From the Guidelines
For status epilepticus, propofol is typically administered as an intravenous loading dose of 2 mg/kg, followed by a continuous infusion of 5 mg/kg per hour, as this regimen has been shown to be effective in treating status epilepticus refractory to benzodiazepines with fewer mechanical ventilation days 1.
Key Considerations
- The infusion should be adjusted based on clinical response and EEG findings, with the goal of achieving burst suppression on EEG monitoring.
- Treatment duration is typically 24-48 hours of seizure freedom before attempting a gradual taper.
- Close hemodynamic monitoring is essential during propofol administration as it can cause hypotension, requiring fluid resuscitation or vasopressors.
- Cardiac monitoring is also necessary due to the risk of propofol infusion syndrome with prolonged high-dose infusions (>48 hours at >5 mg/kg/hour), particularly in children.
Mechanism and Administration
- Propofol works by enhancing GABA-mediated inhibition in the brain, which suppresses neuronal excitability and terminates seizure activity.
- It is considered a third-line agent for status epilepticus after benzodiazepines and antiepileptic drugs have failed, and should be administered in an ICU setting with continuous monitoring.
Potential Side Effects
- Propofol causes dose-dependent respiratory depression and hypotension due to systemic vasodilation 1.
- Other side effects include hypertriglyceridemia, acute pancreatitis, and myoclonus.
- Propofol infusion syndrome (PRIS) is a rare but potentially life-threatening condition associated with prolonged administration of high propofol doses (> 70 μg/kg/min) 1.
From the Research
Propofol Dosing Regimen for Status Epilepticus
- The recommended propofol dosing regimen for status epilepticus is not explicitly stated in the provided studies, but it is mentioned that high infusion rates (>5 mg/kg/h) for more than 48 hours can increase the risk of propofol infusion syndrome 2.
- A study published in 2022 mentions that prolonged administration of propofol in mechanically intubated patients can lead to propofol-related infusion syndrome (PRIS), which is a lethal condition characterized by multiple organ system failures 3.
- Another study published in 2015 states that certain risk factors for the development of propofol infusion syndrome include high propofol doses and durations of administration, carbohydrate depletion, severe illness, and concomitant administration of catecholamines and glucocorticosteroids 4.
- A retrospective analysis at a level 1 trauma center found that risk factors for propofol infusion syndrome (PRIS) include high dose infusions over prolonged periods, and increasing triglyceride levels may serve as reliable biomarkers of impending PRIS 5.
- A study published in 2005 describes the syndrome of irreversible acidosis after prolonged propofol infusion and mentions that risk factors for propofol infusion syndrome in adults include lean body mass index, high dose, and administration of more than 24-hour duration 6.
Key Considerations
- Propofol infusion should be carefully weighted against its real risk to develop propofol infusion syndrome, and alternative agents such as benzodiazepines or barbiturates should be considered for first line therapy 2.
- Clinicians should consider alternative sedative regimes to prolonged propofol infusions and remain within recommended maximal dose limits 4.
- Monitoring of serum creatine kinase, lactic acid levels, electrolytes, and arterial blood gases should be performed frequently to detect potential complications 6.