CLINICAL RESEARCH e-ISSN 1643-3750 © Med Sci Monit, 2015; 21: 1737-1744 DOI: 10.12659/MSM.893944
Period Prevalence of Ketamine-Propofol Admixture “Ketofol” in the Operating Room among Anesthesia Providers at an Academic Medical Center
Received: 2015.02.24 Accepted: 2015.03.17 Published: 2015.06.16
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
ABEF 1 ADEF 1 ADEF 1 ABCDEF 1,2
Corresponding Author: Source of support:
Background:
Material/Methods:
Results:
Conclusions:
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Alliene N. Olson Willow R. Rao Mary E. Marienau Nathan J. Smischney
1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, U.S.A. 2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, U.S.A.
Nathan J. Smischney, e-mail: [email protected] This work was supported by the Department of Anesthesiology
The primary aim of this study was to determine the period prevalence of the single-syringe ketamine-propofol admixture used for sedation and induction among anesthesia providers during a 5-year period before and after educational sessions addressing barriers to its use. Secondary aims were to determine barriers to its use and address the most prevalent concerns through educational sessions. Surveys were administered to certified and student registered nurse anesthetists, anesthesia residents, and anesthesiologists at Mayo Clinic Rochester, MN before and after educational sessions addressing common barriers. Identified barriers were addressed by oral and/or electronic presentations with identical content. Pre-education period prevalence for sedation was 110 (43%) and 64 (25%) for induction. Identified barriers were uncertainty of benefit in 62 respondents (23%), mixed controlled substance disposal in 48 (18%), regulatory/institutional policies in 20 (7%), and compatibility in 9 (3%). Post-education period prevalence for sedation was 102 (44%), and induction 63 (27%). No concerns were noted in 72% of the post-education group verses 42% in the pre-education group (p5 years of experience
CRNA – certified registered nurse anesthetist; SRNA – student registered nurse anesthetist
Percentage of providers
had 6–10 years of experience, and 86 (37%) had greater than 10 years of experience. One hundred and twenty-one respondents (52%) indicated that they had previous education regarding the practice and/or current knowledge of the combination of ketamine and propofol (Figure 1). Period prevalence of single-syringe “ketofol” for sedation and induction Pre-education survey Among the 253 completed surveys, the period prevalence of single-syringe ketamine-propofol admixture used for sedation in the last 5 years was 110 (43%). The period prevalence of single-syringe ketamine-propofol admixture used as an induction agent was 64 (25%) (Table 1 and Figure 2). Of those who had 0–5 years of anesthesia training, 39 (31%) had used the combination as an induction agent in the last 5 years. When asked about the stability of the combination as an induction agent, 20 (51%) stated that the combination was stable, and 17 (44%) rated it as very stable. Of those who had greater than 5 years of experience, 25 (20%) had used the combination as an induction agent in the last 5 years. When asked about the stability of the combination as an induction agent, 15 (60%) stated the combination was stable and 10 (40%) rated it as very stable. Post-education survey Among the 233 completed surveys, the period prevalence of single-syringe ketamine-propofol admixture used for sedation in the last 5 years was 102 (44%). The period prevalence of single-syringe ketamine-propofol admixture used as an induction agent was 63 (27%) (Table 1 and Figure 2). In reference to sedation, 56 (55%) of the respondents had 0–5 years of anesthetic experience, as compared to 46 (45%) that had greater than 5 years of experience. For use as an induction agent, 39
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
50 45 40 35 30 25 20 15 10 5 0
Sedation Induction
Pre-survey
”Ketofol” usage
Post-survey
Figure 2. Period prevalence of ketamine-propofol admixture use before and after education.
(62%) had 0–5 years of anesthetic experience as compared to 24 (38%) who had greater than 5 years of experience. For the participants who indicated they had used the admixture as an induction agent, 39 (62%) rated the hemodynamic profile of the admixture as stable and 23 (37%) rated it as very stable hemodynamically. The post-survey respondents were stratified by those with 0–5 years of experience and those with greater than 5 years of experience. The group with 0–5 years of anesthetic experience used the admixture 56/92 (60%) as compared to 46/141 (32%) in the group with greater than 5 years of anesthetic experience (RR (95% CI); 1.90 (1.41–2.55); p-value £0.01). Preferred ratio of admixture Pre-education survey The majority preferred a 1:1 mixture of propofol and ketamine respectively, with 10:1 being the second most prevalent dose ratio in those who had 0–5 years of anesthesia experience. For those who had greater than 5 years of anesthesia experience,
1740
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Olson A.N. et al.: Period prevalence of ketamine-propofol admixture © Med Sci Monit, 2015; 21: 1737-1744
CLINICAL RESEARCH
Satisfied with current practice Lack of experience Other
40
Figure 3. Reasons for not administering singlesyringe ketamine-propofol admixture for sedation and induction by years of experience among anesthesia providers.
35 Number of providers
30 25 20 15 10 5 0
0–5 years >5 years 0–5 years >5 years Sedation Indution Pre-education
0–5 years >5 years 0–5 years >5 years Sedation Indution Post-education
the majority preferred a 10:1 mixture of propofol and ketamine, with a 1:1 mixture the second most prevalent dose ratio. Post-education survey When asked about admixture concentrations, various responses were obtained. However, the most common dose ratio preferred in those with 0–5 years of experience was 1:1. In respondents who had greater than 5 years of experience, a ratio of 2:1 mixture of propofol and ketamine was the most preferred. Reasons for not administrating single-syringe “ketofol” for sedation and induction Pre-education survey Of those who had 0–5 years of anesthesia experience, 65 (51%) respondents stated they had not used the combination as a sedative in the last 5 years. When asked why they have not used the combination, 24 (37%) indicated they were satisfied with current practice, 33 (51%) indicated lack of experience and/or knowledge of acceptability of the combination, and 8 (12%) indicated “other”, which was most commonly reported as physician preference. Of those who had greater than 5 years of anesthesia experience, 74 (59%) respondents indicated they had not used the combination as a sedative in the last 5 years. When asked why they have not used the combination, 35 (47%) indicated they were satisfied with current practice, 25 (34%) indicated lack of experience and/or knowledge of acceptability of the combination, and 14 (19%) indicated “other”, which was most commonly related to the ability to use separately, issues with wastage, physician preference, and lack of awareness of the combination.
common reason was lack of experience and/or knowledge, 24 (42%). Of the 58 anesthesia providers with greater than 5 years of experience who had not used the combination as an induction agent, 37 (64%) indicated they were satisfied with current practice of giving only 1 at a time. The next most common reason 17 (29%) was lack of experience and/or knowledge, and 4 (7%) indicated it was too time consuming (Figure 3). Post-education survey Out of 233 respondents, 131 (56%) stated they had not used the combination as a sedative. This included 36 (27%) with 0–5 years of experience and 95 (73%) with greater than 5 years of experience. The most common reasons cited for not using the admixture as a sedative included satisfied with current practice of giving only 1 at a time 64 (49%), lack of experience or knowledge regarding the admixture 50 (38%), and “other”, with the most frequent reason being “individualized dosing is much safer than fixed dosing” 17 (13%). Out of 233 respondents, 170 (73%) indicated they had not used the combination as an induction agent. This included 70 (41%) respondents with 0–5 years of experience as compared to 100 (59%) with greater than 5 years of experience. The most common reasons cited for not using the admixture as an induction agent included satisfied with current practice of giving only 1 at a time (92 respondents [54%]), lack of experience or knowledge regarding the admixture (44 respondents [26%]), and “other”, with the most common reason as “too time consuming” (34 respondents [20%]) (Figure 3). Barriers Pre-education survey
Of the 57 anesthesia providers with 0–5 years of experience who indicated they had not used the combination as an induction agent, the primary reason listed was “satisfied with current practice of giving only one”, 26 (46%). The next most
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
Of the 271 respondents who answered the question, “do you have concerns with the use of combination of ketamine and propofol”, 113 (42%) respondents had no concerns, 9 (3%) had
1741
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Olson A.N. et al.: Period prevalence of ketamine-propofol admixture © Med Sci Monit, 2015; 21: 1737-1744
CLINICAL RESEARCH
issues with compatibility, 62 (23%) were uncertain about the benefit of using the 2 drugs together, 9 (3%) indicated that it was not approved by the Food and Drug Administration, 11 (4%) indicated it was not approved by the institution and/or department, and 48 (18%) indicated they were unsure of how to properly dispose of mixed controlled substances. The remaining 19 (7%) indicated “other”, with the most common being ability to titrate separately, concern for emergence delirium, knowledge and/or experience with combination, and unsure of dosages (Figure 4). Post-education survey Out of 233 respondents, 167 (72%) had no concerns. Of the 66 (28%) who stated they had concerns with the admixture, 44 (67%) stated they were uncertain about the benefit of using the 2 drugs together, with 17 (26%) indicating they were unsure of how to properly dispose of mixed controlled substances. The remaining 5 (7%) indicated they had concerns regarding compatibility of the 2 drugs (Figure 4). Education effectiveness The effect of education was assessed using carry forward imputation for missing values to compare pre-education and posteducation groups. No concerns with the combination were noted in 72% (196/271) of the post-education group compared to 42% (113/271) of the pre-education group (RR (95% CI); 1.90 (1.64–2.21); p-value
Period Prevalence of Ketamine-Propofol Admixture “Ketofol” in the Operating Room among Anesthesia Providers at an Academic Medical Center
Received: 2015.02.24 Accepted: 2015.03.17 Published: 2015.06.16
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
ABEF 1 ADEF 1 ADEF 1 ABCDEF 1,2
Corresponding Author: Source of support:
Background:
Material/Methods:
Results:
Conclusions:
MeSH Keywords:
Full-text PDF:
Alliene N. Olson Willow R. Rao Mary E. Marienau Nathan J. Smischney
1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, U.S.A. 2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, U.S.A.
Nathan J. Smischney, e-mail: [email protected] This work was supported by the Department of Anesthesiology
The primary aim of this study was to determine the period prevalence of the single-syringe ketamine-propofol admixture used for sedation and induction among anesthesia providers during a 5-year period before and after educational sessions addressing barriers to its use. Secondary aims were to determine barriers to its use and address the most prevalent concerns through educational sessions. Surveys were administered to certified and student registered nurse anesthetists, anesthesia residents, and anesthesiologists at Mayo Clinic Rochester, MN before and after educational sessions addressing common barriers. Identified barriers were addressed by oral and/or electronic presentations with identical content. Pre-education period prevalence for sedation was 110 (43%) and 64 (25%) for induction. Identified barriers were uncertainty of benefit in 62 respondents (23%), mixed controlled substance disposal in 48 (18%), regulatory/institutional policies in 20 (7%), and compatibility in 9 (3%). Post-education period prevalence for sedation was 102 (44%), and induction 63 (27%). No concerns were noted in 72% of the post-education group verses 42% in the pre-education group (p5 years of experience
CRNA – certified registered nurse anesthetist; SRNA – student registered nurse anesthetist
Percentage of providers
had 6–10 years of experience, and 86 (37%) had greater than 10 years of experience. One hundred and twenty-one respondents (52%) indicated that they had previous education regarding the practice and/or current knowledge of the combination of ketamine and propofol (Figure 1). Period prevalence of single-syringe “ketofol” for sedation and induction Pre-education survey Among the 253 completed surveys, the period prevalence of single-syringe ketamine-propofol admixture used for sedation in the last 5 years was 110 (43%). The period prevalence of single-syringe ketamine-propofol admixture used as an induction agent was 64 (25%) (Table 1 and Figure 2). Of those who had 0–5 years of anesthesia training, 39 (31%) had used the combination as an induction agent in the last 5 years. When asked about the stability of the combination as an induction agent, 20 (51%) stated that the combination was stable, and 17 (44%) rated it as very stable. Of those who had greater than 5 years of experience, 25 (20%) had used the combination as an induction agent in the last 5 years. When asked about the stability of the combination as an induction agent, 15 (60%) stated the combination was stable and 10 (40%) rated it as very stable. Post-education survey Among the 233 completed surveys, the period prevalence of single-syringe ketamine-propofol admixture used for sedation in the last 5 years was 102 (44%). The period prevalence of single-syringe ketamine-propofol admixture used as an induction agent was 63 (27%) (Table 1 and Figure 2). In reference to sedation, 56 (55%) of the respondents had 0–5 years of anesthetic experience, as compared to 46 (45%) that had greater than 5 years of experience. For use as an induction agent, 39
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
50 45 40 35 30 25 20 15 10 5 0
Sedation Induction
Pre-survey
”Ketofol” usage
Post-survey
Figure 2. Period prevalence of ketamine-propofol admixture use before and after education.
(62%) had 0–5 years of anesthetic experience as compared to 24 (38%) who had greater than 5 years of experience. For the participants who indicated they had used the admixture as an induction agent, 39 (62%) rated the hemodynamic profile of the admixture as stable and 23 (37%) rated it as very stable hemodynamically. The post-survey respondents were stratified by those with 0–5 years of experience and those with greater than 5 years of experience. The group with 0–5 years of anesthetic experience used the admixture 56/92 (60%) as compared to 46/141 (32%) in the group with greater than 5 years of anesthetic experience (RR (95% CI); 1.90 (1.41–2.55); p-value £0.01). Preferred ratio of admixture Pre-education survey The majority preferred a 1:1 mixture of propofol and ketamine respectively, with 10:1 being the second most prevalent dose ratio in those who had 0–5 years of anesthesia experience. For those who had greater than 5 years of anesthesia experience,
1740
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Olson A.N. et al.: Period prevalence of ketamine-propofol admixture © Med Sci Monit, 2015; 21: 1737-1744
CLINICAL RESEARCH
Satisfied with current practice Lack of experience Other
40
Figure 3. Reasons for not administering singlesyringe ketamine-propofol admixture for sedation and induction by years of experience among anesthesia providers.
35 Number of providers
30 25 20 15 10 5 0
0–5 years >5 years 0–5 years >5 years Sedation Indution Pre-education
0–5 years >5 years 0–5 years >5 years Sedation Indution Post-education
the majority preferred a 10:1 mixture of propofol and ketamine, with a 1:1 mixture the second most prevalent dose ratio. Post-education survey When asked about admixture concentrations, various responses were obtained. However, the most common dose ratio preferred in those with 0–5 years of experience was 1:1. In respondents who had greater than 5 years of experience, a ratio of 2:1 mixture of propofol and ketamine was the most preferred. Reasons for not administrating single-syringe “ketofol” for sedation and induction Pre-education survey Of those who had 0–5 years of anesthesia experience, 65 (51%) respondents stated they had not used the combination as a sedative in the last 5 years. When asked why they have not used the combination, 24 (37%) indicated they were satisfied with current practice, 33 (51%) indicated lack of experience and/or knowledge of acceptability of the combination, and 8 (12%) indicated “other”, which was most commonly reported as physician preference. Of those who had greater than 5 years of anesthesia experience, 74 (59%) respondents indicated they had not used the combination as a sedative in the last 5 years. When asked why they have not used the combination, 35 (47%) indicated they were satisfied with current practice, 25 (34%) indicated lack of experience and/or knowledge of acceptability of the combination, and 14 (19%) indicated “other”, which was most commonly related to the ability to use separately, issues with wastage, physician preference, and lack of awareness of the combination.
common reason was lack of experience and/or knowledge, 24 (42%). Of the 58 anesthesia providers with greater than 5 years of experience who had not used the combination as an induction agent, 37 (64%) indicated they were satisfied with current practice of giving only 1 at a time. The next most common reason 17 (29%) was lack of experience and/or knowledge, and 4 (7%) indicated it was too time consuming (Figure 3). Post-education survey Out of 233 respondents, 131 (56%) stated they had not used the combination as a sedative. This included 36 (27%) with 0–5 years of experience and 95 (73%) with greater than 5 years of experience. The most common reasons cited for not using the admixture as a sedative included satisfied with current practice of giving only 1 at a time 64 (49%), lack of experience or knowledge regarding the admixture 50 (38%), and “other”, with the most frequent reason being “individualized dosing is much safer than fixed dosing” 17 (13%). Out of 233 respondents, 170 (73%) indicated they had not used the combination as an induction agent. This included 70 (41%) respondents with 0–5 years of experience as compared to 100 (59%) with greater than 5 years of experience. The most common reasons cited for not using the admixture as an induction agent included satisfied with current practice of giving only 1 at a time (92 respondents [54%]), lack of experience or knowledge regarding the admixture (44 respondents [26%]), and “other”, with the most common reason as “too time consuming” (34 respondents [20%]) (Figure 3). Barriers Pre-education survey
Of the 57 anesthesia providers with 0–5 years of experience who indicated they had not used the combination as an induction agent, the primary reason listed was “satisfied with current practice of giving only one”, 26 (46%). The next most
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
Of the 271 respondents who answered the question, “do you have concerns with the use of combination of ketamine and propofol”, 113 (42%) respondents had no concerns, 9 (3%) had
1741
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Olson A.N. et al.: Period prevalence of ketamine-propofol admixture © Med Sci Monit, 2015; 21: 1737-1744
CLINICAL RESEARCH
issues with compatibility, 62 (23%) were uncertain about the benefit of using the 2 drugs together, 9 (3%) indicated that it was not approved by the Food and Drug Administration, 11 (4%) indicated it was not approved by the institution and/or department, and 48 (18%) indicated they were unsure of how to properly dispose of mixed controlled substances. The remaining 19 (7%) indicated “other”, with the most common being ability to titrate separately, concern for emergence delirium, knowledge and/or experience with combination, and unsure of dosages (Figure 4). Post-education survey Out of 233 respondents, 167 (72%) had no concerns. Of the 66 (28%) who stated they had concerns with the admixture, 44 (67%) stated they were uncertain about the benefit of using the 2 drugs together, with 17 (26%) indicating they were unsure of how to properly dispose of mixed controlled substances. The remaining 5 (7%) indicated they had concerns regarding compatibility of the 2 drugs (Figure 4). Education effectiveness The effect of education was assessed using carry forward imputation for missing values to compare pre-education and posteducation groups. No concerns with the combination were noted in 72% (196/271) of the post-education group compared to 42% (113/271) of the pre-education group (RR (95% CI); 1.90 (1.64–2.21); p-value
