What propofol dose is recommended for rapid sequence endotracheal intubation in healthy adults, elderly/frail patients, and children over 1 year, and how should it be adjusted when combined with opioids and neuromuscular blockers?

Propofol Dosing for Rapid Sequence Intubation

For rapid sequence intubation in healthy adults, use propofol 10-20 mg boluses when combined with opioids and neuromuscular blockers; in elderly/frail patients reduce the dose by 50-75%; and in children over 1 year use 2.5-3.0 mg/kg preceded by fentanyl 3 mcg/kg. 1, 2, 3

Healthy Adults

Standard dosing with combination therapy:

• Administer propofol 10-20 mg boluses when combined with opioids and/or benzodiazepines for intubation 1
• The combination with opioids allows a 50-75% dose reduction compared to propofol monotherapy while maintaining excellent intubating conditions 1
• Fentanyl 1-2 mcg/kg (or 25-100 mcg bolus) should be given 3 minutes before propofol to blunt the sympathetic response to laryngoscopy 2

Alternative regimen for hemodynamic stability:

• For hypertensive patients, consider a manually controlled infusion: alfentanil 10 mcg/kg, followed 30 seconds later by propofol 10-12 mg/kg/h infusion for 2 minutes, then propofol 1-1.5 mg/kg bolus 4
• This infusion technique attenuates the pressor response to intubation better than bolus dosing alone 4

Elderly and Frail Patients

Mandatory dose reduction:

• Reduce propofol dose to 25 mcg/kg/min in patients over 60 years or ASA physical status 3 or above to minimize cardiovascular depression 2
• This represents approximately a 50-75% reduction from standard adult dosing 1
• In hemodynamically unstable elderly patients, consider etomidate (10-20 mg) instead of propofol due to superior cardiovascular stability 2

Critical safety consideration:

• Propofol causes dose-dependent decreases in cardiac output, systemic vascular resistance, and arterial pressure—effects that are magnified in elderly patients 1

Children Over 1 Year

Recommended dosing protocol:

• Administer fentanyl 3 mcg/kg first, wait 5 minutes, then give propofol 3.0 mg/kg for adequate intubating conditions without neuromuscular blockers 3
• If neuromuscular blockers are used, propofol 2.5 mg/kg combined with fentanyl 2 mcg/kg provides acceptable conditions 3, 5
• Lower doses (2.5 mg/kg) result in only 20% adequate intubating conditions, while 3.0-3.5 mg/kg provides 75-80% adequate conditions 3

Alternative combination for children:

• Fentanyl 2 mcg/kg + midazolam 0.03 mg/kg + propofol 2.5 mg/kg provides 100% successful intubation and better conditions than lignocaine-based combinations 6
• Premedication with midazolam 0.1 mg/kg given 5 minutes before induction improves intubating conditions 3

Adjustments When Combined with Opioids and Neuromuscular Blockers

Synergistic dose reduction:

• When propofol is combined with remifentanil, total propofol requirements decrease to 35-100 mg compared to 200-300 mg for propofol alone—a 50-75% reduction 7
• The combination produces synergistic respiratory depression exceeding either agent alone, requiring careful titration 7, 1

Specific combination regimens:

• Remifentanil 0.125 µg/kg/min for 2 minutes, then 0.05 µg/kg/min continuous infusion, combined with propofol 10-20 mg boluses every 20-30 seconds until target sedation achieved 7
• For target-controlled infusion: propofol effect-site concentration 0.5-1 mcg/mL with remifentanil 1-3 ng/mL 7, 1

Critical Safety Warnings

Avoid bolus dosing in high-risk situations:

• The Difficult Airway Society specifically warns to avoid bolus dosing of both propofol and remifentanil due to respiratory depression risk 7, 1
• Doses exceeding 1.5 mcg/mL carry significant risk of over-sedation and hypoventilation, particularly with concomitant opioid use 1

Mandatory monitoring requirements:

• Continuous pulse oximetry, capnography, blood pressure, and heart rate monitoring are required 1, 7
• Approximately 5-7% of patients experience transient desaturation below 90% with propofol 1
• A dedicated healthcare provider who performs no other tasks must be present throughout sedation 7
• Bag-mask ventilation equipment, reversal agents (naloxone), and advanced airway equipment must be immediately available 7, 2

Hemodynamic considerations:

• In hypotensive or hemodynamically unstable patients, use ketamine (0.5-2 mg/kg) or etomidate (10-20 mg) instead of propofol 2
• Propofol provides zero analgesic properties—opioids are essential for painful procedures 1, 7