What is the appropriate dosing of propofol for procedural sedation?

From the Guidelines

Propofol is recommended for procedural sedation at an initial dose of 0.5-1 mg/kg IV given as a slow push over 1-2 minutes, followed by maintenance doses of 0.25-0.5 mg/kg as needed, typically every 3-5 minutes, as supported by the most recent and highest quality study 1.

Key Considerations

• For continuous infusion, use 25-75 mcg/kg/min titrated to the desired level of sedation.
• Before administration, ensure the patient has been fasting (6 hours for solids, 2 hours for clear liquids), has IV access established, and is on continuous monitoring including pulse oximetry, ECG, and blood pressure.
• Have resuscitation equipment immediately available.
• Propofol works rapidly (onset 30-60 seconds) with a short duration of action (4-8 minutes) due to its high lipid solubility and rapid redistribution.

Special Populations

• Be aware that propofol can cause dose-dependent respiratory depression and hypotension, particularly in elderly patients or those with cardiovascular compromise, so dose reduction of 30-50% is recommended for these populations 1.
• Avoid propofol in patients with egg or soy allergies.
• Remember that propofol has no analgesic properties, so consider adding an analgesic agent like fentanyl (0.5-1 mcg/kg) if the procedure is painful.

Comparison of Sedation Methods

• Two methods have evolved for the administration of propofol under the direction of an endoscopist: Nurse-administered propofol sedation (NAPS) and Balanced propofol sedation (BPS) 1.
• Both methods involve the administration of small, titrated bolus doses of propofol, but NAPS uses propofol as a single agent and is titrated to deep sedation, while BPS combines propofol with a small induction dose of a narcotic, a benzodiazepine, or both, and is targeted to moderate sedation.

Monitoring and Safety

• Careful assessment of a patient’s physiologic and clinical parameters throughout the procedure is crucial.
• The potential for pharmacologic reversibility is retained using naloxone or flumazenil when propofol is combined with small doses of an opioid analgesic and a benzodiazepine 1.
• Propofol infusion syndrome (PRIS) is a rare but potentially life-threatening condition that can occur with prolonged administration of high propofol doses, and early recognition and discontinuation of propofol in patients with suspected PRIS are critically important 1.

From the FDA Drug Label

For initiation of MAC sedation, either an infusion or a slow injection method may be utilized while closely monitoring cardiorespiratory function. With the infusion method, sedation may be initiated by infusing propofol injectable emulsion at 100 mcg/kg/min to 150 mcg/kg/min (6 mg/kg/h to 9 mg/kg/h) for a period of 3 minutes to 5 minutes and titrating to the desired clinical effect while closely monitoring respiratory function. Maintenance of MAC Sedation For maintenance of sedation, a variable rate infusion method is preferable over an intermittent bolus dose method. With the variable rate infusion method, patients will generally require maintenance rates of 25 mcg/kg/min to 75 mcg/kg/min (1.5 mg/kg/h to 4.5 mg/kg/h) during the first 10 minutes to 15 minutes of sedation maintenance.

The appropriate dosing of propofol for procedural sedation is:

• Initiation: 100 mcg/kg/min to 150 mcg/kg/min (6 mg/kg/h to 9 mg/kg/h) for 3 minutes to 5 minutes
• Maintenance: 25 mcg/kg/min to 75 mcg/kg/min (1.5 mg/kg/h to 4.5 mg/kg/h) 2

From the Research

Propofol Dosing for Procedural Sedation

The appropriate dosing of propofol for procedural sedation can vary depending on the patient population, procedure, and desired level of sedation.

• The median propofol dose used in one study was 174 mg (SD = 164 mg) for infusion-dosed propofol in the emergency department (ED) 3.
• Another study found that a median dose of 75mg of propofol was effective for procedural sedation in the ED, with a higher procedure success rate and shorter sedation duration compared to midazolam 4.
• In pediatric patients, a bolus dose of 1 mg/kg of propofol, followed by additional doses of 0.5 mg/kg, was used for painful procedures in the ED, with a median propofol dose of 2.7 mg/kg 5.
• For outpatient monitored anesthesia care, a propofol infusion of 25-50 microg x kg(-1) x min(-1) in combination with an alfentanil infusion of 0.2-0.4 microg x kg(-1) x min(-1) is recommended 6.
• Simulations for ketofol (propofol mixed with racemic ketamine) dosing suggest an optimal ratio of 1:3 for boluses during short procedures (5-20 minutes), with initial doses of 0.1 mL/kg in children and 0.05 mL/kg in adults 7.

Key Considerations

• The choice of propofol dosing regimen should take into account the patient's age, weight, and medical history, as well as the type and duration of the procedure.
• Monitoring of vital signs and level of sedation is crucial to ensure patient safety and adjust the dosing regimen as needed.
• The use of propofol for procedural sedation should only be performed by trained healthcare professionals in a setting with appropriate equipment and monitoring capabilities.