S-ketamine and Propofol Combination (Ketofol) in ECT Anesthesia

Out on PubMed from investigators Alexander (Sascha) Sartorius and colleagues in Germany is this study:
Empirical ratio of the combined use of S-ketamine and propofol in electroconvulsive therapy and its impact on seizure quality.
Sartorius A, Beuschlein J, Remennik D, Pfeifer AM, Karl S, Bumb JM, Aksay SS, Kranaster L, Janke C.Eur Arch Psychiatry Clin Neurosci. 2020 Jul 22. doi: 10.1007/s00406-020-01170-7. Online ahead of print.PMID: 32699969
The abstract is copied below:
Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders. In certain cases, ECT-associated anaesthesia can be improved by the use of ketofol (i.e., S-ketamine + propofol). We aimed to evaluate the empirical mixing ratio of ketofol in these cases for better clinical implementation. We retrospectively investigated n = 52 patients who received 919 ECT sessions with S-ketamine plus propofol as anaesthetic agents. Several anaesthesia and ECT-related parameters including doses of S-ketamine and propofol were analysed. The mean empirically determined S-ketamine/propofol ratio was 1.38 (SD ± 0.57) for 919 individual ECT sessions and 1.52 (SD ± 0.62) for 52 patients, respectively. The mean relative dose was 0.72 (± 0.18) mg/kg S-ketamine and 0.54 (± 0.21) mg/kg propofol. Higher propofol dose was associated with poorer seizure quality. Seizure quality and time in recovery room were significantly influenced by age. Ketofol could be an option to exploit the advantageous qualities of S-ketamine and propofol, if both doses are reduced compared with single use of S-ketamine or propofol. Patients with poor seizure quality may benefit from lower propofol doses, which are applicable by the addition of ketamine. An empirically determined mixing ratio in favour of ketamine turned out to be preferable in a clinical setting. Recovery time was primarily prolonged by higher age rather than by ketamine dose, which had previously often been associated with a prolonged monitoring time in the recovery room. These new findings could improve electroconvulsive therapy and should be replicated in a prospective manner.
The pdf is here.
Anesthesia for ECT continues to be refined; this retrospective experience from a busy ECT service in Germany adds very useful data about how to combine ketamine and propofol, a combination referred to as "ketofol." The idea is to combine the "smooth" anesthetic characteristics of propofol (better wake up, less hypertension), but replace some of it with ketamine, to reduce the potent anticonvulsant effect of propofol and get some of the benefits of ketamine (lower, or no, anticonvulsant effect, possible intrinsic antidepressant enhancement). Note that the approximate S-ketamine/propofol ratio of ~1.5 would be ~3 with the racemic mix of ketamine, assuming that only the s-enantiomer has activity.)
ECT may be the medical procedure that relies most heavily on anesthetic management for optimal outcomes; seizure quality is a function of anesthesia technique, via medication choices and airway management (hyperventilation). The collaborative working relationship between anesthesia provider and ECT practitioner is the key to highest quality ECT, IMO.

CK

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