Does propofol cause less hypotension than sevoflurane?

Hemodynamic Comparison of Propofol vs. Sevoflurane

Sevoflurane maintains better hemodynamic stability with less hypotension compared to propofol for anesthesia induction.

Hemodynamic Effects

Blood Pressure Effects

• Propofol causes more significant hypotension than sevoflurane:
  • Propofol leads to approximately 28-36% reduction in mean arterial pressure compared to only 14-15% with sevoflurane 1
  • Sevoflurane demonstrates better preservation of systemic vascular resistance (SVR) with only 20% reduction versus 31% reduction with propofol 2
  • Hypotension occurs more frequently with propofol anesthesia due to its direct vasodilatory effects and sympatholytic properties 3

Cardiac Effects

• Sevoflurane tends to cause more bradycardia:
  • Greater reduction in pulse rate with sevoflurane (9.18%) compared to propofol (5.28%) 1
  • Both agents have negative inotropic effects, but through different mechanisms 3
  • Propofol reduces cardiac output primarily through vasodilation and decreased preload 3
  • Sevoflurane reduces cardiac output through a combination of myocardial depression and moderate vasodilation 3

Clinical Implications

Specific Patient Populations

• For hypertensive patients:
  • Propofol anesthesia is associated with more hypertensive episodes (13/30 patients) compared to sevoflurane (1/31 patients) 4
  • Sevoflurane anesthesia favors arterial hypotension (22/31 patients) versus propofol (12/30 patients) 4

Response to Vasopressors

• Propofol enhances the pressor response to ephedrine compared to sevoflurane 5
  • This suggests that hypotension during propofol anesthesia may be more easily corrected with vasopressors

Metabolic Considerations

• Propofol is more frequently associated with lactic acidosis during longer procedures 4
  • Metabolic acidosis occurred in 7/29 patients with propofol versus 1/31 with sevoflurane

Practical Considerations

Dosing Impact

• Even reducing propofol dosing does not significantly improve hemodynamic stability:
  • Low-dose propofol (1.4 mg/kg) versus high-dose propofol (2.7 mg/kg) showed no clinically significant difference in blood pressure reduction 2

Cost Considerations

• Sevoflurane induction is generally less expensive than propofol induction 1

Patient Acceptance

• Patient acceptance is similar between both agents 1
  • Sevoflurane may have an unpleasant smell
  • Propofol causes pain on injection in up to 30% of patients 6

Clinical Decision Making

When selecting between propofol and sevoflurane for anesthesia induction:

1. For hemodynamically unstable patients or those at risk for hypotension:

   • Choose sevoflurane for induction due to better blood pressure preservation

2. For patients with bradycardia or conduction abnormalities:

   • Consider propofol as sevoflurane tends to cause more bradycardia

3. For patients with hypertension:

   • Sevoflurane may provide better control of blood pressure spikes

4. For longer procedures:

   • Be aware of potential metabolic acidosis with prolonged propofol use

5. When rapid vasopressor response may be needed:

   • Propofol may be advantageous due to enhanced response to ephedrine

Conclusion

Based on the most recent and highest quality evidence, sevoflurane provides better hemodynamic stability with less hypotension compared to propofol during anesthesia induction. This makes sevoflurane potentially preferable for patients where maintaining blood pressure is a priority for reducing morbidity and mortality.