DOI: 10.1097/TA.0b013e31815eb16b

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PMID: 18188128

Issn Print: 0022-5282

Publication Date: 2008/01/01


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Letters to the Editor

Babak Sarani; Vicente Gracias

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We read with interest the brief review by Rosen et al. in the August issue of the Journal of Trauma regarding the safety and efficacy of propofol.1 We echo many of the same concerns and experiences with high dose propofol that the authors report; however, we think that propofol, when dosed correctly, has proven benefit as a sedative in the adult intensive care unit. Furthermore, we suggest caution in exaggerating the risk of propofol infusion syndrome for fear of “throwing the baby out with the bathwater”.
Propofol is a safe drug with many advantages over other sedatives when used within the limits that the authors state their institution now uses. The patients that the authors cite received doses between 70 and 200 μg/kg/min for at least 72 hours, and many of the references cited to illustrate the risk of propofol infusion syndrome refer to either pediatric patients or extremely high doses used as a part of a general anesthetic. Most institutions, including ours and now the authors’, limit the use of propofol in the intensive care unit (ICU) to 80 μg/kg/min. Other causes for agitation must be examined or other agents must be used in cases where this dose is not sufficient to obtain the depth of sedation desired. Using higher doses to lower intracranial pressure is not evidence-based and may be dangerous. Longer duration of use at this maximal dose may also be safe and efficacious, but propofol’s utility as a short acting agent decreases as the duration of use increases. Where the cost-benefit ratio of propofol to other less expensive but longer acting agents, such as lorazepam, makes propofol less favorable varies based on drug acquisition cost, dosing regimen, and adherence to a daily interruption regimen for sedation in the ICU. A recent randomized study by Carson et al. found that median ventilator days were significantly shorter (5.8 days vs. 8.4 days) for patients who received continuous propofol instead of intermittent lorazepam despite longer duration of infusion.2 The maximal propofol dose used in this study was 80 μg/kg/min and there were no adverse side effects.
In conclusion, we agree that high dose propofol may be hazardous, even with short infusion times. However, when dosed appropriately, propofol is a safe sedative in the ICU and has been shown to decrease the time to extubation, which, in turn, may decrease the incidence of nosocomial pneumonia in critically ill patients.
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