Is propofol (propofol) safe to use for sedation in patients with pulmonary hypertension (Pulm HTN)?

Propofol Use in Patients with Pulmonary Hypertension

Propofol should be used with extreme caution in patients with pulmonary hypertension due to its potential to cause significant hemodynamic instability, particularly decreased cardiac output, systemic vascular resistance, and arterial pressure. 1, 2

Cardiovascular Effects of Propofol in Pulmonary Hypertension

• Propofol causes dose-dependent respiratory depression and hypotension due to systemic vasodilation, which can be particularly problematic in patients with pulmonary hypertension 1
• The cardiovascular effects include decreases in cardiac output, systemic vascular resistance, and arterial pressure, which can worsen right ventricular function in patients with pulmonary hypertension 1, 2
• Propofol has been shown to decrease pulmonary vascular resistance in some studies, but this effect may not be sufficient to offset the negative impact on cardiac output in pulmonary hypertension 3
• A recent study (2021) found that propofol administration during catheter-directed interventions for intermediate-risk pulmonary embolism was associated with significantly higher rates of adverse events compared to other sedatives 4

Risk Factors and Monitoring

• Cardiopulmonary instability with propofol administration is more likely to occur in patients with baseline respiratory insufficiency and/or cardiovascular instability, which are common in pulmonary hypertension 1
• Negative cardiac inotropy and respiratory depression can be seen with propofol use, although these effects typically respond rapidly to dose reduction or interruption of drug infusion 1
• Continuous monitoring of heart rate, blood pressure, and pulse oximetry is essential during propofol administration in these high-risk patients 2

Alternative Approaches

• Consider combination propofol regimens that allow for lower propofol doses while maintaining adequate sedation 2
• When propofol is combined with small doses of an opioid analgesic and a benzodiazepine, analgesia and amnesia can be achieved with subhypnotic doses of propofol, potentially reducing hemodynamic instability 2
• Dexmedetomidine may be a safer alternative for sedation in patients with pulmonary hypertension, as reported in a case study where it helped avoid endotracheal intubation and positive pressure ventilation in a patient with significant pulmonary hypertension 5

Administration Guidelines if Propofol Must Be Used

• Administer intravenous propofol in small, incremental doses or by slow infusion, carefully titrating to the desired endpoints 2
• Allow sufficient time between doses to assess the peak effect of each dose before subsequent administration 2
• Be prepared for rapid intervention if hemodynamic compromise occurs, including:
  • Immediate discontinuation of propofol
  • Administration of intravenous fluids
  • Use of vasopressors if needed 1, 2

Potential Beneficial Effects

• Interestingly, one laboratory study suggests propofol may increase angiotensin-converting enzyme 2 (ACE2) expression in human pulmonary artery endothelial cells, which could theoretically have therapeutic potential for pulmonary arterial hypertension 6
• However, this potential benefit is outweighed by the immediate hemodynamic risks in clinical practice 4

Conclusion

When sedating patients with pulmonary hypertension, the risks of propofol-induced hemodynamic instability must be carefully weighed against its benefits. Alternative sedatives or significantly reduced propofol doses combined with other agents should be strongly considered for these high-risk patients.