Physostigmine for propofol reversal

[timgasman]

Has anyone heard of using 1 mg of physostigmine to reverse the effects of propofol? I tried it based on anecdotal evidence from a colleague. What are your thoughts?

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[MirrorTodd]

What effects of propofol are you trying to reverse?

 

[jacobus1919]

While, I only had a year in anesthesiology, I haven't heard of this reversal though. But, propofol has a short half life, what effects do you want to reverse? Apnea?

 

[Orin]

Yeah, so physostigmine increases central cholinergic tone which can increase wakefulness. Folks use it as an antidote for baclofen overdose.

It can help reverse propofol induced consciousness, but I'm not sure if it's worth the risk/benefit.

Physostigmine reverses propofol-induced unconsciousness and attenuation of the auditory steady state response and bispectral index in human volunte... - PubMed - NCBI
Cholinergic Neurons in the Basal Forebrain Promote Wakefulness by Actions on Neighboring Non-Cholinergic Neurons: An Opto-Dialysis Study

 

[caligas]

No practical application of this

 

[San Marzano]

I would imagine that the propofol would have worn off by the time the pharmacy was able to send that to you.

 

[linkin06]

https://www.openanesthesia.org/propofol_mechanism_of_action/

if you had told me flumazenil i'd be more likely to believe it?

 

[deleted162650]

10mg of ephedrine works.

 

[anbuitachi]

10mg of ephedrine works.

Agreed. Ephedrine works great

 

[Psai]

The propofol probably wears off by the time the physostigmine is running in

 

[OB1🤙]

Tincture of Time is a rapid propofol reversal agent with minimal side effects.

 

[BLADEMDA]

Effect of flumazenil on recovery from anesthesia and the bispectral index after sevoflurane/fentanyl general anesthesia in unpremedicated patients

 

[BLADEMDA]

10mg of ephedrine works.

It looks like 10-20 mg of ephedrine does indeed work to speed up the recovery from propofol:

Recovery from propofol anesthesia may be sped by use of common stimulant

solid post

 

[WashMe]

It looks like 10-20 mg of ephedrine does indeed work to speed up the recovery from propofol:

Recovery from propofol anesthesia may be sped by use of common stimulant

solid post

Where is there a mention of ephedrine in that link?

 

[Noyac]

10mg of ephedrine works.

That’s top tier level **** there, boys and girls.
I use it on occasion after those long as **** spine cases that have nearly emptied the pharmacy’s supply of propofol.

 

[epidural man]

Interesting...

I have used physostigmine one time after giving scopolamine and the patient woke up super crazy and physostigmine fixed it. It was crazy cool.

Doxepram is a great propofol reversal agent.

Actually, a useful combination is mixing doxepram IN the propofol infusion.

 

[Dejavu]

No practical application of this

With all humble respect, in 42 yrs of anesthesia, I have used it, every couple of years, to wake up those rare patients who are 3-4 hrs into PACU time and just aren’t responding. Surgeon and PACU nurses are nervously asking, “What’s going on?”.

Give 1mg, three minutes later, patient awake, everybody happy, no more anxious phone calls.

I know, anecdotal as all hell, but I’m not arguing with success when it puts out a PACU brush fire and doesn’t harm the patient.

Want some more anecdotes? Also good for Atropine overdose craziness. Admittedly a rare event.

 

[Planktonmd]

Physostigmine is called "antilirium" because it was marketed as a treatment of post-op delirium, usually secondary to inhaled anesthetics, and it actually does work on the elderly when they go crazy in the recovery room.

 

[Noyac]

With all humble respect, in 42 yrs of anesthesia, I have used it, every couple of years, to wake up those rare patients who are 3-4 hrs into PACU time and just aren’t responding. Surgeon and PACU nurses are nervously asking, “What’s going on?”.

Give 1mg, three minutes later, patient awake, everybody happy, no more anxious phone calls.

I know, anecdotal as all hell, but I’m not arguing with success when it puts out a PACU brush fire and doesn’t harm the patient.

Want some more anecdotes? Also good for Atropine overdose craziness. Admittedly a rare event.

More top tier ****. Thanks
What side effects can we expect to see?
How does the elderly tolerate it?

 

[acidbase1]

What about precedex? You guys recommend ephedrine to reverse the sedative effects?

 

[chocomorsel]

That’s top tier level **** there, boys and girls.
I use it on occasion after those long as **** spine cases that have nearly emptied the pharmacy’s supply of propofol.

Never knew this. But it makes perfect sense considering how the drugs work.
Learn something new every day

 

[pgg]

Physostigmine is called "antilirium" because it was marketed as a treatment of post-op delirium, usually secondary to inhaled anesthetics, and it actually does work on the elderly when they go crazy in the recovery room.

What about the young?

I've read about it being the treatment for central anticholinergic syndrome (it's on every ITE and the written) ... didn't know it was useful for other etiologies.

I wish I'd known about it a week ago, might have given it a try. I had a patient with some very strange mental status changes in the PACU.

I was going to post the case here for discussion but it'd be hard to keep identifying details out of it, because the story behind the surgery is so weird that anyone who casually knows the patient would instantly know this case discussion was about him. And I still haven't figured out what happened ... at least, I have no satisfying answer. So it'd be an open ended thread without any real resolution. Unsatisfying to say the least.

 

[Planktonmd]

More top tier ****. Thanks
What side effects can we expect to see?
How does the elderly tolerate it?

Side effects are generic cholinesterase inhibitor side effects: Bradycardia, cramps, nausea... usually mild though with physostigmine low dose (0.5-1 mg).