Is it good practice to use propofol (2,6-diisopropylphenol) for sedation and intubation despite its potential to cause pain?

From the Guidelines

Using propofol alone for sedation and intubation is not considered good practice due to its lack of analgesic properties and potential to cause pain. While propofol is an excellent sedative-hypnotic agent that provides rapid onset of sedation and amnesia, it does not relieve pain and can actually cause pain during injection, as noted in the study by 1. For intubation, a balanced approach combining propofol with an analgesic (typically an opioid like fentanyl 1-2 mcg/kg) and often a neuromuscular blocking agent (such as rocuronium 0.6-1.2 mg/kg or succinylcholine 1-2 mg/kg) is recommended.

Key Considerations

• The study by 1 highlights the safety and efficacy of propofol when used in combination with other agents, such as fentanyl, for sedation in pediatric patients.
• The use of propofol alone for sedation and intubation can lead to patient discomfort and potentially dangerous sympathetic responses to painful stimuli.
• Combining propofol with an opioid like fentanyl or remifentanil provides both sedation and analgesia, as discussed in the study by 1.
• The pain of propofol injection can be minimized by using the larger antecubital veins, administering lidocaine (20-40 mg) prior to propofol, or mixing lidocaine with propofol.

Recommendations

• A multimodal approach, combining propofol with an analgesic and a neuromuscular blocking agent, is recommended for intubation.
• For procedural sedation, combining propofol with an opioid like fentanyl or remifentanil provides both sedation and analgesia.
• The use of propofol should be guided by the principles of patient selection, education and training of nursing personnel, use of an established protocol for drug administration, and careful assessment of a patient’s physiologic and clinical parameters throughout the procedure, as emphasized in the study by 1.

From the FDA Drug Label

Administration with Lidocaine If lidocaine is to be administered to minimize pain on injection of propofol, it is recommended that it be administered prior to propofol administration or that it be added to propofol immediately before administration and in quantities not exceeding 20 mg lidocaine/200 mg propofol

The use of propofol for sedation and intubation despite its potential to cause pain is a common practice. To minimize pain, lidocaine can be administered prior to propofol or added to propofol immediately before administration. Key considerations include:

• Using lidocaine in quantities not exceeding 20 mg lidocaine/200 mg propofol.
• Administering lidocaine prior to propofol or adding it to propofol immediately before administration. It is essential to weigh the benefits of using propofol against the potential risks, including pain, and to take steps to minimize these risks, such as using lidocaine 2.

From the Research

Sedation and Intubation with Propofol

• Propofol is a commonly used sedative-hypnotic agent for induction of general anesthesia and has been investigated for sedation in intensive care units (ICUs) 3, 4.
• It has a rapid onset and short duration of action, making it suitable for short-term sedation, and is associated with good hemodynamic stability 3.
• Propofol provides satisfactory sedation and is comparable to or better than midazolam in terms of quality of sedation and time to recovery 3.

Potential Risks and Side Effects

• Propofol can cause pain at the injection site, with some studies suggesting that preinduction doses of lidocaine or propofol can reduce this discomfort 5.
• The use of propofol for procedural sedation by non-anesthesiologists is a topic of debate, with some societies recommending that it only be administered by personnel trained in general anesthesia 6.
• Propofol can cause systemic vasodilatation, ventilatory depression, and hypertriglyceridemia, particularly with prolonged administration or in patients with disordered triglyceride metabolism 4.

Clinical Use and Efficacy

• Propofol has been shown to be effective and safe for sedation in the emergency department, but its use should be carefully considered and monitored 7.
• The benefits of using propofol for sedation, including faster recovery times and reduced need for other medications, may outweigh the additional costs 3, 4.
• Further research is needed to determine the potential clinical and cost benefits of using propofol for sedation in various settings 3, 4.