Propofol Infusion Starting Dose
For ICU sedation in mechanically ventilated adults, initiate propofol at 5 mcg/kg/min (0.3 mg/kg/h) as a continuous infusion, then increase by increments of 5-10 mcg/kg/min every 5 minutes until desired sedation is achieved. 1
ICU Sedation Protocol
Initial Dosing Strategy
- Start at 5 mcg/kg/min (0.3 mg/kg/h) for intubated, mechanically ventilated adults to minimize hypotension 1
- Allow a minimum of 5 minutes between dose adjustments for peak drug effect 1
- Increase by increments of 5-10 mcg/kg/min (0.3-0.6 mg/kg/h) until target sedation level is reached 1
Maintenance Dosing
- Most adult ICU patients require 5-50 mcg/kg/min (0.3-3 mg/kg/h) for maintenance 1
- Medical ICU patients or those recovered from general anesthesia may require ≥50 mcg/kg/min for adequate sedation 1
- Never exceed 4 mg/kg/h (approximately 67 mcg/kg/min) unless benefits clearly outweigh risks 1
Critical Safety Considerations
Propofol Infusion Syndrome (PRIS)
- Doses >70 mcg/kg/min (4.2 mg/kg/h) for >48 hours dramatically increase PRIS risk, which carries up to 33% mortality 2
- PRIS presents with metabolic acidosis, rhabdomyolysis, cardiac arrhythmias, myocardial failure, renal failure, and hepatomegaly 3
- Recent case reports document PRIS at rates as low as 1.9-2.6 mg/kg/h, indicating the safe dosage threshold may need re-evaluation 3
Hemodynamic Monitoring Requirements
- Propofol causes dose-dependent decreases in cardiac output, systemic vascular resistance, and arterial pressure 2
- Continuous monitoring of heart rate, blood pressure, and oxygen saturation is mandatory 2
- Hypotension occurs in 5-7% of patients and is more likely at higher infusion rates 2
High-Risk Populations Requiring Dose Reduction
- Reduce initial dose by 20-80% in elderly, debilitated, or ASA-PS III-IV patients who demonstrate exaggerated hemodynamic responses 1
- Patients with compromised myocardial function, intravascular volume depletion, or abnormal vascular tone (e.g., sepsis) are more susceptible to hypotension 1
- Patients receiving large doses of narcotics require reduced propofol dosing 1
Alternative Dosing for Specific Contexts
Procedural Sedation (Non-ICU)
- For endoscopic procedures using nurse-administered propofol sedation (NAPS), initial bolus doses range from 10-60 mg, with additional 10-20 mg boluses every 20-30 seconds as needed 4
- Mean total doses for colonoscopy range from 144-287 mg depending on target sedation depth 4, 2
Palliative Sedation
- For refractory symptoms at end of life, use a loading dose of 20 mg followed by maintenance infusion of 50-70 mg/h 2, 5
Key Clinical Pitfalls
Analgesic Requirements
- Propofol has zero analgesic properties and must be combined with opioids or other analgesics for painful procedures 2
- Adequate pain management with analgesics may reduce propofol requirements 1
Pharmacogenomic Considerations
- For CYP2B6 poor metabolizers, reduce maintenance infusion to 25 mcg/kg/min (approximately 50% reduction from standard range) 2
Daily Assessment Protocol
- Evaluate sedation level and CNS function daily to determine minimum effective dose 1
- Avoid abrupt discontinuation; taper gradually to prevent rapid awakening with anxiety, agitation, and ventilator resistance 1
- Recovery from sedation is typically rapid, averaging 15.5 minutes after stopping infusion 6