Side Effects of Propofol Infusion
Propofol infusion can cause numerous side effects ranging from common hemodynamic changes to rare but potentially fatal propofol infusion syndrome, with respiratory depression and hypotension being the most significant immediate concerns.
Common Side Effects
Cardiovascular Effects
- Hypotension: The most common cardiovascular effect, sometimes exceeding 30% decrease in arterial pressure 1, 2
- Decreased cardiac output, especially with assisted or controlled ventilation 2
- Bradycardia, particularly when combined with opioids 3
- Hypertension may occur with loading doses of dexmedetomidine 1
Respiratory Effects
- Respiratory depression: Dose-dependent and may be profound 1, 2
- Apnea: Common during induction
- Airway obstruction risk, especially with rapid bolus administration 2
Metabolic/Endocrine Effects
- Hypertriglyceridemia: Due to the lipid emulsion (10% soybean oil) 1, 3
- Risk of acute pancreatitis with prolonged infusions 1, 3
- Metabolic acidosis (particularly with propofol infusion syndrome) 1, 4
Other Common Side Effects
- Pain on injection (up to 30% of patients) 3, 2
- Myoclonus 1
- Allergic reactions in patients with egg or soybean allergies 1, 3
- Sulfite reactions with some generic formulations 1, 3
Propofol Infusion Syndrome (PRIS)
PRIS is a rare but potentially fatal complication with approximately 1% incidence 1, characterized by:
- Worsening metabolic acidosis
- Hypertriglyceridemia
- Progressive hypotension with increasing vasopressor requirements
- Cardiac arrhythmias
- Rhabdomyolysis (cardiac and skeletal muscle)
- Acute kidney injury
- Hyperkalemia
- Liver dysfunction 1, 4, 5
Risk Factors for PRIS
- Prolonged administration (>48 hours) 4, 5
- High doses (>70 μg/kg/min, though can occur at lower doses) 1, 5
- Concomitant administration of catecholamines and/or glucocorticosteroids 4, 5
- Carbohydrate depletion 4
- Severe illness, particularly acute neurological or inflammatory conditions 5
Pathophysiology of PRIS
- Impaired mitochondrial beta-oxidation of fatty acids 1, 4, 5
- Disruption of electron transport chain 4
- Blockage of beta-adrenoreceptors and cardiac calcium channels 4
- Diversion of carbohydrate metabolism to fat substrates 1
- Propofol metabolite accumulation 1
Special Considerations
Elderly, Debilitated, or ASA-PS III/IV Patients
- More sensitive to propofol's cardiorespiratory effects 2
- Rapid bolus administration should be avoided 2
- Lower doses recommended (1-1.5 mg/kg) 2
Long-term Administration
- Tissue saturation can lead to prolonged emergence 1
- Increased risk of PRIS with infusions >48 hours 4, 5
- Monitoring of serum triglyceride levels recommended 3
Infection Risk
- Lipid emulsion can support microbial growth 3
- Strict aseptic technique required during handling 3
- Isolated reports of sepsis from contaminated vials 3
Management of Side Effects
For PRIS
- Immediate discontinuation of propofol 1, 4
- Supportive management including:
- Hemodialysis
- Hemodynamic support
- Extracorporeal membrane oxygenation in refractory cases 4
For Hypotension
- Fluid administration
- Vasopressors if needed
- Slower administration rates 2
For Respiratory Depression
- Airway management and ventilatory support as needed
- Careful titration of dosage 2
Prevention Strategies
- Avoid prolonged (>48h) propofol sedation at doses >5 mg/kg/h 5
- Consider alternative sedative agents for high-risk patients 4, 5
- Allow adequate intervals (3-5 minutes) between dose adjustments 2
- Use slow infusion or injection techniques rather than rapid bolus 2
- Strict monitoring for signs of myocytolysis in high-risk patients 5
Remember that while propofol offers advantages of rapid onset and recovery, its side effect profile requires vigilant monitoring and appropriate patient selection.