What is the recommended propofol (Total Intravenous Anesthesia (TIVA)) infusion regimen?

Propofol Infusion for TIVA: Recommended Regimen

For maintenance of general anesthesia using propofol-based TIVA, administer a continuous infusion of 50-100 mcg/kg/min (3-6 mg/kg/hr) combined with short-acting opioids such as remifentanil (1-3 ng/ml via target-controlled infusion) or fentanyl boluses. 1, 2

Induction Dosing

Adult patients (ASA I-II, <55 years):

• Administer 2-2.5 mg/kg propofol titrated as 40 mg boluses every 10 seconds until loss of consciousness 2
• Avoid rapid bolus administration 3

Elderly, debilitated, or ASA III-IV patients:

• Reduce induction dose to 1-1.5 mg/kg administered as 20 mg boluses every 10 seconds 2
• Critical safety warning: Never use rapid bolus dosing in these populations due to severe cardiorespiratory depression risk 2

Pediatric patients (3-16 years, ASA I-II):

• Induction dose: 2.5-3.5 mg/kg, with younger children requiring higher doses than older children 2
• After sevoflurane induction, use reduced propofol bolus of 1 mg/kg to avoid burst suppression on EEG monitoring 4

Maintenance Infusion Rates

Standard TIVA maintenance (propofol as primary agent):

• Initial 10-15 minutes: 150-200 mcg/kg/min 2
• After first 30 minutes: Decrease by 30-50% 2
• Optimal maintenance: 50-100 mcg/kg/min to optimize recovery times 2
• Do not use rates <100 mcg/kg/min when propofol is the primary agent 2

Opioid-based technique (propofol as adjunct):

• Maintenance rate: minimum 50 mcg/kg/min 2
• Must ensure adequate amnesia with this lower-dose regimen 2

Pediatric maintenance:

• Initial rate: 200-300 mcg/kg/min immediately following induction 2
• After first 30 minutes: 125-150 mcg/kg/min 2
• Younger children require higher rates than older children 2

Target-Controlled Infusion (TCI) Dosing

When using TCI systems:

• Effect-site concentration: 0.5-1 mcg/ml for sedation 3
• Caution: Concentrations >1.5 mcg/ml significantly increase over-sedation and hypoventilation risk, especially with concurrent opioids 3
• Always avoid bolus dosing with TCI 3

Opioid Combination Regimens

Remifentanil combination (preferred for TIVA):

• TCI effect-site concentration: 1-3 ng/ml 3
• Continuous infusion: 0.2 mcg/kg/min 5
• Warning: This combination produces synergistic respiratory depression beyond either agent alone 6

Fentanyl combination:

• Bolus: 0.5-1 mcg/kg, with subsequent 0.5 mcg/kg doses as needed 3
• Morphine premedication (0.15 mg/kg) reduces required propofol maintenance rates by approximately 30-50% 2

Alfentanil combination:

• Bolus: 5 mcg/kg, with subsequent 1-3 mcg/kg doses as required 3
• Simplified technique: Mix 45 ml propofol 1% with 2,500 mcg alfentanil in 50 ml syringe for remote locations 7

Critical Safety Monitoring

Mandatory continuous monitoring includes: 6

• Pulse oximetry
• Blood pressure and heart rate
• Capnography for early hypoventilation detection
• Processed EEG monitoring (BIS 40-60) to prevent awareness and avoid excessive depth 1, 4

Immediate availability required: 1, 6

• Vasopressors (ephedrine or metaraminol) for hypotension
• Airway management equipment
• Reversal agents (naloxone for opioid reversal)

Hemodynamic Considerations

Propofol causes dose-dependent decreases in: 1, 8

• Cardiac output
• Systemic vascular resistance
• Mean arterial pressure

Management strategy:

• Have vasopressors immediately available 1
• Consider lower extremity elevation for hypotension 1
• Reduce infusion rates by 50% in CYP2B6 poor metabolizers (start at 25 mcg/kg/min) 8

Neurosurgical Considerations

For neurosurgical cases: 1, 2

• Use slower induction: 20 mg boluses every 10 seconds
• Reduced induction requirements: 1-2 mg/kg total
• Maintenance: 50-100 mcg/kg/min
• Propofol decreases cerebral blood flow, cerebral metabolic rate, and intracranial pressure 1

Common Pitfalls to Avoid

Contraindications and allergies: 1, 8

• Avoid in egg, soy, or sulfite allergies (propofol contains 10% soybean oil and 1.2% egg phosphatide)
• Not contraindicated in sulfonamide allergy 8

Propofol Infusion Syndrome (PRIS): 8

• Risk increases with doses >70 mcg/kg/min for >48 hours
• Presents with metabolic acidosis, rhabdomyolysis, arrhythmias, myocardial failure
• Immediately discontinue propofol if PRIS suspected 8

Analgesia requirements: 1, 8

• Propofol provides zero analgesic properties—always combine with opioids for painful procedures 1, 6, 8

Injection pain: 8

• Occurs in up to 30% of patients with IV bolus
• Pretreat with lidocaine or use larger veins 2

Dosing Adjustments

Allow 3-5 minutes between dose adjustments to assess clinical effects 2

Reduce propofol doses by 50-75% when combining with remifentanil due to synergistic effects 6

Titrate infusion rates downward in absence of surgical stimulation to avoid unnecessarily high rates 2