Pharmacology

Propofol

Propofol (Diprivan) is perhaps the most well known intravenous hypnotic used in perioperative and intensive care medicine. This “milk of amnesia” is prepared in a lecithin-based (purified egg yolk) emulsion. Similar to many other IV anesthetics, propofol potentiates GABA, one of the primary inhibitory neurotransmitters in the central nervous system, to hyperpolarize post-synaptic neurons. Its perfusion-dependent hepatic metabolism and favorable context-sensitive half-time make propofol infusions a wonderful option in a myriad of contexts.

As an intensivist, I most commonly use propofol (in combination with agents like fentanyl and dexmedetomidine) to provide sedation for patients on mechanical ventilation. I also use it for bedside procedures like dressing changes on patients who sustained large area burns.

As an anesthesiologist, propofol is the staple for nearly all of my general anesthetic inductions, the backbone of my total intravenous anesthesia (TIVA) cases, a great option for monitored anesthesia care (MAC) cases (remi-fol, keto-fol), a rescue antiemetic in the PACU, an anticonvulsant, a form of neuroprotection (ie, prior to deep hypothermic circulatory arrest), a way to quickly deepen an anesthetic prior to intense stimuli (ie, Mayfield skull pins), and in my opinion, a very “predictable” medication.

Although it’s a myocardial depressant, decreases afterload, and can create myoclonic movements, perhaps propofol’s most concerning side effect is PRIS – propofol infusion syndrome. This rare presentation is characterized by muscle breakdown, metabolic acidosis, kidney failure, high triglycerides, and heart failure.

Because of its lipid emulsion, propofol actually has 1.1 kcal/cc (which can add up with high dose infusions!) Also, phenolic metabolites can manifest as green urine!

Drop me a comment below with questions! 🙂

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