Use Of Propofol Infusion Research Articles

Survey of Pharmacists Regarding the Use of Propofol Infusions in the PICUs in North America

The objective of this survey was to assess the current use of continuous infusion propofol in PICUs across the United States and Canada. A list of institutions with PICU beds/units was identified through the residency directories available on the American Society of Health-Systems Pharmacists (ASHP) and Canadian Society of Hospital Pharmacists (CHSP) Web sites. A REDCap questionnaire was sent to each identified institution's program director via email. An initial reminder email was sent out 2 weeks later and a second reminder email was sent 4 weeks after the initial request. The survey was closed at 6 weeks. A total of 514 emails were sent to residency program directors, and 50 pharmacists responded to the survey. Of the pharmacists that did respond, 27 (54%) reported using propofol while 23 (46%) did not. Of those that did not, 43.5% reported the FDA boxed warning as the primary reason. Thirty-seven percent of respondents using propofol felt comfortable using a maximum infusion rate of 200 mcg/kg/min. Twenty-nine percent, 25%, and 33% of those who responded as using propofol felt comfortable using this agent for a maximum duration of 24, 48, and 72 hours, respectively. The majority of respondents using propofol did not have a case of propofol-related infusion syndrome. Despite the FDA warning, propofol is used as a continuous infusion (with variable limitations) by a majority of pharmacists in North America. Self-reported incidence of propofol-related infusion syndrome (PRIS) remains low.

Anaesthesia Management and Use of Sugammadex in a Patient with Ullrich’s Disease

Here, we report anaesthesia management and the successful use of total intravenous anaesthesia and sugammadex in a patient with Ullrich's disease. Propofol and remifentanyl infusion was used for anaesthesia. After the end of the surgery, when the train-of-four value was 0%, 4 mg kg(-1) sugammadex was administered, and the patient was successfully extubated after 36 s. No adverse effects or safety concerns were observed. In conclusion, we suggest that the use of propofol infusion to avoid the use of inhalation anaesthetics and the use of sugammadex for the reversal of the effects of rocuronium is safe in patients with Ullrich's disease.

Is Propofol a Friend or a Foe of the Pediatric Intensivist? Description of Propofol Use in a PICU*

The primary objective is to describe the practice patterns of nonprocedural propofol use in a single-center referral PICU. The secondary objective is to describe the rate of concordance of propofol use with the PICU local practice of a maximum mean rate of 4 mg/kg/hr and a maximum duration of 24 hours and to assess for signs and symptoms of propofol infusion syndrome. Retrospective descriptive cohort study. PICU of a tertiary care teaching hospital and referral hospital for the Western Canada. Children 1 month to 17 years old who received a nonprocedural propofol infusion between January 1, 2009, and December 31, 2009. None. Two hundred twenty-three infusions (representing 210 unique patients) were included in the study. The median average infusion rate (interquartile range) including boluses was 2.7 mg/kg/hr (1.9-3.6 mg/kg/hr), and the mean infusion duration (SD) was 10.3 hours (6.7 hr). Eighty-seven percent and 98% of infusions were concordant with PICU intensivists self-reported practice maximum rate and duration, respectively. No cases of propofol-related infusion syndrome or deaths associated with propofol infusions were identified. The use of propofol infusions was in concordance with PICU local practice, and propofol infusion syndrome did not developed in patients. In agreement with previous recommendations, propofol infusions in the PICU appear to be safe when limiting doses to 4 mg/kg/hr and for less than 24 hours; however, appropriate monitoring of adverse effects is still warranted due to absence of robust evidence.

A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures

There is controversy whether proceduralist-directed, nurse-administered propofol sedation (PDNAPS) is safe. To assess the frequency of adverse events when PDNAPS is used for implantable cardioverter-defibrillator (ICD)-related procedures and to determine the patient and procedural characteristics associated with adverse events. Consecutive ICD-related procedures using PDNAPS from May 2006 to July 2009 at a tertiary-care hospital were evaluated. Serious adverse events were defined as procedural death, unexpected transfer to an intensive care unit, respiratory failure requiring intubation/bag-mask ventilation, or hypotension requiring vasoconstrictor/inotrope support. Nonserious adverse events were defined as hypotension requiring fluid resuscitation or hypoxemia requiring augmented respiratory support with non-rebreather mask, oral airway, or jaw lift. Of 582 patients (age 64 ± 14 years, 72.3% males) undergoing ICD-related procedures using PDNAPS, 58 (10.0%) patients had serious adverse events with no procedural death and 225 (38.7%) had nonserious adverse events. Longer procedure duration (relative risk [RR] = 2.1 per hour; 95% confidence interval [CI] = 1.6-2.8; P < .001) and biventricular implant (RR = 2.7; CI = 1.4-5.3; P = .003) were independent predictors of serious adverse events. A longer procedure duration (RR = 1.4 per hour; CI = 1.1-1.7; P = .001), heart failure class (RR = 1.4 per 1 class; CI = 1.1-1.7; P = .002), and use of propofol infusion (RR = 3.5; CI = 2.2-5.7; P < .001) were independent predictors of nonserious adverse events. PDNAPS for shorter ICD procedures including single- and dual-chamber implants, generator changes, and defibrillation threshold testing have acceptable rates of serious adverse events and manageable nonserious adverse events and should be considered for further study. Biventricular implants and other complex procedures should be done with an anesthesiologist.

A national survey of propofol infusion use by paediatric anaesthetists in Great Britain and Ireland

Since the introduction of propofol in 1977, it has been widely used for the induction and maintenance of anaesthesia and for sedation on the intensive care unit. Recently, case reports of suspected propofol infusion syndrome (PRIS) following short term infusions have been published. We set out to obtain a picture of the current use of propofol infusions by paediatric anaesthetists in Great Britain and Ireland. A questionnaire concerning the use of propofol infusions was sent to 388 paediatric anaesthetists. A total of 242 (62%) replies were received. 26% of anaesthetists used propofol infusions with at least a monthly frequency. 136 (56%) anaesthetists thought that propofol infusions were of benefit in reducing postoperative nausea and vomiting. The majority of anaesthetists did not state a maximum infusion rate or length of infusion. Of those anaesthetists who answered the questions the maximum rate used was 30 mg x kg(-1) x h(-1) and the longest time considered for an infusion was 72 h. Only 5 (2%) anaesthetists regularly used BIS monitoring, although 106 (44%) expressed a desire to use it if it was freely available in their hospitals. Modifications to infusions from 1% to 2% propofol were used by 38 (16%) anaesthetists and 28 (12%) used glucose infusions intra-operatively. There is a wide variety in the use of propofol infusions by paediatric anaesthetists. The mechanisms underlying PRIS are poorly understood and require further work to ensure propofol infusions are used appropriately for anaesthesia in children.

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Paediatric total intravenous anaesthetic use: a nationwide study

Introduction: Propofol is widely used for induction and maintenance of anaesthesia in paediatric patients. Following the initial reports of deaths following prolonged high dose infusions on intensive care (1), the propofol infusion syndrome was described (2). The exact cause of this is still uncertain but consistent biochemical abnormalities have been described (3, 4). Initially the cases were all in children on intensive care units, but more recently cases have been reported in adults. Of greater concern to paediatric anaesthetists are the reports of deaths following propofol infusions in theatre (5, 6). We set out to define the current use of propofol infusions by Paediatric Anaesthetists within the UK. Methods: A list of names and addresses of paediatric anaesthetists was composed by contacting anaesthetic departments at the hospitals by telephone and asking for the names of their paediatric anaesthetists. An 18 question survey with an enclosed stamped, addressed envelope was posted to 388 consultant paediatric anaesthetists in 51 hospitals throughout the UK. The survey was re-submitted once to consultants who had not initially replied. The results were tabulated onto a database and analysed. Results: We received a total of 242 replies (63% of surveyed population), 240 of which regularly anaesthetised children. Within the last year 13% had used propofol infusions on children under 1, 31% in children 1–5 years, 41% in children 5–10 years and 46% in the over 10 s. The two most common surgical specialties with which propofol TIVA was used were ENT (n = 66), and orthopaedics (n = 53), the most common operations stated being middle ear surgery, muscle biopsy and scoliosis surgery. The reasons for using propofol in these patients were broad and included both anaesthetic and surgical considerations. 60 consultants questioned used propofol infusions in children at least monthly, 98 rarely and 72 never. Over 50% of replies believed that propofol infusions reduced the rate of postoperative nausea and vomiting in respect to inhalational techniques, less agreed that there was faster recovery time or time to discharge. Remifentanil was commonly used with propofol infusions but target controlled infusion devices were uncommonly used. The longest time anyone considered using propofol for was 72 h, although the mode of all positive responses was 6 h. The majority of people failed to give a maximum infusion rate. Conclusions: Propofol infusions are used widely throughout the UK for their perceived anaesthetic and surgical benefits. Given that there are well documented catastrophic, albeit rare side effects, it is surprising that there are no guidelines for infusions in theatre. Further work is required to elucidate the exact mechanism of propofol infusion syndrome to guide future anaesthetic practice. References 1 Parke TJ, Stevens JE, Rice AS et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. Br Med J 1992; 305: 613–616. 2 Bray RJ. Propofol infusion syndrome in children. Paediatr Anaes 1998; 8: 491–499. 3 Wolf AR, Weir P, Segar P, et al. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001; 357: 606–607. 4 Wolf AR, Potter F. Propofol infusion in children: when does an anesthetic tool become an intensive care liability? Paediatr Anaesth 2004; 14: 435–438. 5 Mehta N, DeMunter C, Habibi P et al. Short-term propofol infusions in children. Lancet 1999; 354: 866–867. 6 Kill C, Leonhardt A, Wulf H. Lacticacidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003; 13: 823–826.

Use of propofol infusion in Australian and New Zealand paediatric intensive care units.

Despite the risk of propofol infusion syndrome, a rare but often fatal complication of propofol infusion in ventilated children and possibly adults, propofol infusion remains in use in paediatric intensive care units (PICU). This questionnaire study surveys the current pattern of use of this sedative infusion in Australian and New Zealand PICUs. Thirty-three of the 45 paediatric intensive care physicians surveyed (73%), from 12 of the 13 intensive care units, returned completed questionnaires. The majority of practitioners (82%) use propofol infusion in children in PICU, the main indication being for short-term sedation in children requiring procedures. 39% of respondents consider propofol infusion useful in ventilated children requiring longer-term sedation. 67% of paediatric intensivists use maximum infusion doses that may be considered dangerously high (> or = 10 mg/kg/h). Nineteen per cent use propofol infusion for prolonged periods (> 72 hours). A smaller proportion (15%) of respondents indicate that they may use both higher doses and prolonged periods of infusion, a practice likely to lead to a greater chance of serious adverse events. Knowledge of local protocols for the use of propofol infusion is associated with a significantly greater level of monitoring for possible adverse events. We suggest that national guidelines for the use of propofol infusion in children should be developed. These should include clear indications and contraindications to its use, a maximum dose rate and maximum period of infusion, with a ceiling placed on the cumulative dose given and clearly stated minimum monitoring requirements.

Propofol infusion syndrome in children.

The use of propofol infusions to sedate children in intensive care units has decreased after reports of deaths from myocardial failure. More recently it has been suggested that propofol might have been prematurely condemned. Information about 18 children who had received propofol infusions and suffered serious unwanted effects was used to define their common features. Three of the deaths occurred in one intensive care unit where propofol infusions had been used between 1987 and 1993. During this period 44 children with respiratory tract infections had been admitted to this unit and sedated for at least 48 h. Nine had received long-term (> 48 h), high-dose (> 4 mg.kg-1.h-1) propofol infusions and three had developed progressive myocardial failure and died. There was a significant association between receiving a long-term, high-dose propofol infusion and developing progressive myocardial failure (Fisher's Exact Test, two-tailed hypothesis, P = 0.0128) although a causative relationship could not be proved.

The changing role of monitored anesthesia care in the ambulatory setting.

The changing role of monitored anesthesia care in the ambulatory setting.

Mitral Valve Replacement in a Patient with Acute Intermittent Porphyria

Mitral Valve Replacement in a Patient with Acute Intermittent Porphyria

Use of propofol infusion for sedation following coronary artery surgery

Use of propofol infusion for sedation following coronary artery surgery