Propofol and Remifentanil Combination for Deep Sedation
Recommended Regimen
For deep sedation, administer remifentanil via target-controlled infusion (TCI) at 1 ng/mL combined with propofol TCI titrated to effect-site concentrations of 2.6-3.3 µg/mL, as this approach minimizes respiratory depression while maintaining adequate sedation depth. 1, 2
Initial Dosing Protocol
Start with remifentanil 0.125 µg/kg/min for 2 minutes, then reduce to 0.05 µg/kg/min continuous infusion, combined with propofol boluses of 10-20 mg every 20-30 seconds until target sedation is achieved. 1, 3
- For procedures requiring deep sedation, target propofol effect-site concentrations averaging 2.6 µg/mL (maximum 3.3 µg/mL) and remifentanil 0.84 ng/mL (maximum 0.99 ng/mL) when using TCI delivery 2
- Manual bolus dosing requires propofol 10-60 mg initial dose, followed by 10-20 mg increments with minimum 20-30 seconds between doses 4
- Allow sufficient time between doses for peak effect assessment before administering additional drug 3
Critical Advantage of TCI Over Manual Administration
Target-controlled infusion of remifentanil significantly reduces respiratory complications compared to manual infusion—apnea and hypopnea occurred in only 7 patients with TCI versus 16 patients with manual administration (P < 0.05). 1
- TCI remifentanil at 1 ng/mL decreases propofol requirements while maintaining deep sedation 1
- Manual continuous infusion (0.05 µg/kg/min maintenance) carries higher risk of respiratory depression 1
- The 2018 ASA guidelines note that propofol combined with remifentanil produces deeper sedation and less recall but increases respiratory depression risk 3
Expected Drug Consumption
For deep sedation procedures, anticipate:
- Propofol: 175-249 mg total dose 5
- Remifentanil: continuous infusion at 0.84-0.99 ng/mL effect-site concentration 2
- Patient-controlled sedation uses significantly less propofol (175 mg) compared to anesthesiologist-managed constant infusion (249 mg) without compromising satisfaction 5
Mandatory Monitoring Requirements
Continuous monitoring must include pulse oximetry, blood pressure, heart rate, capnography for early hypoventilation detection, and a dedicated healthcare provider who performs no other tasks during sedation. 3, 6
- Maintain vascular access throughout the procedure and until cardiorespiratory depression risk has resolved 3
- Supplemental oxygen administration is mandatory 6
- Have reversal agents (naloxone for remifentanil) and airway management equipment immediately available 6
Specific Adverse Event Profile
Significant hypotension occurs in 8.8% of patients and significant desaturation in 1.6% when using propofol-remifentanil TCI for moderate-to-deep sedation. 2
- Severe desaturation occurs in 0.6% and severe hypertension in 0.2% of cases 2
- In a large cohort of 2,937 procedures, zero deaths, zero CPR events, and zero unplanned ICU admissions occurred 2
- Transient apnea risk increases to 52% when propofol is added to remifentanil in patient-controlled sedation without lockout intervals 7
Patient-Specific Risk Factors
Higher BMI increases desaturation risk, while increased age and lower BMI increase hypotension risk—adjust target concentrations accordingly. 2
- Younger patients tolerate higher propofol concentrations; reduce maximum targets in elderly patients 2
- Patients with higher BMI require lower maximum propofol effect-site concentrations 2
- Longer procedure duration increases risk of both desaturation and hypotension 2
Recovery Characteristics
Time to achieve target sedation averages 63 seconds, with awakening occurring within 92 seconds after stopping drug infusion. 8
- Median time to home discharge is less than 70 minutes for both remifentanil alone and remifentanil-propofol combinations 7
- All patients maintain ability to move themselves to stretcher at procedure end 7
- Patient-controlled sedation with propofol-remifentanil achieves 95% success rate for ERCP procedures 5
Critical Safety Warnings
Never use remifentanil-propofol patient-controlled sedation without a minimum 1-2 minute lockout interval, as zero-lockout protocols increase apnea incidence from 15% to 52%. 7
- Propofol provides zero analgesic properties—remifentanil is essential for painful procedures 4, 9
- The combination produces synergistic respiratory depression beyond either agent alone 3, 9
- Propofol is contraindicated in egg, soy, or sulfite allergies 4
- Dose-dependent decreases in cardiac output and blood pressure occur with propofol 4
Hemodynamic Stability Data
In spontaneously breathing patients receiving propofol-remifentanil for deep sedation:
- Mean systolic blood pressure: 139 mmHg 8
- Mean arterial pressure: 107 mmHg 8
- Mean heart rate: 74 bpm 8
- All patients remained hemodynamically stable throughout procedures 8
Procedural Advantages
The combination provides superior procedural conditions compared to propofol alone, with fewer patient movements, coughing, and hiccups that interfere with examination. 1