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Propofol
Aka: Propofol, Diprivan
- See Also
- Procedural Sedation and Analgesia (PSAA)
- Rapid Sequence Intubation
- Mechanism
- Sedative hypnotic
- Potentiates gamma-aminobutyric acid receptors
- No Analgesic effect
- Administer concurrent Analgesics (typically given 20-30 minutes prior to Propofol start)
- Drug Abuse potential (especially among anesthesiologists, nurse anesthetists, emergency medicine staff, dentists)
- Increases Dopamine levels which may reinforce addiction
- Increases Serotonin levels which may be Hallucinogenic
- References
- Majoewsky (2012) EM:RAP 12(1): 3
- Precautions
- See Procedural Sedation and Analgesia (PSAA)
- Propofol has no Analgesic effect, and therefore Opioid Analgesics are often used before Propofol
- Propofol (esp. with concurrent Opioids) increases the risk of cardiopulmonary depression (Hypoxia, Hypotension)
- Close monitoring is critical (second provider skilled in airway management is preferred)
- Consider pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
- Consider oxygen via nasal canula at 2 L/min
- Suction, Bag-valve mask, Nasopharyngeal Airway, and intubation equipment should be ready for use
- Consider Capnography
- Pharmacokinetics
- Rapid onset and short half-life
- Lipid-soluble and crosses blood-brain barrier
- Onset: 30-45 seconds (<1 minute)
- Duration: 6 minutes on average (5 to 15 minutes, prolonged with repeated dosing)
- Lipid emulsion bottle is at risk of Bacterial contamination and growth once accessed
- Discard any open bottles after 12 hours
- Preparation
- See Procedural Sedation
- Second provider skilled in airway management (preferred)
- Preventive measures
- Pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
- Oxygen via nasal canula at 2 L/min
- Opioid Analgesics given at least 20 minutes before procedure
- Monitoring Equipment
- Pulse Oximetry (Oxygen Saturation and Heart Rate)
- Blood Pressure cuff, manual or automatic cycled every few minutes
- Consider Capnography
- Emergency Equipment
- Wall Suction (typically with yanker catheter tip)
- Bag-valve mask
- Nasopharyngeal Airway
- Intubation equipment (see Advanced Airway)
- Dosing: Adults
- Conscious Sedation (not FDA approved)
- Adult (preferred procedural Sedative)
- Initial: 0.5 to 1 mg/kg IV over 20-30 seconds (typically given as smaller increments)
- Obese patients: Consider 0.7 to 0.8 mg/kg for starting dose
- Thin young patients: Consider 1.5 mg/kg for starting dose (risk of respiratory depression)
- Frail elderly patients: Consider 20-30 mg IV for starting dose
- Next: 0.25 to 0.5 mg/kg IV every 1 to 3 minutes
- Decrease dose in older patients (cummulative required total dose decreases with age)
- Age 18-40 years old: 2 mg/kg total dose
- Age 41-64 years old: 1.7 mg/kg total dose
- Age >64 years old: 1.2 mg/kg total dose
- Patanwala (2013) J Emerg Med 44(4): 823-8 +PMID:23333181 [PubMed]
- Typically no respiratory depression at 1 mg/kg dose
- Amnesia occurs at this dose
- Perform painful procedures immediately following infusion
- Amnestic effect wears off prior to sedation
- Propofol Infusion for Procedural Sedation
- Infusion: 100 to 150 mcg/kg/min (6 to 9 mg/kg/h)
- Intubation Sedation (not FDA approved)
- Dose 2 to 2.5 mg/kg IV over 20 to 30 seconds
- Ventilator sedation in ICU
- Infusion: 5-50 mcg/kg/min
- Anesthesia
- Age under 55 years old
- Titration: 40 mg IV every 10 seconds until induction achieved
- Typical cummulative total dose: 2 to 2.5 mg/kg
- Maintenance infusion: 100-200 mcg/kg/min
- Age 55 years old or older
- Decrease dose from that list above for younger patients
- Dosing: Children
- Avoid for prolonged ICU use
- Conscious Sedation (not FDA approved)
- Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
- Dose per kilogram typically higher in children than adults for adequate sedation
- Age <3 years: 2 mg/kg
- Older children and teens: 1.5 mg/kg
- May repeat 0.5 to 1 mg/kg IV (up to 20 mg maximum) every 1 to 3 minutes as needed
- Propofol Infusion for Procedural Sedation
- Infusion: 100 to 250 mcg/kg/min (6 to 15 mg/kg/h)
- Anesthesia (age 3 years and older)
- Typical cummulative total dose: 2.5 to 3.5 mg/kg over 20-30 seconds
- Maintenance infusion: 125-300 mcg/kg/min
- Indications
- Procedural Sedation and Analgesia (PSAA)
- Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
- Rapid Sequence Intubation
- Other agents (e.g. Etomidate, Ketamine) are preferred for emergency department induction (Hypotension risk)
- Contraindications: Relative
- See Procedural Sedation and Analgesia (PSAA)
- Age <6 months or weight <5 kg
- Age >75 years old
- ASA Physical Status Class 3 and above
- Soy allergy (soybean allergy) is no longer considered a contraindication
- Egg allergy (egg Lecithin allergy) is no longer considered a contraindication
- Adverse Effects
- Propofol Infusion Syndrome
- Seen with prolonged use (not associated with short-term Procedural Sedation and Analgesia)
- Hypertriglyceridemia (with prolonged infusion)
- Propofol is a lipid-based infusion that contains 1 kcal/ml
- Risk of Acute Pancreatitis
- Devlin (2005) Pharmacotherapy 25(10):1348-52 +PMID:16185179 [PubMed]
- Cardiopulmonary adverse effects (reduced by administering with lower dose and slower titration)
- Respiratory depression
- More common in older adults
- Close monitoring by a second provider skilled in airway management is preferred
- Consider oxygen via nasal canula at 2 L/min
- Suction, Bag-valve mask, Nasopharyngeal Airway, and intubation equipment should be ready for use
- Consider Capnography
- Transient Hypotension and myocardial depression
- Systolic Blood Pressure drops 10-18 mmHg, Diastolic Blood Pressure drops 10-16 mmHg
- Consider pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
- Increase time (>20 minutes) between IV Opioids and Propofol
- Consider alternative Sedatives (e.g. Etomidate or Ketamine) in hypotensive patients
- Phenylephrine may be used to counter the hypotensive effects of Propofol
- Overdose
- No antidote
- Manage with ABC Management and supportive care
- Safety
- No delay in Lactation
- Pregnancy category B
- However, minimal data available
- Not Teratogenic based on limited data
- References
- Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
- Miller (2019) Ann Emerg Med 73(5): 470-80 [PubMed]