Clinical beta

FMBM is currently in clinical beta. Content is for professional review/testing and must not replace local protocols, senior clinical judgment, or official prescribing references.

Drug Monograph

Propofol

USE IF: Induction, procedural sedation, ICU sedation (adult only)

AVOID IF: Pediatric ICU sedation, hemodynamic instability

Propofol

IV anesthetic (GABA-A agonist sedative-hypnotic)

ICU sedationAnesthesia inductionPRIS riskRapid onset

Indication

Induction, procedural sedation, ICU sedation (adult only)

At a glance

INDICATION -> Ultra-short-acting IV sedative with NO analgesia and high PRIS risk

ADULT DOSE -> Induction 1-2.5 mg/kg IV; ICU sedation 25-50 mcg/kg/min

MAX DOSE -> PRIS risk: >4 mg/kg/hr and >48 hours infusion

CONTRA -> Prolonged high-dose infusion (>48 h), pediatric ICU sedation

ANTIDOTE -> No specific antidote -> supportive care + hemodynamic stabilization

Quick facts

Onset

<30 sec

Duration

Peak 1-2 min; bolus duration 5-10 min; half-life 2-4 h (context-sensitive increase with infusion).

Routes

IV only

Pregnancy

Avoid if possible

Renal

No adjustment

Hepatic

Reduce dose

Do not miss

Time to action: onset <30 sec

PRIS warning

  • PRIS = metabolic acidosis + bradycardia -> cardiac arrest.
  • PRIS triad: metabolic acidosis + rhabdomyolysis + cardiovascular collapse.

Critical risks

  • No analgesia: co-prescribe opioid for pain control.
  • Pediatric ICU sedation is contraindicated.
  • Rapid bolus can trigger cardiovascular collapse.

Antidote

  • No specific antidote -> supportive care + hemodynamic stabilization.

High-risk scenarios

  • Contamination risk: strict 12-hour discard/tubing change practice.

Key interactions

  • Opioids.
  • Benzodiazepines.
  • Beta-blockers.
  • QT-prolonging agents.
  • Valproate.

Indications

Primary

  • Induction of anesthesia
  • ICU sedation (adult ventilated)
  • Procedural sedation

Secondary

  • Status epilepticus
  • Endoscopy sedation

Other

  • Antiemetic at low dose
  • ICP control (off-label)

Dosing

Standard: ICU: 25-50 mcg/kg/min

Max daily dose

  • PRIS risk: >4 mg/kg/hr AND >48 hours infusion.

Adult - IV

  • Induction: 1-2.5 mg/kg IV.
  • Maintenance: 50-200 mcg/kg/min.

ICU sedation

  • ICU sedation: 25-50 mcg/kg/min (titrate to target).

Pediatric

  • Induction only.
  • ICU sedation: CONTRAINDICATED.

Renal adjustment

  • No dose change typically required.

Hepatic adjustment

  • Reduce dose by ~25-50% based on response.

Warnings

Clinical warnings

  • PRIS can be fatal.
  • PRIS triad: metabolic acidosis + rhabdomyolysis + cardiovascular collapse.
  • Hypotension.
  • Causes hypotension via systemic vasodilation and myocardial depression.
  • Bradycardia.
  • Apnea and respiratory depression.
  • Hypertriglyceridemia with infusion.
  • Lipid emulsion supports bacterial growth -> strict aseptic handling and 12-hour line change rule.
  • QT prolongation risk.
  • No analgesic effect.

Adverse effects

  • Common: hypotension, apnea, injection-site pain.
  • Serious: PRIS, severe bradyarrhythmia, cardiac collapse.

Contraindications / caution

Do not use

  • Pediatric ICU sedation.
  • Hypersensitivity (egg/soy per product label).
  • Use without airway support capability.

Use caution / avoid high doses

  • Elderly.
  • Shock states/hemodynamic instability.
  • Cardiac disease.
  • Hypertriglyceridemia.

Drug interactions

  • Opioids -> increased respiratory depression.
  • Benzodiazepines -> increased sedation.
  • Beta-blockers -> increased bradycardia/hypotension.
  • QT-prolonging agents (e.g., amiodarone) -> arrhythmia risk.
  • Valproate can increase propofol exposure/effect.

Special populations

Pediatrics

Induction only; ICU sedation contraindicated.

Pregnancy

Avoid when possible; neonatal depression risk.

Breastfeeding

Consider holding breastfeeding for 8-12 h after dose.

Elderly

Reduce dose by ~20-30%.

Liver disease

Reduce dose and titrate carefully.

Renal impairment

No routine adjustment required.

Administration

  • IV only.
  • Bolus with slow titration (e.g., 20-40 mg increments).
  • Use infusion pump; do not run by gravity.
  • Change tubing every 12 h per local protocol.
  • Single-patient vial use only.
  • Airway equipment MUST be immediately available.

Monitoring

  • RASS sedation score.
  • Continuous BP and HR.
  • SpO2 and respiratory rate.
  • Daily triglycerides during ongoing infusion.
  • Monitor triglycerides with prolonged infusion -> risk of hypertriglyceridemia and pancreatitis.
  • Lactate for PRIS detection.
  • CK for rhabdomyolysis risk.
  • ECG (QT and PRIS-related changes).
  • Line/tubing timing compliance (12-hour rule).

Overdose / toxicity

STOP infusion immediately -> airway + 100% oxygen -> hemodynamic support -> suspect PRIS if prolonged infusion.

Recognition

  • Risk rises with >4 mg/kg/hr and/or prolonged infusion.
  • Bradycardia, metabolic acidosis, rhabdomyolysis suggest severe toxicity/PRIS.

Immediate actions

  • Supportive care only.
  • Vasopressors as needed.
  • Correct acidosis and hyperkalemia.
  • Aggressive organ support in ICU.

Antidote

  • No specific antidote -> supportive care + hemodynamic stabilization.

Decontamination

  • Not applicable for IV sedative toxicity.

Escalation

  • ICU escalation; consider ECMO in refractory cardiovascular collapse.

Clinical pearls

Common mistakes, resistance logic, and bedside traps

PRIS pattern

  • PRIS can present early with bradycardia before overt hypotension.

Duration risk

  • No clearly safe high dose when infusion is prolonged.
  • Rapid offset does NOT prevent accumulation with prolonged infusion.

Analgesia gap

  • No analgesic effect -> ALWAYS combine with opioid for painful procedures.
  • Always combine sedation plan with adequate analgesia.

Sedation strategy

  • Daily sedation interruption can reduce cumulative risk.

Nutrition impact

  • Propofol lipid calories materially affect ICU nutrition plans.

Infection control

  • Infection risk is mainly handling/procedural, not direct pharmacologic toxicity.

Pharmacokinetics

  • Rapid CNS penetration.
  • Highly lipophilic.
  • Primarily hepatic metabolism (UGT pathways).
  • Renal excretion of inactive metabolites.
  • Context-sensitive half-time increases with prolonged infusion.

Mechanism of action

  • Potentiates GABA-A receptor signaling.
  • Enhances chloride influx causing CNS depression.
  • Reduces cerebral metabolism and blood flow.

Common brand names

Saudi Arabia

Propoven · Recofol · Diprivan

Global

Propofol Fresenius · Generic propofol

Common trade names are curated examples only — formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Widely available in GCC hospitals (Diprivan, Propoven, Recofol).
  • Standard ICU sedative in Saudi/UAE adult ventilated patients.
  • Strict infection control is enforced, including 12-hour tubing change protocols.
  • Used heavily for ER procedural sedation due to rapid recovery.

Saudi Arabia — confirm with local formulary.