What should I do if a patient's level of consciousness is deeper than intended during moderate sedation with propofol (a hypnotic agent)?

From the Guidelines

If a patient's level of consciousness becomes deeper than intended during moderate sedation with propofol, immediately stop the propofol infusion and assess the patient's airway, breathing, and circulation. This is based on the pharmacological properties of propofol, which can cause dose-dependent respiratory depression and hypotension due to systemic vasodilation 1. Ensuring the patient has adequate oxygenation by administering supplemental oxygen and considering repositioning the airway if needed is crucial.

Key Considerations

• Monitor vital signs closely, including oxygen saturation, blood pressure, heart rate, and respiratory rate.
• If respiratory depression occurs, provide ventilatory support with bag-mask ventilation.
• The effects of propofol are typically short-acting, with most patients recovering consciousness within 5-10 minutes after stopping the infusion due to its rapid redistribution and clearance 1.
• During this recovery period, continue to monitor the patient closely and document the event.

Resuming the Procedure

Once the patient recovers to the intended level of sedation, you may cautiously resume the procedure with a reduced propofol dose if still needed, typically starting at 50% of the previous rate. It's essential to be aware that propofol can rapidly progress from moderate sedation to deep sedation or general anesthesia with relatively small increases in dosage 1.

Safety Precautions

Given the potential for propofol infusion syndrome (PRIS), a rare but potentially life-threatening condition associated with prolonged administration of high propofol doses, early recognition and discontinuation of propofol in patients with suspected PRIS are critically important 1. The signs and symptoms of PRIS include worsening metabolic acidosis, hypertriglyceridemia, hypotension with increasing vasopressor requirements, and arrhythmias.

From the FDA Drug Label

When propofol injectable emulsion is administered for MAC sedation, rates of administration should be individualized and titrated to clinical response... Infusion rates should always be titrated downward in the absence of clinical signs of light sedation until mild responses to stimulation are obtained in order to avoid sedative administration of propofol injectable emulsion at rates higher than are clinically necessary

If a patient's level of consciousness is deeper than intended during moderate sedation with propofol, stop the propofol infusion until the patient is responsive and re-evaluate. This is because the goal of moderate sedation is to achieve a level of sedation that allows the patient to respond to verbal commands, and a deeper level of sedation may indicate that the patient is at risk of respiratory depression or other complications.

• Titrate the infusion rate downward to avoid sedative administration of propofol at rates higher than clinically necessary.
• Monitor the patient's vital signs and level of consciousness closely to ensure that they are not experiencing any adverse effects from the propofol.
• Re-evaluate the patient's condition and adjust the propofol infusion rate as needed to achieve the desired level of sedation 2.

From the Research

Appropriate Action

If a patient's level of consciousness is deeper than intended during moderate sedation with propofol, the following steps should be considered:

• Stop the propofol infusion immediately until the patient is responsive and re-evaluate their condition, as indicated by studies 3, 4.
• This action is crucial because propofol infusion syndrome, a rare but potentially fatal condition, can occur with prolonged administration of propofol, especially in critically ill patients or those receiving high doses 3, 4, 5.
• Continuous monitoring of the patient's vital signs, including electrocardiogram (ECG), serum creatine kinase, lipase, amylase, lactate, liver enzymes, and myoglobin levels in urine, is essential to promptly identify any abnormalities that may suggest propofol infusion syndrome 4.

Management of Propofol Infusion Syndrome

Management of propofol infusion syndrome requires immediate discontinuation of the propofol infusion and supportive care, which may include:

• Hemodialysis
• Hemodynamic support
• Extracorporeal membrane oxygenation in severe cases, as mentioned in 3 and 5.
• It is also important to be aware of the risk factors for propofol infusion syndrome, such as critical illness, high doses of propofol, and concomitant administration of catecholamines and glucocorticosteroids, to prevent its occurrence 3, 4.

Reversal of Propofol

There is no specific antidote for propofol, and reversal is primarily supportive, focusing on stopping the infusion and providing supportive care until the drug is cleared from the body, as noted in 5.

• Naloxone is not used to reverse propofol, as it is an opioid antagonist and does not counteract the effects of propofol, which is a hypnotic agent 5.