Propofol for

Rapid recovery and its antiemetic properties make propofol anesthesia very popular as an induction agent for outpatient anesthesia. Propofol can also be used to supplement inhalational anesthesia in longer procedures. Both continuous infusion of propofol for conscious sedation and with opioids for the maintenance of anesthesia for cardiac surgery are acceptable techniques. 

An anxious 5-year-old child with chronic otitis media and a history of poorly controlled asthma presents for placement of ventilating ear tubes. General anesthesia is required for this short elective ambulatory surgery procedure. What preanesthetic medication should be administered Which of the three commonly used anesthetic techniques would you choose to use in this situation (1) inhalational anesthesia with sevoflurane for induction and maintenance in combination with nitrous oxide, (2) intravenous anesthesia with propofol for induction and maintenance of anesthesia in combination with remifentanil, or (3) balanced anesthesia using propofol for induction of anesthesia followed by a combination of sevoflurane and nitrous oxide for maintenance of anesthesia ... 

Diprivan (propofol for injection) package insert. AstraZeneca 2001, 2004. 

Lactic acidosis and rhabdomyolysis have been reported in a child receiving an infusion of propofol for sedation in an intensive care unit (965). 

Kill C, Leonhardt A, Wulf H. Lactic acidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003 13 823-6. 

Martin PH, Murthy BV, Petros AJ. Metabohc, biochemical and haemodynamic effects of infusion of propofol for long-term sedation of children undergoing intensive care. Br J Anaesth 1997 79 276-9. 

Forty anxious day-case patients undergoing extraction of third molar teeth under local anesthesia with sedation, were studied in a randomized, double-blind, controlled trial (38). A target-controlled infusion of propofol was compared with patient-controlled propofol for sedation, combined with a small dose of intravenous midazolam (0.03 mg/kg) to improve amnesia. Five patients became over-sedated in the target-controlled group compared with none in the patient-controlled group. 

Crawford M, Pollock J, Anderson K, Glavin RJ, MacIntyre D, Vernon D. Comparison of midazolam with propofol for sedation in outpatient bronchoscopy. Br J Anaesth 1993 70(4) 419-22. 

The incidence of adverse events related to an endoscopy sedation regimen that included propofol (in addition to midazolam and fentanyl), delivered by specially trained general practitioners, has been examined in a prospective audit (8) 28 472 procedures were performed over 5 years. There were 185 sedation-related adverse events, 107 with airway or ventilation problems 123 interventions were necessary to maintain ventilation. No patients required tracheal intubation and there were no deaths. The authors concluded that appropriately trained general practitioners encountered a low incidence of adverse events and could safely use propofol for sedation during endoscopy. It should be noted that aU the general practitioners had some experience in anesthesia or intensive care and were individually trained by the Director of Anesthesia. 

Joo HS, Perks WJ. Sevoflurane versus propofol for anesthetic induction a meta-analysis. Anesth Analg 2000 91(1) 213-19. 

Philip BK, Lombard LL, Roaf ER, Drager LR, Calalang I, Philip JH. Comparison of vital capacity induction with sevoflurane to intravenous induction with propofol for adult ambulatory anesthesia. Anesth Analg 1999 89(3) 623-7. 

Charuluxananan S, Kyokong O, Somboonviboon W, Lertmaharit S, Ngamprasertwong P, Nimcharoendee K. Nalbuphine versus propofol for treatment of intrathecal morphine-induced pruritus after cesarean delivery. Anesth Analg 2001 93(l) 162-5. 

Hepatocellular injury has been reported after the sole use of propofol for outpatient anesthesia (60). 

There have been several reports of postoperative pancreatitis in association with propofol-induced anesthesia (61-63). In view of the very widespread use of propofol for induction of anesthesia, the very rare reports, and the complexity of establishing the cause of acute pancreatitis, a causal relation between propofol and pancreatitis has not been clearly established. 

A healthy 21-year-old woman developed acute pancreatitis a day after an anesthetic that lasted 138 minutes, with propofol for induction (66). She recovered after supportive therapy for 6 days. There was no evidence of gallstones on abdominal imaging and there was no defect in lipid metabolism. 

Rhabdomyolysis has been reported in two patients receiving propofol for sedation while being ventilated for severe asthma (69). 

Propofol infusion syndrome mimics the mitochondrial myopathies, in which there are specific defects in the mitochondrial respiratory chain. The clinical features of mitochondrial myopathy result from a disturbance in lipid metabolism in cardiac and skeletal muscle. These patients generally remain well until stressed by infection or starvation, although subclinical biochemical abnormalities of mitochondrial transport can be demonstrated. It has been suggested that early management of critically iU children may not include adequate calorific intake to balance the increase in metabolic demands, and that in susceptible children the diversion of metabolism to fat substrates may cause the propofol infusion sjmdrome. It is unclear if the dose or duration of propofol infusion alters this effect. As adults have larger carbohydrate stores and require lower doses of propofol for sedation, this may account for the relative rarity of the sjmdrome in adults. The authors suggested that adequate early carbohydrate intake may prevent the propofol infusion syndrome (71). 

A 13-year-old girl with a head injury, who received a high-dose infusion of propofol for 4 days, developed the propofol infusion syndrome (73). 

Reimann FM, Samson U, Derad 1, Fuchs M, Schiefer B, Stange EF. Synergistic sedation with low-dose midazolam and propofol for colonoscopies. Endoscopy 2000 32(3) 239 4. 

In eight subjects the concentration of remifentanil was significantly increased when therapeutic concentrations of propofol were present in the body (41). The combination of propofol and remifentanil can cause cardiovascular depression. As with other opioids, remifentanil competes with propofol for hydrophobic binding in the lungs and heart. 

Krenn H, Deusch E, JeUinek H, Oczenski W, Fitzgerald RD. Remifentanil or propofol for sedation during carotid endarterectomy under cervical plexus block. Br J Anaesth 2002 89(4) 637-. ... 

Hogue CW Jr, Bowdle TA, O Leary C, Duncalf D, Miguel R, Pitts M, Streisand J, Kirvassilis G, Jamerson B, McNeal S, Batenhorst R. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient smgery. Anesth Analg 1996 83(2) 279-85. 

Traditionally, emulsions have been used to deliver oils (castor oil, liquid paraffin) in a palatable form. This is now a minor use, but there is a growing interest in the possibility of improving delivery by the use of lipid o/w emulsions as vehicles for lipophilic dmgs (e.g. diazepam, propofol) for intravenous use. Griseofulvin, presented as an emulsion, exhibits enhanced oral absorption an emulsion of indoxole has superior bioavailability over other oral forms. Medium-chain triglycerides and mono- and diglycerides promote the absorption of ceftriaxone and cefoxitin as well as ciclosporin. 

Mama K R, Steffey E P, Pascoe P J 1996 Evaluation of propofol for general anesthesia In premedicated horses. American Journal of Veterinary Research 57 512-516 Manley S V, Kelly A B, Hodgson D 1983 Malignant... 

C. A. Knibbe, K. P. Zuideveld, J. DeJongh, P. F. Kuks, L. P. Aarts, and M. Danhof, Population pharmacokinetic and pharmacodynamic modeling of propofol for long-term sedation in critically ill patients a comparison between propofol 6% and propofol 1%. Clin Pharmacol Ther 72 670-684 (2002). 

A combination of alfentanil and propofol for deep procedural sedation in an emergency department was not beneficial [61 ]. It was not associated with improved pain control or recall after the procedure. A higher proportion of patients who received the combination (31 of 71) required stimulation to induce respiration. 

Metabolism The propofol infusion syndrome has been predominantly reported anecdotally. Now the incidence has been assessed in a prospective, multicenter, observational study in 1017 patients who received propofol for at least 24 hours [41 ]. The syndrome was defined as a metabolic acidosis plus cardiac dysfunction plus one or more of rhabdomyolysis, hypertriglyceridemia, and renal failure. The criteria were satisfied in 11 patients (1.1%) 2 developed 3 criteria within 24 hours of propofol infusion and 10 developed three criteria within 3 days. Susceptibility factors were identified 10 of the 11 patients... 

A 3%-year-old girl was repeatedly sedated with propofol for radiotherapy, and during the first and fifth episodes developed hiccups rapidly after propofol induction. The first episode passed uneventfully, but the second was complicated by laryngospasm. This was managed by bag and mask ventilation and recovery was uneventful. She had two further similar episodes, both of which were treated with lidocaine. 

A 35-year-old woman, scheduled for an emergency cesarean section, was anesthetized with propofol 2 mg/kg and rocuronium 0.9 mg/kg and maintained with sevoflurane. About 15 minutes before the end of the operation she became tachycardic, difficult to ventilate, and hypoxic despite 70% oxygen. After a second dose of propofol for reintubation, she again became hypotensive and profoundly hypoxic and required inotropic support. Pulmonary edema was diagnosed. Afterwards, a skin test showed a strong weal and flare reaction to propofol. 

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