Propofol Dosing for Intubation
For rapid sequence intubation in adults, administer propofol 2 mg/kg IV over 30 seconds, with dose reduction to 1-1.5 mg/kg (approximately 20 mg every 10 seconds) in elderly, debilitated, or ASA-PS III-IV patients to minimize cardiorespiratory depression. 1
Standard Adult Dosing
Induction Dose:
- Healthy adults (ASA-PS I-II, <55 years): 2-2.5 mg/kg IV, titrated as approximately 40 mg every 10 seconds until clinical signs show onset of anesthesia 1
- Elderly, debilitated, or ASA-PS III-IV patients: 1-1.5 mg/kg (approximately 20 mg every 10 seconds) - this represents an approximately 50% dose reduction from standard dosing 1
- Rapid bolus administration must be avoided in high-risk patients as it significantly increases the likelihood of hypotension, apnea, airway obstruction, and oxygen desaturation 1
Combination Therapy with Opioids
When propofol is combined with opioids for intubation, significantly lower propofol doses are required due to synergistic effects:
- Initial propofol bolus: 10-20 mg when combined with opioids and/or benzodiazepines 2, 3
- Remifentanil + propofol regimen: Remifentanil 2-4 mcg/kg IV over 90 seconds, followed by propofol 2 mg/kg IV over 30 seconds, with intubation attempted 90 seconds after remifentanil completion 4, 5
- The ED95 for remifentanil in this context is 2.4 mcg/kg (95% CI: 1.9-9.0 mcg/kg), with remifentanil 4 mcg/kg providing excellent intubating conditions in 95% of patients 4, 5
The combination approach allows for 50-75% reduction in propofol doses compared to monotherapy while maintaining excellent intubating conditions 6
Awake Intubation Sedation
For awake tracheal intubation (ATI), the Difficult Airway Society recommends a fundamentally different approach:
- Target-controlled infusion (TCI) at effect-site concentration of 0.5-1 mcg/mL 7
- Avoid bolus dosing entirely due to respiratory depression risk 7
- Doses exceeding 1.5 mcg/mL carry significant risk of over-sedation and hypoventilation, particularly with concomitant opioid use 7
Critical Safety Considerations
Cardiovascular Effects:
- Propofol causes dose-dependent decreases in cardiac output, systemic vascular resistance, and arterial pressure 2, 3
- In cardiac patients, use slower induction with boluses of 20 mg every 10 seconds, targeting total dose of 0.5-1.5 mg/kg 1
- Anticholinergic agents should be administered when increases in vagal tone are anticipated 1
Respiratory Depression:
- Approximately 5-7% of patients experience transient desaturation below 90% 2
- When combined with opioids, respiratory depression is synergistic and exceeds either agent alone 6
- Continuous pulse oximetry and capnography monitoring are mandatory 2, 6
Common Pitfalls to Avoid:
- Never use rapid bolus dosing in elderly or hemodynamically unstable patients - this is the most common cause of severe hypotension and apnea 1
- Do not exceed 70 mcg/kg/min for prolonged infusions due to risk of propofol infusion syndrome (PRIS), characterized by metabolic acidosis, rhabdomyolysis, cardiac failure, and death 8
- Propofol has zero analgesic properties - always consider adding analgesics for painful procedures 2, 6
- Allow adequate time between doses (at least 10 seconds per bolus) for peak effect assessment before administering additional drug 1
Real-World ICU Experience
A large prospective study of 472 urgent endotracheal intubations in the medical ICU demonstrated that propofol (average dose 99 mg per person) was safe and effective, with complication rates of: desaturation <80% in 7%, hypotension <70 mmHg in 4%, and 100% successful intubation 9. This real-world data supports propofol's utility even in critically ill patients when dosed appropriately.
Monitoring Requirements
Mandatory monitoring includes: