What is the recommended dosage and administration of Propofol (propofol) for sedation or anesthesia?

Propofol Dosage and Administration for Sedation and Anesthesia

For adult patients requiring sedation or anesthesia, propofol should be administered at an initial dose of 1-2 mg/kg for induction, followed by maintenance infusion of 50-100 mcg/kg/min, with dosage adjustments based on clinical response and monitoring of vital signs. 1

Mechanism of Action and Pharmacokinetics

• Propofol (2,6-diisopropylphenol) is a potent intravenous hypnotic agent that potentiates GABA by reducing the rate of dissociation of the GABA receptor 2
• It has a rapid onset of action (30-45 seconds) and short duration of effect (4-8 minutes) 2
• Propofol is highly lipophilic, allowing rapid passage through the blood-brain barrier 2
• It is rapidly metabolized in the liver by conjugation to glucuronide and sulfate, producing water-soluble compounds excreted by the kidneys 2, 3

Dosing for Adult Patients

Induction of Anesthesia

• Most adults under 55 years (ASA-PS I or II): 2-2.5 mg/kg 1
• Elderly, debilitated, or ASA-PS III or IV patients: 1-1.5 mg/kg (approximately 20 mg every 10 seconds) 1, 4
• Administer by titration (approximately 40 mg every 10 seconds) until clinical signs show onset of anesthesia 1

Maintenance of General Anesthesia

• Continuous infusion: 100-200 mcg/kg/min initially, then decrease to 50-100 mcg/kg/min during maintenance 1
• Intermittent bolus: 25-50 mg increments when changes in vital signs indicate response to surgical stimulation 1

Monitored Anesthesia Care (MAC) Sedation

• Initiation: 100-150 mcg/kg/min (6-9 mg/kg/h) for 3-5 minutes and titrate to desired effect 1
• Alternative initiation method: 0.5 mg/kg administered over 3-5 minutes 1
• Maintenance: 25-75 mcg/kg/min (1.5-4.5 mg/kg/h) 1
• For elderly, debilitated, or ASA-PS III or IV patients: reduce dosage to approximately 80% of usual adult dosage 1

ICU Sedation

• Initiation: 5 mcg/kg/min (0.3 mg/kg/h) 1
• Increase by increments of 5-10 mcg/kg/min (0.3-0.6 mg/kg/h) until desired sedation level is achieved 1
• Maintenance: 5-50 mcg/kg/min (0.3-3 mg/kg/h) 1
• Administration should not exceed 4 mg/kg/hour unless benefits outweigh risks 1

Dosing for Pediatric Patients

Induction of Anesthesia

• Children 3-16 years (ASA-PS I or II): 2.5-3.5 mg/kg 1
• Lower dosage recommended for pediatric patients classified as ASA-PS III or IV 1

Maintenance of General Anesthesia

• Children 2 months or older: 200-300 mcg/kg/min initially 1
• After first half-hour: 125-150 mcg/kg/min 1
• Younger pediatric patients may require higher maintenance infusion rates than older children 1

Procedural Sedation in Pediatric Emergency Department

• Initial dose: 1 mg/kg of propofol (often preceded by fentanyl for analgesia) 5
• Subsequent doses: 0.5 mg/kg administered at physician discretion 5
• Mean total dose ranges from 2.9-3.9 mg/kg 5

Administration Considerations

• Allow sufficient time between doses to assess peak effect before subsequent administration 6
• Administer intravenous propofol in small, incremental doses or by infusion, titrating to desired endpoints 6
• Pain on injection occurs in up to 30% of patients and can be reduced by administering through larger veins or pretreatment with lidocaine 2, 3
• If lidocaine is used to minimize injection pain, administer prior to propofol or add immediately before administration (not exceeding 20 mg lidocaine/200 mg propofol) 1

Monitoring and Safety Considerations

• Continuous monitoring of heart rate, blood pressure, and pulse oximetry is essential during propofol administration 6
• Propofol causes dose-dependent decreases in cardiac output, systemic vascular resistance, and arterial pressure 2, 6
• Respiratory depression is a common side effect that responds rapidly to dose reduction or interruption of infusion 2, 6
• Propofol should be avoided in individuals with allergies to eggs, soy, or sulfites due to its formulation (1% propofol, 10% soybean oil, 2.25% glycerol, 1.2% egg phosphatide) 2
• Co-administration with opioids or other CNS depressants potentiates the sedative effect and may enhance hemodynamic effects 2, 6
• Propofol infusion syndrome is a rare but potentially fatal complication characterized by metabolic acidosis, rhabdomyolysis, arrhythmias, and organ failure, typically associated with prolonged infusion (>48 hours) at high doses (>4 mg/kg/h) 7

Combination Approaches

• When propofol is combined with small doses of opioid analgesics and/or benzodiazepines, adequate sedation can be achieved with lower propofol doses, reducing the risk of hemodynamic instability 6
• For painful procedures, propofol is often combined with fentanyl for analgesia 5
• Propofol combined with remifentanil may provide better sedation than propofol alone for certain procedures 5