Propofol Contraindications
Propofol is contraindicated only in patients with known hypersensitivity to propofol itself or any of its components, and in patients with documented allergies to eggs, egg products, soybeans, or soy products, according to the FDA label. 1
Absolute Contraindications
- Known hypersensitivity to propofol or any component of the formulation 1
- Documented allergy to eggs or egg products 1
- Documented allergy to soybeans or soy products 1
The current propofol formulation contains 1% propofol, 10% soybean oil, 2.25% glycerol, and 1.2% purified egg phosphatide, which explains these contraindications. 2, 3
Important Clarification: Sulfonamide Allergy is NOT a Contraindication
Propofol is not contraindicated in patients with sulfonamide allergy, despite common misconceptions. 2, 3 This is a critical distinction that prevents unnecessary avoidance of propofol in patients with sulfa drug allergies.
The Food Allergy Controversy: Evidence vs. Label
While the FDA label lists egg and soy allergy as contraindications 1, emerging evidence suggests propofol may be safely administered to most patients with food allergies to egg, soy, or peanut:
Supporting Evidence for Safe Use Despite Food Allergies:
In a 2022 study of 64 patients with confirmed food allergies (egg, soy, or peanut), only 1 patient (1.6%) tested positive on propofol skin testing, suggesting cross-reactivity is rare. 4
A 2014 study of 60 adult eosinophilic esophagitis patients (86% sensitized to egg, soy, or peanut) underwent 404 upper endoscopies with propofol sedation without any allergic adverse events. 5
A 2017 pediatric study of 1365 esophagogastroduodenoscopies found no difference in complication rates when propofol was used in children with food allergies or eosinophilic esophagitis. 6
Practical Clinical Approach:
For patients with egg or soy allergy:
- Use extreme caution in patients with a history of anaphylaxis to egg or soy 4, 7
- Consider propofol safe in patients with mild-to-moderate food sensitivities or positive skin testing without clinical anaphylaxis 4, 5
- Have full resuscitation equipment immediately available 7
- Consider alternative sedatives (midazolam, dexmedetomidine) if there is any history of severe anaphylactic reactions to these foods 8
Relative Contraindications and High-Risk Situations
Propofol Infusion Syndrome (PRIS) Risk Factors:
Avoid or use extreme caution with propofol in:
- Prolonged infusions >48 hours, especially at doses >70 mcg/kg/min 8
- Critically ill patients requiring high-dose vasopressor support 8
- Patients with acute neurological illnesses or severe inflammatory conditions 8
- CYP2B6 poor metabolizers (reduce dose by 50% if used) 3
PRIS presents with metabolic acidosis, rhabdomyolysis, cardiac arrhythmias, myocardial failure, renal failure, and carries up to 33% mortality. 3, 8
Cardiovascular Considerations:
Use with caution in:
- Patients with pulmonary hypertension (risk of hemodynamic instability) 3
- Hemodynamically unstable patients (propofol decreases cardiac output, systemic vascular resistance, and arterial pressure) 2, 3
- Patients with severe cardiac dysfunction (negative inotropic effects) 2, 3
Drug Interactions:
Exercise caution when co-administering:
- Opioids, barbiturates, or other CNS depressants (potentiate sedative effects and increase risk of respiratory depression) 2, 3
Common Pitfalls to Avoid
- Do not confuse sulfonamide allergy with a contraindication to propofol 2, 3
- Do not automatically avoid propofol in all patients with food allergies—assess severity of prior reactions 4, 5
- Do not use propofol for prolonged ICU sedation beyond 48 hours without daily reassessment and consideration of alternative agents 8
- Do not forget that propofol has no analgesic properties—combine with opioids for painful procedures 3
- Monitor for early signs of PRIS (unexplained metabolic acidosis, hypertriglyceridemia, increasing vasopressor requirements) and discontinue immediately if suspected 8