Propofol Infusion Rate for TIVA in Breast Surgery
For a typical adult patient undergoing breast surgery with TIVA, maintain propofol at 100-200 mcg/kg/min (6-12 mg/kg/hr) combined with a continuous opioid infusion, with the specific rate depending on your opioid choice and depth of anesthesia monitoring. 1
Standard Maintenance Regimen
When propofol is the primary anesthetic agent combined with nitrous oxide (60-70%), infusion rates of 100-200 mcg/kg/min provide adequate anesthesia for general surgery procedures including breast cases. 1 The FDA label specifies that higher rates (150-200 mcg/kg/min) are typically required during the first 10-15 minutes following induction, then should be decreased by 30-50% during the first half-hour of maintenance. 1
Target maintenance rates of 50-100 mcg/kg/min during the later maintenance phase to optimize recovery times. 1 This lower range is appropriate once adequate depth is established and when combined with appropriate opioid analgesia.
Opioid Combination Strategies
The propofol requirement varies significantly based on your opioid selection:
Alfentanil-Based TIVA
- Propofol: 25-50 mcg/kg/min combined with alfentanil 0.2-0.4 mcg/kg/min provides adequate sedation, analgesia, and amnesia for breast surgery in patients premedicated with midazolam 2 mg. 2
- Research in breast biopsy procedures demonstrated this combination produced appropriate sedation (OAA/S scores 2-4) with minimal side effects. 2
- For induction, administer alfentanil 5 mcg/kg bolus, followed by 1-3 mcg/kg doses as needed during maintenance. 3
- A comparative study in breast surgery found alfentanil 20 mcg/kg for induction with 30 mcg/kg/hr maintenance required more frequent propofol boluses to maintain adequate anesthesia compared to sufentanil. 4
Sufentanil-Based TIVA
- Sufentanil 0.2 mcg/kg for induction followed by 0.3 mcg/kg/hr maintenance provides more stable anesthesia with less frequent need for additional propofol boluses. 4
- Patients receiving sufentanil had significantly less postoperative pain (P=0.03) and required less rescue opioids (0.4 vs 1.9 mg piritramid, P=0.04) compared to alfentanil. 4
Remifentanil-Based TIVA
- Target effect-site concentration of 1-3 ng/ml for remifentanil when using target-controlled infusion systems. 3
- A 2023 study demonstrated that propofol-remifentanil mixtures delivered by single TCI pump provided adequate hypnotic and analgesic effects under BIS and ANI monitoring for breast cancer surgery. 5
Critical Dosing Considerations
When Propofol is Primary Agent
Maintenance infusion rates should not be less than 100 mcg/kg/min when propofol is the primary anesthetic, and must be supplemented with analgesic levels of continuous opioid administration. 1 This ensures adequate depth of anesthesia and prevents awareness.
When Opioid is Primary Agent
If using high-dose opioid technique, propofol maintenance rates should not be less than 50 mcg/kg/min, with careful attention to ensuring amnesia. 1 Higher propofol doses will reduce opioid requirements. 1
Avoid High-Dose Opioid Technique
Do not combine propofol with high-dose opioid technique as this increases the likelihood of hypotension. 1
Titration Strategy
Initiate propofol at 150-200 mcg/kg/min immediately following induction for the first 10-15 minutes, then decrease by 30-50% to achieve maintenance rates of 50-100 mcg/kg/min. 1
- Administer incremental boluses of 25-50 mg when vital signs indicate response to surgical stimulation or light anesthesia. 1
- Allow 3-5 minutes between dose adjustments to assess clinical effects, as propofol blood concentrations at steady-state are proportional to infusion rates. 1
- Titrate infusion rates downward in the absence of clinical signs of light anesthesia until a mild response to surgical stimulation is obtained to avoid unnecessarily high rates. 1
Monitoring Depth of Anesthesia
Use processed EEG monitoring (BIS 40-60) to prevent awareness and avoid excessive depth. 3 The combination of BIS and ANI (Analgesia Nociception Index 50-70) monitoring allows precise titration of both hypnotic and analgesic components. 5
Special Population Adjustments
Elderly or ASA III-IV Patients
Avoid rapid bolus administration in elderly, debilitated, or ASA-PS III-IV patients as this increases cardiorespiratory depression including hypotension, apnea, and oxygen desaturation. 1 Reduce maintenance infusion rates accordingly based on clinical response.
Patients with Reduced Clearance
In patients with CYP2B6 poor metabolizer genotypes, reduce propofol infusion by approximately 50% (to 25 mcg/kg/min) to avoid excessive drug exposure and prolonged sedation. 6
Hemodynamic Management
Propofol decreases cardiac output, systemic vascular resistance, and arterial pressure in a dose-dependent manner. 3, 6
- Have vasopressors immediately available (ephedrine or metaraminol) to treat hypotension. 3
- Monitor heart rate, blood pressure, and pulse oximetry continuously throughout the case. 3
- Expect systolic/diastolic blood pressure decreases of 20/10-15 mmHg after induction. 7
Recovery Optimization
Maintaining propofol at 50-100 mcg/kg/min during the maintenance phase optimizes recovery times. 1 Research demonstrates a significant correlation between total propofol consumption and recovery time, with recovery ranging from 5.2 minutes at lower doses to 9.9 minutes at higher doses. 7
Common Pitfalls
- Never use propofol infusion rates below 100 mcg/kg/min when propofol is the primary anesthetic, as this risks inadequate anesthesia and awareness. 1
- Avoid rapid bolus dosing, which causes undesirable cardiorespiratory depression; instead use slow incremental boluses of 25-50 mg. 1
- Remember propofol has no analgesic properties—always combine with continuous opioid infusion for painful procedures. 6
- Do not exceed 70 mcg/kg/min for prolonged periods (>48 hours) to avoid Propofol Infusion Syndrome risk, though this is rarely relevant for breast surgery cases. 8