What are the contraindications for using a propofol (propofol) drip in patients?

Propofol Drip Contraindications

Propofol is absolutely contraindicated in patients with known hypersensitivity to propofol itself, and in those with allergies to eggs, egg products, soybeans, or soy products, as stated in the FDA prescribing information. 1

Absolute Contraindications

• Hypersensitivity to propofol or any formulation component is an absolute contraindication per FDA labeling 1
• Allergy to eggs or egg products (propofol contains 1.2% purified egg phosphatide) 2, 1
• Allergy to soybeans or soy products (propofol contains 10% soybean oil) 2, 1
• Allergy to sulfites (some formulations contain metabisulfite as a preservative) 2

Important Caveat on Food Allergies

• Propofol is NOT contraindicated in patients with sulfonamide allergy (distinct from sulfite allergy) 2
• Recent evidence suggests propofol may be safe in patients with nonanaphylactic food allergies to egg or soy, though the FDA contraindication remains in effect 3
• Patients with documented anaphylactic reactions to egg or soy should absolutely avoid propofol 4

Relative Contraindications and High-Risk Situations

Cardiovascular Conditions Requiring Extreme Caution

• Acute heart failure and cardiogenic shock: Propofol causes significant decreases in preload, afterload, cardiac contractility, and cardiac output, making benzodiazepines a safer alternative in this population 2
• Severely depressed left ventricular function: The European Heart Journal recommends avoiding propofol in patients with failing hearts due to reports of severe hemodynamic instability 2
• Significant valvular heart disease: Propofol causes hypotension and reduced cardiac output in this population 2
• Hypovolemia: Even small induction doses (0.75-1.5 mg/kg) can produce profound hypotension in volume-depleted patients 5, 6

Propofol Infusion Syndrome (PRIS) Risk Factors

• Prolonged infusions >48 hours at doses >70 mcg/kg/min carry significant risk for PRIS, which has 33% mortality 7
• PRIS has been reported at doses as low as 1.9-2.6 mg/kg/hr 8
• Switch to dexmedetomidine or benzodiazepines after 48 hours of continuous propofol infusion to minimize PRIS risk 7

Neurological Considerations

• Intracranial hypertension without normal compliance: While propofol decreases intracranial pressure, ketamine is contraindicated in this setting—propofol may actually be beneficial 6
• Status epilepticus: Propofol has potent anticonvulsant properties and is not contraindicated 9

Metabolic and Organ Dysfunction

• Cirrhosis or renal failure do NOT significantly affect propofol pharmacokinetics and are not contraindications 2, 8
• Monitor for hypertriglyceridemia with prolonged use (propofol contains 10% soybean oil) 7, 9

Clinical Algorithm for Propofol Use Decision-Making

Step 1: Screen for Absolute Contraindications

• History of anaphylaxis to propofol, eggs, soy, or sulfites → DO NOT USE 1

Step 2: Assess Cardiovascular Status

• Cardiogenic shock or acute decompensated heart failure → Use benzodiazepines + opioids instead 2
• Severe LV dysfunction (EF <30%) → Strongly consider benzodiazepines as safer alternative 2
• Hypovolemia → Resuscitate first, or use etomidate for rapid sequence intubation 6
• Stable cardiovascular status → Propofol acceptable with careful titration 2

Step 3: Duration of Sedation Planning

• <48 hours → Propofol acceptable at 5-50 mcg/kg/min 7
• >48 hours anticipated → Start with propofol but plan transition to dexmedetomidine (0.2-0.7 mcg/kg/hr) or midazolam-based sedation at 48-hour mark 7
• Never exceed 70 mcg/kg/min to prevent PRIS 7

Step 4: Monitor for PRIS

• Daily monitoring of triglycerides, arterial blood gases, renal and liver function 7
• Immediately discontinue propofol if unexplained metabolic acidosis, hypertriglyceridemia, hypotension with increasing vasopressor requirements, or arrhythmias develop 8, 7

Common Pitfalls to Avoid

• Do not use propofol for sleep promotion in ICU patients—it suppresses REM sleep without benefit 7
• Do not forget analgesia—propofol has minimal analgesic effect and must be combined with opioids for painful procedures 2, 8
• Do not give rapid boluses in hemodynamically unstable patients—start at 5 mcg/kg/min without loading dose 7
• Do not confuse sulfonamide allergy with sulfite allergy—only sulfite allergy is a contraindication 2