What is the recommended dosing for propofol (intravenous anesthetic agent)?

Propofol Dosing Recommendations

For adult patients, propofol should be administered at an initial induction dose of 2-2.5 mg/kg for healthy adults, reduced to 1-1.5 mg/kg for elderly, debilitated, or ASA-PS III/IV patients, followed by maintenance infusion rates of 50-100 mcg/kg/min for optimal recovery times. 1

Induction Dosing

Adult Patients

• Most healthy adults under 55 years (ASA-PS I or II) require 2-2.5 mg/kg for induction when unpremedicated or when premedicated with oral benzodiazepines or intramuscular opioids 1, 2
• Elderly, debilitated, or ASA-PS III/IV patients require lower doses of approximately 1-1.5 mg/kg (administered as approximately 20 mg every 10 seconds) 1
• For neurosurgical patients, slower induction is recommended using boluses of 20 mg every 10 seconds, generally resulting in reduced induction requirements (1-2 mg/kg) 1

Pediatric Patients

• Most patients aged 3-16 years (ASA-PS I or II) require 2.5-3.5 mg/kg for induction when unpremedicated or lightly premedicated 1, 3
• Younger pediatric patients may require higher induction doses than older pediatric patients within this range 1
• Lower dosages are recommended for pediatric patients classified as ASA-PS III or IV 1

Maintenance Dosing

Continuous Infusion

• For adults undergoing general surgery, maintenance infusion rates of 100-200 mcg/kg/min with 60-70% nitrous oxide and oxygen provide adequate anesthesia 1
• Higher rates (150-200 mcg/kg/min) are generally required during the first 10-15 minutes following induction 1
• Infusion rates should be decreased by 30-50% during the first half-hour of maintenance 1
• For optimal recovery times, maintenance rates of 50-100 mcg/kg/min are recommended for most adult patients 1, 4
• For ICU sedation, most adult patients require maintenance rates of 5-50 mcg/kg/min (0.3-3 mg/kg/h) 5

Intermittent Bolus

• Increments of 25-50 mg may be administered with nitrous oxide in adult patients undergoing general surgery 1
• Boluses should be administered when changes in vital signs indicate a response to surgical stimulation or light anesthesia 1
• For nurse-administered propofol sedation (NAPS), initial boluses range from 10-60 mg, with additional boluses of 10-20 mg administered with a minimum of 20-30 seconds between doses 6

Special Considerations

Cardiac Patients

• Avoid rapid bolus induction; use a slow rate of approximately 20 mg every 10 seconds until induction onset (0.5-1.5 mg/kg) 1
• For cardiac anesthesia, maintenance infusion rates should not be less than 100 mcg/kg/min when propofol is used as the primary agent and should be supplemented with opioids 1
• When an opioid is used as the primary agent, propofol maintenance rates should not be less than 50 mcg/kg/min 1

Combination Therapy

• When propofol is combined with opioids and/or benzodiazepines, lower initial doses of 10-20 mg are recommended 7
• The American College of Physicians recommends an initial bolus dose of 20-40 mg, reduced to 10-15 mg in elderly patients or when combined with other sedatives 7
• Combination therapy allows for lower propofol doses and reduced total propofol requirements 7

Monitoring and Safety

• Continuous monitoring of heart rate, blood pressure, and pulse oximetry is essential during propofol administration 7, 6
• Supplemental oxygen administration is recommended in most protocols 6, 7
• Monitor for propofol infusion syndrome (PRIS), especially with doses >70 mcg/kg/min or prolonged infusions 5, 8
• Propofol should be avoided in persons with allergies to egg, soy, or sulfite 6
• Pain on injection occurs in up to 30% of patients 6, 2

Cardiovascular and Respiratory Effects

• Propofol causes dose-dependent decreases in cardiac output, systemic vascular resistance, and arterial pressure 6, 9
• Negative cardiac inotropy and respiratory depression typically respond rapidly to dose reduction or interruption of drug infusion 6
• Approximately 5-7% of patients may experience transient desaturation below 90% when administered propofol 5
• The effect site concentration at recovery is approximately 50% of the induction value, suggesting the need to set lower levels during target-controlled infusion for early recovery 10

Common Pitfalls to Avoid

• Administering loading doses in hemodynamically unstable patients 5
• Using high doses (>70 mcg/kg/min) or prolonged infusions without monitoring for PRIS 5, 8
• Not accounting for propofol's caloric contribution (1.1 kcal/ml from lipid emulsion) when calculating nutritional requirements 5
• Failing to recognize that propofol has no analgesic properties, making it necessary to consider adding analgesics for painful procedures 7