafol group after 25 minutes after treatment.

Figure 9: The average Diastolic BP of the patients given Ketamine is more than the average for the Ketafol patient’s up to 30 minutes and the average is lower than the Ketafol group from 40 minutes after treatment.

Figure 10: The average MAP of the patients given Ketamine is more than the average for the Ketafol patients’ up to 30 minutes and the average is lower than the Ketafol group from 40 minutes after treatment. 

Just 4 (8%) patients given Ketofol experienced post procedural adverse events compared with 26 (52%) given Ketamine experienced post procedural adverse events (Table 7). During PSA, visual analogue pain scaleis summarized in (Table 8), revealing 82% of Ketofol patients and 72% Ketamine patients showing zero visual analogue scales. Patient satisfaction score (0=unsatisfied; 10=satisfied) 90% of the Ketofol patients gave a ten score for satisfaction, and 56% of the Ketamine patients gave a ten score for satisfaction. 

Adverse Events

Treatment group

Size effect
( 95% IC )

 

Ketofol
(%),
n=50

Ketamine
(%),
n=50

 
 
 

Hypoxia

21.60%

34%

0.26(0.12_0.66)

 

Emergency reaction

6.00%

20.00%

0.4 (0.23_0.81)

 

Drowsiness

0.00%

14.00%

0.56(0.16_0.96)

 

Vomiting

2.00%

10.00%

0.29 (0.99_0.68)

 

Muscular hypertonicity

0.00%

4.00%

0.28 (-0.10_0.67)

 

Table 7: Adverse Events Table. 

Visual analog scale

Treatment group

Total

 

Ketafol

Ketamine

 

No pain

41, 82.0%

36,72.0%

77, 77.0%

 

Slight

4, 8.0%

8,16.0%

12, 12.0%

 

Mild

5, 10.0%

3,6.0%

8,8.0%

 

Moderate

0, 0%

2,4.0%

2, 4.0%

 

Sever

0,.0%

1,2.0%

1, 2.0%

 

Horrible

0,.0%

0,.0%

0, .0%

 

Total

50, 100%

50, 100%

100, 100.0%

 

Interpretation: 82% of Ketofol patients while 72% of Ketamine patients felt no pain.

 
 

Table 8: Visual analog scale by Treatment group.

Limitations of the Study

It was a single-center study in which patients were enrolled as a convenience sample according to predetermined inclusion and exclusion criteria. The paediatric population was not included in the study as PSA requirement is more in this age group. The sample size was near minimum for adequate power (95%) with a confidence interval (10%).The study did not contain a Propofol only arm, and thus we are unable to comment on whether Ketofol has any advantage over Propofol alone.

Discussion

To our knowledge, this is the first prospective randomized controlled study comparing single-shot sub-dissociative dose ketofol versus Ketamine alone for adults’ procedural sedation and analgesia in the emergency department setting. The typical PSA should provide credible onset with an expected depth of sedation, a short duration of action and rapid, uneventful recovery. 

The total sedation time and full physiological recovery (SRT) of Ketofol group were significantly faster than in the Ketamine group, but how far it is of clinical value? So if we compare the recovery times from procedural sedation and analgesia induced by intravenous ketamine range between 50 – 110 minutes [21], to that induced by Ketofol range between 8-15 minutes [1, 12, 22]. As a result, we had hypothesized a 10-minutes difference as clinically meaningful, shown in (Figure 3), where the number of patients discharged overtime is 10 minutes more in the Ketofol group than the ketamine group. 

The incidence of hypoxia in Ketofol group was 21.6% which was acceptable compared to the incidence of hypoxia with 3-arm randomized trial done by Miner et al [23]. They report the incidence as Propofol alone was 29%, Ketofol formulation: 1:1 was 19%, and 1:4 was 32%. Higher incidence of hypoxia in the ketamine group (34%), Miner et al [23] detected a higher rate of subclinical respiratory depression in patients sedated with Ketamine than in patients sedated with Propofol. It is well known that rapid intravenous infusion of Ketamine has the potential to cause apnea [24]. Ketamine is an attractive PSA drug, especially in paediatric age group but in massive doses or combined with other sedative agents; however, respiratory depression and apnea can occur [25-27]. Independent idiosyncratic effects seen after iatrogenic administration include laryngospasm, hypersalivation, and bronchorrhea [28-30]. Generally, the average percentage of oxygen saturation of the patients given Ketofol is higher than the average for the Ketamine patients. It justified by rapid onset and extremely short half-life of Propofol and sub dissociative doses of Ketamine which do not have anaesthetic effects but rather has analgesic effects [30], except at 5 minutes when the maximum effect of the Propofol induces mild respiratory depression but of no significant clinically. In Fact, during PSA in adults’ breathing room air, desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified [31]. 

There were no reported cases of significant cardiovascular adverse events in this study in either treatment group. The average of the pulse rate, systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure is consistently normal more in Ketofol group than Ketamine patients. Indicates that the patients with Ketofol group are cardiovascular stable than Ketamine group except after 30 minutes when the patient of Ketofol group start wake up and probably feel of the pain there are an increase in pulse rate, systolic blood pressure, diastolic blood pressure and mean arterial blood pressure. 

The adverse events of our trail show an effective synergy between Ketamine and Propofol agents. Patients in the Ketamine group exhibited nausea and vomiting in 10% of cases, the incidence of which is estimated to be between 5% and 15% in adults [24], compared with only 2% of cases in the Ketofol group similar finding in Shah et al. [18]. The incidence of problematic recovery agitation in adults receiving Ketamine is estimated to be between 10% and 20% [24].Our study was 20% in the Ketamine group compared to 6% in Ketofol group this difference confirm the blunting effect of the Propofol in inhibiting the emergence reaction of the Ketamine. The same blunting effect was justified about muscle hypertonicity during the Ketamine group PSA, which was 4% compared with nil in the Ketofol group.

Conclusion

In conclusion, when compared with Ketamine alone for adult procedural sedation and analgesia in emergency department setting, the Ketofol with rapid onset of action, faster recoveries with essential cardio respiratory stability, less adverse events, and more comfortable the patient during the procedure and better score of patient satisfaction.

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Citation: Al-Sheikh S, Ahmad MJ, Khan ZM, Mohammadiih MR, Al Tabatabai M, et al. (2021) Single-Shot Sub-Dissociative Dose Ketofol versus Ketamine Alone for Emergency Department Procedural Sedation and Analgesia in Adult. J Emerg Med Trauma Surg Care 8: 058

Copyright: © 2021  Shihab AL Sheikh, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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