Can patients be extubated while still on a propofol (propofol) infusion?

From the Guidelines

Patients can be extubated while on a propofol drip, but this approach requires careful consideration and monitoring, with a focus on minimizing morbidity, mortality, and optimizing quality of life. The propofol infusion should be reduced to a minimal sedative dose, typically 5-20 mcg/kg/min, before extubation is attempted, as supported by the guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit 1. The patient must demonstrate adequate respiratory drive, protective airway reflexes, and hemodynamic stability despite the ongoing sedation. Prior to extubation, the patient should be able to follow commands, have adequate tidal volumes, appropriate respiratory rate, and oxygen saturation above 92% on acceptable FiO2 levels.

Key Considerations

• The use of propofol for sedation in ICU patients has been associated with a range of benefits, including rapid onset and offset of sedation, and a reduced risk of delirium compared to benzodiazepines 1.
• However, propofol can also cause dose-dependent respiratory depression and hypotension, and long-term administration can lead to the saturation of peripheral tissues and prolonged emergence 1.
• The Difficult Airway Society guidelines for the management of tracheal extubation emphasize the importance of careful planning and monitoring during extubation, including the use of techniques such as laryngoscopy and suction under direct vision, and the insertion of a laryngeal mask airway (LMA) if necessary 1.

Monitoring and Management

• Post-extubation, continuous monitoring of respiratory status and hemodynamics is essential, with immediate access to airway equipment and personnel capable of reintubation if needed.
• The patient should be closely monitored for signs of respiratory depression, hypotension, and other potential complications of propofol administration, such as propofol infusion syndrome (PRIS) 1.
• The use of remifentanil infusions has been described as a method of providing conscious sedation for awake fibreoptic intubation and emergence, and may be useful in certain situations, such as neurosurgical or neurocritical care settings 1.

From the FDA Drug Label

Infusions of propofol injectable emulsion should be adjusted to maintain a light level of sedation prior to weaning patients from mechanical ventilatory support. Throughout the weaning process, this level of sedation may be maintained in the absence of respiratory depression Because of the rapid clearance of propofol injectable emulsion, abrupt discontinuation of a patient's infusion may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation, making weaning from mechanical ventilation difficult It is therefore recommended that administration of propofol injectable emulsion be continued in order to maintain a light level of sedation throughout the weaning process until 10 minutes to 15 minutes prior to extubation, at which time the infusion can be discontinued

Yes, patients can be extubated while still on a propofol drip, but the infusion should be adjusted to maintain a light level of sedation prior to weaning from mechanical ventilation and discontinued 10-15 minutes prior to extubation 2.

• The goal is to maintain a light level of sedation throughout the weaning process.
• Abrupt discontinuation of the infusion should be avoided to prevent rapid awakening and associated complications.
• The infusion can be continued until 10-15 minutes prior to extubation, at which time it can be discontinued 2.

From the Research

Extubation While on Propofol Drip

• Patients can be extubated while still on a propofol drip, as evidenced by studies comparing sedoanalgesia regimes in pediatric patients after elective surgery 3, 4.
• These studies found that patients treated with propofol-remifentanil had significantly shorter times to wake up and extubation after stopping the medication compared to those treated with midazolam-fentanyl.
• Another study found that propofol and midazolam are safe and effective sedative agents permitting early extubation in cardiac patients, with no differences in haemodynamic values, arterial blood gas tensions, and pulmonary function 5.
• However, extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% of patients, and identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection are necessary to decrease the occurrence of difficult or failed extubation 6.
• In the emergency department (ED) setting, a subset of intubated patients can safely be extubated, but patients selected for extubation should have a low or near zero risk of reintubation or extubation failure, and intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements 7.