Episode 62- Walking Home from the ICU meets ER-Rx: Propofol
Episode Summary:
Listen as Kali Dayton and I discuss ICU sedation and the good, bad, and ugly of propofol on the Walking Home from the ICU podcast
Show Notes:
Key Points:
“Walking Home from the ICU meets ER-Rx: Propofol:”
– Per PAD/PADIS guidelines, always start with “A1” or analgesia-first sedation with opioids. Propofol can be used as an addition to or alternative to opioids given its relative safety when compared to thing like barbiturates and benzodiazepines
– Propofol should be titrated to a RASS goal of -1 – +1 (light sedation) in most patients. It is typically started at 5-10 mcg/kg/min and titrated by 5-10 mcg/kg/min every 5-10 minutes. We usually max at 40-50 mcg/kg/min and use an ideal body weight for dosing in overweight/ obese patients
– Propofol is very easy to use. Most hospitals have propofol readily available in automated dispensing machines in the ER, eliminating the need to wait for an opioid/ other sedative to be made in IV pharmacy. It is also not a controlled substance making it easier for nurses to pull and waste
– Propofol also has a good pharmacokinetic/ pharmacodynamic profile. It works by activating central GABA(A) receptors and also modulates our sleep pathways. It has amnestic, anxiolytic, anticonvulsant, muscle relaxant, and bronchodilatory effects. We don’t have to adjust its dose for hepatic or renal dysfunction and it has very few drug-drug interactions
– Given its lipophilicity, it crosses the blood-brain barrier quickly and starts to work within 1 minute. With short term use, its duration is about 5-10 minutes as it is rapidly metabolized by the liver. Remember that with prolonged use, the lipophilicity means that propofol hangs around in fatty tissues and when the propofol is turned off, it leeches back into the central circulation- which can be especially problematic in our obese patients
– Some common side effects include: hypotension (up to 25%); bradycardia; elevated triglycerides which can lead to pancreatitis; and propofol related infusion syndrome (PRIS; < 1%, but has a high mortality rate of ~30%)
– PRIS is associated with high doses (> 70 mcg/kg/min for prolonged use > 48 hours) and causes CV collapse, metabolic acidosis, rhabdomyolysis, hyperlipidemia, and renal failure
– Some uncommon side effects include: negative effects on myocytes; myopathy/myalgia; insulin resistance; infusion site reactions; paresthesias; and thrombosis
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