Professional Documents
Culture Documents
5 May 1999
ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
Propofol is a sedative-hypnotic intravenous anesthetic agent that has gained wide use in outpatient oral and maxillofacial surgery since its clinical introduction in 1985. Propofol has several therapeutic advantages that make it an excellent
choice for use in all phases of general anesthesia and conscious sedation. It is associated with minimal side effects, a controllable anesthetic state, and rapid recovery. This review of propofol discusses its pharmacologic character, administration, and
side effects and presents anesthetic drug interaction information and comparisons. (Oral Surg Oral Med Oral Pathol Oral
CLINICAL PHARMACOKINETICS OF
PROPOFOL
Propofol pharmacokinetics involve a 3-compartment
linear model; the compartments represent plasma,
rapidly equilibrating tissues, and slowly equilibrating
tissues.2 The rapid onset of anesthesia and sedation
after an IV bolus of propofol is due to the rapid equilibration between plasma and the highly perfused tissue
aGeneral Practice Resident.
Received for publication May 29, 1998; returned for revision July 2,
1998; accepted for publication Dec. 2, 1998.
Copyright 1999 by Mosby, Inc.
1079-2104/99/$8.00 + 0 7/12/96477
530
Cillo 531
Effect(s)
Cardiovascular
Respiratory
Central nervous
Hepatorenal
Gastrointestinal
Endocrine
Immune
Endocrine system
Surgery provokes a generalized stress response that
leads to profound changes in endocrine function and
metabolism, resulting in the release of hormones
such as adrenaline, noradrenaline, and cortisol. In
surgical situations, endocrine stress responses are
undesirable because they may delay recovery to
normal metabolic states and impair defense mechanisms and wound healing, particularly in patients
with preexisting disease. Like other anesthetic
agents, such as benzodiazepines, propofol does not
induce adrenal steroidogenesis.11
Patients with hyperthyroidism may suffer from
tachycardia, increased stroke volume, increased
cardiac output, and decreased peripheral resistance. In
these patients, propofol is a beneficial anesthetic agent
because it does not stimulate the sympathetic nervous
system and because it decreases heart rate and blood
pressure.12 However, distribution volume and clearance of propofol are increased in patients with hyperthyroidism; increased infusion rates are thus required
for the sake of achieving therapeutic levels.12
Respiratory system
Respiratory depression is a usual side effect of some
commonly used anesthetic agentsspecifically,
benzodiazepines and barbiturates. Although hypoxia
may occur when these agents are used, deaths from
respiratory arrest are rare. Propofol produces dose-
532 Cillo
Methohexital
Sedative-hypnotic
Ultra-shortacting barbiturate
1-2.5 mg/kg
0.5-2.5 mg/kg
80-150 g/kg/min IV
0.25-1 mg/kg IV
10-50 g/kg/min IV
5-25 mg IV bolus
<40 s
<60 s
4-8
5-7
30-60
10.9-12.1
3.5-4.5
1.1-2.2
0.5-1
1
95-99
73
Liquid, 20-mL and
Powder, 5g/500-mL
50-mL ampule, 10 mg/mL
multidose vial
Midazolam
Ketamine
Benzodiazepine
0.1-0.2 mg/kg
150-300 g/kg IV
1-2.5 mg IV bolus
3-5 min
10-20
7.5
1.1-1.7
2-4
80
Liquid, 5-mL vial,
1 mg/mL
Phencyclidine derivative
0.25-0.75 mg/kg
10-50 g/kg/min IV
0.2-8 mg/kg IV
30 s
7-11
16-18
2.5-3.5
1-2
12
Liquid, 5-mL
vial, 100 mg/mL
Cardiovascular system
Most pharmacologic investigation into the administration of propofol has concerned hemodynamic factors
involving heart rate, heart contractility, and blood pressure. Propofol does not directly induce bradyarrhythmias
because it does not depress sinoatrial node activity or
atrioventricular conduction at therapeutic doses.14
However, propofol shows a simultaneous decrease in
heart contractility (negative inotropy) and afterload
reduction, which leads to hypotension.15 This resulting
hypotension involves significant reductions in systolic,
diastolic, and mean arterial pressures that are not
followed by the less-than-expected increase in heart rate
or cardiac output.14 In comparison with other anesthetic
agents, such as methohexital,16 propofol IV infusion is
associated with reductions in arterial blood pressure that
are more marked and hypotensive reactions that are more
frequent. There are 2 proposed mechanisms for propofolinduced hypotension. Mackenzie and Grant17 speculate
that propofol-induced hypotension is mediated by an
inhibition of the sympathetic nervous system and impairment of the baroreflex regulatory mechanism. Li et al18
postulate that the disturbance in Ca2+ transport and availability may cause a decrease in energy production and
produce propofols negative inotropic effect.
Immune system
Many anesthetic agents and adjuvants, such as
opioids and muscle relaxants, can cause the release of
histamine from mast cells. This can lead to several
undesirable consequences, including hypotension,
tachycardia, urticaria, pruritis, and bronchospasm. In
some instances, these events can lead to life-threatening reactions during anesthetic administration.
Although propofol can cause allergic reactions in
patients who are allergic to this agent, it is generally
safe from anaphylactoid reactions because when
administered at therapeutic doses it does not promote
the release of histamine from mast cells.19 However,
because propofol and its lipid emulsion, Intralipid, do
not contain preservatives or antimicrobial agents, they
support rapid microbial growth at room temperature.20
The use of improper aseptic techniques in handling
propofol vials has resulted in numerous reported cases
of postoperative bloodstream and surgical site infections.20,21 The etiologic agents in these infections have
been Staphylococcus aureus, Candida albicans,
Moraxella osloensis, Enterobacter agglomerans, and
Serratia marcescens.20
ADMINISTRATION TECHNIQUES OF
PROPOFOL ANESTHESIA FOR OUTPATIENT
ORAL AND MAXILLOFACIAL SURGERY
Propofols acceptance in outpatient oral and maxillofacial surgery is due to its favorable safety and efficacy
for general anesthesia and sedation. Propofol has both
rapid onset and psychomotor recovery characteristics;
these implicate it for use in an ambulatory anesthesia
and sedation. For this reason, and because of its
extremely low occurrence of postoperative nausea and
vomiting, it is particularly useful in pediatric,22 geriatric,5,23 and mentally and/or physically handicapped24
patients who benefit from expeditious recovery without
numerous postoperative complications.
Methods of administration
Several techniques for the administration of propofol
anesthesia have been reported: continuous infusion,
patient-controlled infusion, and manual bolus infusion.
Continuous infusion. Continuous infusion of
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Results
Propofol/methohexital
Propofol/midazolam
Propofol/ketamine
Propofol/fentanyl
Propofol/alfentanil
Propofol/sufentanil
Propofol/remifentanil
Propofol/diazepam
Propofol/nitrous oxide
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Comparison
Propofol vs methohexital
Propofol vs midazolam
Propofol vs diazepam
Propofol vs sevoflurane
Propofol vs isoflurane
Propofol vs halothane
Dosage
Propofol is compared with other IV anesthetic agents
in Table II and in the sections that follow.
The induction dose of 1% propofol is 1 to 2.5 mg/kg
IV. For the maintenance of general anesthesia, propofol
should be administered at a rate of 80 to 150 g/kg/min.
This can be combined with an opiate and/or nitrous
oxide or volatile anesthetic. For conscious sedation,
propofol should be administered at 10 to 50 g/kg/min,
either alone or in combination with an opiate. Because
propofol is a lipid-soluble anesthetic agent, it is
expected to have a prolonged effect in patients in whom
the proportion of fat is significant with respect to total
Recovery
One of the more beneficial aspects reported for
propofol is its rapid recovery time.16,29-31 The fastest
reported recovery times after propofol general anesthesia were 5 minutes16 and 30 minutes.31 Whereas
patients undergoing deep sedation with either propofol
or methohexital recover psychomotor performance
faster with propofol, both agents produce similar
recovery characteristics 20 minutes postoperatively.32
Propofol is a safe and effective anesthetic agent in
both short-duration and long-duration procedures, with
recovery rates similar to those of some volatile anesthetics.10,31 Propofol has lower incidences of postoperative shivering than do other anesthetic agents, such as
methohexital33 and halothane.34 In addition, patients
are reported to be clear-headed and well oriented and to
experience fewer postoperative complications on
awakening after propofol anesthesia and sedation.33,34
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Ketamine
Ketamine (Ketalar, Parke-Davis) is an anesthetic agent
that is known to reduce hypotension by increasing heart
rate, cardiac output, and arterial blood pressure through
sympathetic nervous system activation.41 The combination of ketamine and propofol has been used in an
attempt to balance the cardiostimulatory effects of ketamine with the cardiodepressant effects of propofol for the
sake of achieving improved cardiovascular stability.42
The sedative effects of these 2 drugs have an additive
effect at endpoints of hypnosis and anesthesia, and there
is less probability of apnea. This combination of propofol
with ketamine for total IV anesthesia provides greater
intraoperative hemodynamic stability than does the
administration of propofol alone.42
Methohexital
Methohexital (Brevital, Jones Medical) is a nonanalgesic short-acting barbiturate IV anesthetic agent
commonly used for sedation and anesthesia. Propofols
influences on immediate postoperative mood state are
different from and more favorable than those of methohexital. Propofol is associated with a more elated, more
agreeable, and less anxious patient (with better postoperative psychomotor performance on cessation of
anesthesia) than is methohexital.29 This is in the very
early recovery period, however; after 20 minutes,
recovery characteristics for the 2 anesthetics are essentially identical.31,35 Comparisons of the 2 agents with
respect to conscious sedation show that the significant differences are increases in heart rate with methohexital35 and a greater percentage of episodes of
hypotension with propofol.29 There are no significant
differences in cooperation, cardiopulmonary stability,
recovery time, amnesia, comfort, or incidence of
PONV after 24 hours.35 Methohexital administered
concomitantly with propofol, in comparison with
propofol alone, resulted in no significant differences
in induction properties and complications, intraoperative variables, rate of recovery, or postoperative
sequelae.36 The use of both anesthetic agents provides
safe and reliable anesthesia for outpatient oral and
maxillofacial surgery. However, propofol is significantly more expensive than methohexital, which makes
the cost-effectiveness of methohexital superior to that
of propofol.
Midazolam
Midazolam (Versed, Roche Labs) is a benzodiazepine indicated for use in sedation and general
anesthesia. In comparison with midazolam at equal
sedation levels, propofol was found to produce the
same degree of memory impairment 37 while
producing less respiratory depression and achieving
faster cognitive and psychomotor recovery. 38 The
addition of midazolam to the propofol regimen
decreases the propofol dose requirement while
producing no additional consequences with respect
to recovery characteristics, postoperative mood, incidence of postoperative dreams, and patient satisfaction. 39 Immediate premedication with 2 mg of IV
midazolam before propofol infusion produces
increased sedation, amnesia, and anxiolysis.40
Opioids
Fentanyl (Sublimaze), alfentanil (Alfenta), sufentanil
(Sufenta), and remifentanil (Ultivar) are opioid analgesics used as adjuncts for sedation and general anesthesia. These short-acting opioids are primarily used to
attenuate the response to the painful stimulus of local
anesthesia administration.
Premedication with a typical 100-g dose of
fentanyl decreases induction time and reduces
propofol requirements in very short procedures, but it
does not improve the recovery time or quality of anesthesia.43 Combined sufentanil-propofol anesthesia
results in less vomiting during the early postoperative
period than does propofol-induced isoflurane anesthesia.44 Alfentanil reduces the amount of propofol
required to achieve hypnotic effects and increases the
respective sedative and analgesic properties of both
drugs45; however, alfentanil does not assure more
hemodynamic stability during induction because in
some patients it may potentiate the hemodynamic
propofols depressant effects to nearly the same degree
that it potentiates its sedative effects.45 In comparison
with anesthesia with propofol alone, remifentanil
anesthesia provides comparable intraoperative conditions and patient comfort at a lower sedation level but
results in greater respiratory depression and longer
recovery times.46
Diazepam
Diazepam (Valium) is a benzodiazepine used as an
anxiolytic and anticonvulsant in sedation and general
anesthesia. Diazepam administration during propofol
anesthesia provides reliable sedation, the combination
being superior to separate administration of the 2 drugs,
with minimal side effects and no change in recovery
time.47 In comparison with IV diazepam alone, IV
propofol alone provides faster recovery times and better
amnesia and has a higher patient preference.48
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Nitrous oxide
Nitrous oxide is a colorless inorganic gas that is
nonirritating and has a pleasant odor. A nitrous
oxide/oxygen combination is commonly used in
mildly apprehensive individuals. Propofolnitrous
oxide sedation, in comparison with propofol-room air
sedation, decreases postanesthesia shivering49 and
causes less nausea and vomiting.50,51 In addition, this
combination decreases the propofol dose requirement50,51 while having no effect on postoperative
analgesia and recovery time.50
CONCLUSION
Propofol is an excellent anesthetic agent for use in
outpatient oral and maxillofacial surgery of short or
long duration. Propofol possesses many ideal anesthetic
agent characteristics, including rapid onset, fast and
clear recovery, reliability of action, and lack of allergic
responses. It is a beneficial anesthetic agent for patients
suffering from renal failure, cirrhosis, and hyperthyroidism. Intraoperatively, propofol does not induce
malignant hyperthermia, although it may cause
hypotension and dose-dependent respiratory depression. Aseptic technique is imperative during the
handling of propofol vials inasmuch as postoperative
infections have been traced to extrinsically contaminated vials. Whether it is used alone or in combination
with other anesthetic agents to produce balanced anesthesia, propofol provides reliable sedation. It causes
pain on injection that is diminished with prior administration of lidocaine or meperidine. Postoperatively, it
produces minimal confusion with comparably fast
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Reprint requests:
Joseph E. Cillo, Jr., DMD
661 Terrace Blvd. Apt 1
Depew, NY 14043