In a 68-year-old woman with chronic kidney disease, diabetes, and recent myocardial infarction undergoing coronary angiography, can I combine target-controlled infusion (TCI) of remifentanil with TCI of propofol for procedural sedation?

Can You Combine TCI Remifentanil with TCI Propofol?

No—propofol is strictly contraindicated in this patient with recent myocardial infarction, chronic kidney disease, and diabetes undergoing coronary angiography, regardless of delivery method. 1

Why Propofol Is Contraindicated in This Clinical Context

Propofol causes severe hemodynamic instability in post-MI and heart failure patients, including refractory cardiogenic shock. 1 The drug reduces cardiac output by up to 20% through combined vasodilation, sympatholysis, and direct myocardial depression. 1 It can precipitate marked hypotension and bradycardia via muscarinic-receptor activation, which is particularly dangerous in patients with already compromised cardiac function. 1

Your patient's recent myocardial infarction places her at extreme risk for these complications, making propofol an unacceptable choice even when delivered via target-controlled infusion.

Recommended Sedation Strategy for This Patient

First-Line Agent: Fentanyl

Fentanyl is the recommended first-line analgesic/sedative because it preserves coronary vasomotion, lowers myocardial oxygen demand, and maintains hemodynamic stability in ischemic hearts. 1 This is critical for your patient with recent MI.

• Fentanyl is explicitly preferred over morphine in this setting. 1 Morphine's active metabolites accumulate in renal failure (relevant given her CKD) and diminish the bioavailability of ADP-receptor antiplatelet agents, potentially increasing mortality after myocardial infarction. 1

When Deeper Sedation Is Required: Add Benzodiazepines

If fentanyl alone provides insufficient sedation, add a benzodiazepine such as midazolam. 1 Benzodiazepines produce a "nitroglycerin-like" effect by reducing cardiac filling pressures without compromising coronary blood flow. 1

• Benzodiazepines do not provoke myocardial ischemia and may actually augment coronary blood flow while decreasing oxygen consumption in ischemic myocardium. 1
• Their blood pressure impact is modest, mediated by direct vasodilation with clinically insignificant negative inotropic effects. 1

Additional Agents to Avoid

Dexmedetomidine should also be avoided during the acute angiography procedure. 1 It is linked to refractory cardiogenic shock, bradycardia, and hypotension in vulnerable cardiac patients, and reduces cardiac output at both low and high infusion rates. 1

Critical Contrast Management for This Patient

Given her combination of CKD and diabetes, contrast-induced nephropathy is a major concern:

• Estimate creatinine clearance and adjust all renally cleared drug doses accordingly. 2
• Use iso-osmolar contrast agents for patients with chronic kidney disease undergoing angiography. 2
• Provide adequate pre-procedural hydration to mitigate contrast-induced nephropathy. 2
• Limit total contrast volume to <350 mL or <4 mL/kg and keep the contrast-volume-to-eGFR ratio below 3.4. 1
• The combination of diabetes and renal impairment raises the incidence of contrast-induced nephropathy to approximately 20-50%. 1

Hemodynamic Monitoring Requirements

Continuous invasive or non-invasive hemodynamic monitoring is essential. 1 The coexistence of recent myocardial infarction, chronic kidney disease, and diabetes increases cardiovascular mortality risk by 10- to 30-fold compared with the general population. 1

Regarding TCI Propofol-Remifentanil in General Populations

While your specific patient cannot receive propofol, it's worth noting that in appropriate patients without recent MI or heart failure, TCI remifentanil can be safely combined with TCI propofol. 3, 4 Research demonstrates that remifentanil administered via TCI results in decreased propofol requirements and a lower incidence of apnea and respiratory depression compared to manually controlled remifentanil administration. 3 The combination reduces propofol effect-site concentration requirements by approximately 29% (from 2.19 to 1.55 μg/mL). 4

However, this combination carries significant hemodynamic effects, with major decreases in systolic arterial pressure (30-32%), cardiac output (32%), and systemic vascular resistance (24-28%) during induction. 5 These effects make the combination particularly dangerous in your patient population.