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 potenPropofol (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. Like 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 good context-sensitive half-time make propofol infusions an excellent option in many contexts.

As a CVICU intensivist, I most commonly use propofol combined with agents like fentanyl and dexmedetomidine to provide sedation for patients on mechanical ventilation. As a cardiothoracic anesthesiologist, propofol is the staple for nearly all of my general anesthetic inductions, the backbone of my total intravenous anesthesia cases, a great option for monitored anesthesia care cases (plain propofol, remi-fol, keto-fol), a rescue antiemetic in the PACU, an anticonvulsant, a form of neuroprotection (e.g., before deep hypothermic circulatory arrest), a way to deepen an anesthetic before intense stimuli (e.g., Mayfield skull pins), and in my opinion, a very “predictable” medication.

Although it’s a myocardial depressant, decreases afterload, and can create myoclonic movements, propofol’s most concerning side effect is propofol infusion syndrome (PRIS). This rare presentation is characterized by muscle breakdown, metabolic acidosis, kidney failure, high triglycerides, and heart failure. It’s seen more often with high dose, long-duration infusions.

Because of its lipid emulsion, propofol has 1.1 kcal/cc, leading to overfeeding when coupled with enteral feeds! Also, propofol’s phenolic metabolites can present as green urine!

Drop me a comment below with questions! :-)