Propofol Overdose = Deadly???

[Spinach Dip]

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I honestly don't know what forum this question belongs in, so I'll ask it here. Forgive me if this is the wrong place.



I've been hearing a lot about propofol overdoses recently, including in some in clinical settings. As a (hopeful) future anesthesiologist, this both frightens and confuses me. Perhaps you guys can help set me straight.

Propofol is an anesthetic only, right? I know it has largely replaced barbiturates, and that it can cause respiratory arrest in high doses.

But can it kill on its own?
Or is death the result of respiratory arrest?
If a patient is being monitored correctly (pulse ox and 3-lead EKG minimum), and there is an ambu bag nearby, is there any excuse for a patient dying of propofol overdose?



Thanks for the help.

 

[moto_za]

It's commonly used in the ICU setting and not a major concern for placing patients at higher risk of mortality. It's a fat so at high doses it does provide a high amount of calories so may need to be monitored if a patient is on tube-feeding or parenteral enteral nutrition.

I honestly don't know what forum this question belongs in, so I'll ask it here. Forgive me if this is the wrong place.



I've been hearing a lot about propofol overdoses recently, including in some in clinical settings. As a (hopeful) future anesthesiologist, this both frightens and confuses me. Perhaps you guys can help set me straight.

Propofol is an anesthetic only, right? I know it has largely replaced barbiturates, and that it can cause respiratory arrest in high doses.

But can it kill on its own?
Or is death the result of respiratory arrest?
If a patient is being monitored correctly (pulse ox and 3-lead EKG minimum), and there is an ambu bag nearby, is there any excuse for a patient dying of propofol overdose?



Thanks for the help.

 

[alpinism]

Toxicology 101: http://en.wikipedia.org/wiki/The_dose_makes_the_poison

At high enough doses, yes it can kill on its own (just like water or oxygen).

Propofol functions mainly as a GABA-A agonist but also as a Na channel blocker. ODs can be lethal due to a variety of causes such as hypotension, arrythmias, or seizues.

 

[calvnandhobbs68]

I honestly don't know what forum this question belongs in, so I'll ask it here. Forgive me if this is the wrong place.



I've been hearing a lot about propofol overdoses recently, including in some in clinical settings. As a (hopeful) future anesthesiologist, this both frightens and confuses me. Perhaps you guys can help set me straight.

Propofol is an anesthetic only, right? I know it has largely replaced barbiturates, and that it can cause respiratory arrest in high doses.

But can it kill on its own?
Or is death the result of respiratory arrest?
If a patient is being monitored correctly (pulse ox and 3-lead EKG minimum), and there is an ambu bag nearby, is there any excuse for a patient dying of propofol overdose?



Thanks for the help.

What do you mean by this? If it caused the respiratory arrest then yes...it did kill on it's own.

 

[Spinach Dip]

What do you mean by this? If it caused the respiratory arrest then yes...it did kill on it's own.

I meant: can it kill through some effect which is not a result of its sedative properties? For example, can it cause cardiac arrest or brain swelling (2 things which might lead to death which are not a result of its sedative properties)?

 

[Carboxide]

I think it would be highly unlikely to cause death if monitored well and used ALONE. Of course, how often is a patient given propofol but NOT given any sort of opioid or other depressant? That's your confounding variable.

 

[bradycakes]

http://www.newswise.com/articles/st...f-propofol-abuse-by-health-care-professionals

 

[oceanillusion42]

Insert Michael Jackson reference here

 

[msk86]

Definitely not a common thing for somebody to die from propofol OD, but it can obviously happen. If you've ever seen a rapid sequence induction, you're giving a big bolus of propofol over a few seconds. It can cause profound vasodilation, and couple this with a patient who has probably been NPO for 12+ hours, and you are always running the risk of hemodynamic instability. There's some mild respiratory depression with propofol, but I would think the most common cause of death would be from hypotension.

 

[EMquest3]

Toxicology 101: http://en.wikipedia.org/wiki/The_dose_makes_the_poison

At high enough doses, yes it can kill on its own (just like water or oxygen).

Propofol functions mainly as a GABA-A agonist but also as a Na channel blocker. ODs can be lethal due to a variety of causes such as hypotension, arrythmias, or seizues.

I get the hypotension and arrythmias, but I find it hard to believe you can generate a seizure with a GABA agonist.

 

[delano2000]

The only thing that comes to mind with propofol OD is usually with high dose infusions over a few days. That can lead to propofol-related infusion syndrome which has a high mortality rate (dysrhythmias, renal failure, shock, HF etc). I am not sure what the incidence of this occurring is like though.

 

[inmyslumber]

Spinach Dip, propofol is a potent dose-dependent respiratory depressant, as you probably know. The main reason for deaths is hypoxia and subsequent arrest from inadequate ventilation.

If you are not trained to use propofol, it should be a drug that scares you. Do a rotation with your Anesthesia Department or ask to shadow for a day. We use propofol every day.

-in my slumber

 

[alpinism]

I get the hypotension and arrythmias, but I find it hard to believe you can generate a seizure with a GABA agonist.

AFAIK, seizures rarely happen, but they are possible via off-target effects (ie non-GABA mediated) with large ODs. Likely via its effects on Na channels or other receptors. They can also occur secondary to hypotension
(propofol decreases cerebral blood flow).

edit:
It's listed on the package insert as a side effect (less than 1% incidence) under CNS effects.
Propofol also commonly causes involuntary muscle movements (peds=17% incidence). There are also a ton of other side effects listed that have the potential to be lethal esp in already sick pts undergoing surgery.

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=14327

 

[typhoonegator]

I'm a neurointensivist. We use propofol for burst suppression as a treatment for status epilepticus. I've never seen it cause a seizure.

Propofol can cause pancreatitis from the high fat load, so you need to watch your amy/lip and transaminases while on it for a prolonged period.

Propofol can cause mitochondrial oxidative decoupling, called propofol infusion syndrome, which results in profound anion-gap lactic acidosis and death if it goes on long enough without being noticed. Predominantly effects the pediatric population, but has a dose-dependent effect in adults as well. I've seen people die of it.

Propofol can cause a life-threatening cardiac stunning that can occur immediately on bolus. Seems to occur idiosyncratically but can be disasterous, particularly when you're giving it as part of your emergent intubation induction and they are already hemodynamically unstable. It looks like a profound hypotensive response, but the natural reaction to increase neo to fight the peripheral vasodilation effect of propofol is counterproductive. I've seen people die of it.

Finally, propofol is a fat solution, and some preparations contain egg or soy proteins, which can cause acute anaphylaxis.

If people are going to die from propofol exposure, it is far more likely to be because it was used for procedural sedation, the patient got too much, they go into PEA because you weren't paying attention or you couldn't get an airway, they code, and die. But you should know the side effects, even the uncommon ones, of any medication you are ordering.

 

[45408]

Definitely not a common thing for somebody to die from propofol OD, but it can obviously happen. If you've ever seen a rapid sequence induction, you're giving a big bolus of propofol over a few seconds. It can cause profound vasodilation, and couple this with a patient who has probably been NPO for 12+ hours, and you are always running the risk of hemodynamic instability. There's some mild respiratory depression with propofol, but I would think the most common cause of death would be from hypotension.

Propofol is actually not usually part of a rapid sequence intubation. Etomidate is the classic, but you can use a variety of sedatives.

There's also more than "mild respiratory depression from propofol." It can most certainly make you apneic, and unless someone was hypotensive before, I doubt that it would kill you by bottoming out your blood pressure.

I'd hazard a guess that most of these stories making the news were respiratory arrests from propofol.

 

[Stellar Clouds]

Propofol is actually not usually part of a rapid sequence intubation. Etomidate is the classic, but you can use a variety of sedatives.

There's also more than "mild respiratory depression from propofol." It can most certainly make you apneic, and unless someone was hypotensive before, I doubt that it would kill you by bottoming out your blood pressure.

I'd hazard a guess that most of these stories making the news were respiratory arrests from propofol.

Maybe not in the unit, but in the OR it's commonly used during an RSI.

 

[NickNaylor]

Maybe not in the unit, but in the OR it's commonly used during an RSI.

You do realize the guy you responded to is a surgical resident, right?

Sent from my Nexus 7

 

[Stellar Clouds]

You do realize the guy you responded to is a surgical resident, right?

Sent from my Nexus 7

Good for him. He's probably paid more attention during intubations in the SICU than in the OR.

Surgery residents don't typically sit over the anesthesiologist's shoulder during induction. They are too busy writing their notes, putting in orders, etc.

 

[45408]

Maybe not in the unit, but in the OR it's commonly used during an RSI.

Different situation. Those patients aren't usually critically unstable, and if they are, they probably won't use propofol even if they are in the OR. It causes vasodilation and cardiac depression (negative inotrope). Ketamine or etomidate are better choices.

Good for him. He's probably paid more attention during intubations in the SICU than in the OR.

Surgery residents don't typically sit over the anesthesiologist's shoulder during induction. They are too busy writing their notes, putting in orders, etc.

You usually write orders after the case, and I rarely see RSI in the OR, because most of them have been NPO.

 

[Stellar Clouds]

Different situation. Those patients aren't usually critically unstable, and if they are, they probably won't use propofol even if they are in the OR. It causes vasodilation and cardiac depression (negative inotrope). Ketamine or etomidate are better choices.

I agree with you, and in a way, that was my point that it is a different situation between very sick patients in the unit and a relatively healthy patient who is getting an RSI due to a history of severe reflux.

 

[IlDestriero]

Different situation. Those patients aren't usually critically unstable, and if they are, they probably won't use propofol even if they are in the OR. It causes vasodilation and cardiac depression (negative inotrope). Ketamine or etomidate are better choices.

Correct. Someone's been paying attention.
If you give an unstable patient a big propofol dose for induction you're a fool.

 

[Rendar5]

I unfortunately am sometimes stuck using it as an rsi drug in the ed since we're out of etomidate and ketamine in our ed that night. Had a pt code who turned out to be in septic shock (based on lact levels). Coded post-intubation despite using only a third of the recommended rsi dose.

 

[IlDestriero]

He may have been so fragile that he would have coded anyway. You would be surprised with how little propofol you need to induce a critically ill patient. You could give some midazolam and a bit of fentanyl before the sux +/- scopolomine and an apology. Midazolam and fentanyl are usually well tolerated in trauma patients from my experience. BTW, Ketamine will DEFINITELY produce significant hypotension in critically ill, hypovolemic, catecholamine depleted patients.
Alive with some bad memories beats dead every time.

 

[Rendar5]

He may have been so fragile that he would have coded anyway. You would be surprised with how little propofol you need to induce a critically ill patient. You could give some midazolam and a bit of fentanyl before the sux +/- scopolomine and an apology. Midazolam and fentanyl are usually well tolerated in trauma patients from my experience. BTW, Ketamine will DEFINITELY produce significant hypotension in critically ill, hypovolemic, catecholamine depleted patients.
Alive with some bad memories beats dead every time.

Well luckily we got this one back. But next time maybe succ only (totally clamped down, the reason ems couldn't get the tube.

 

[Impromptu]

I honestly don't know what forum this question belongs in, so I'll ask it here. Forgive me if this is the wrong place.



I've been hearing a lot about propofol overdoses recently, including in some in clinical settings. As a (hopeful) future anesthesiologist, this both frightens and confuses me. Perhaps you guys can help set me straight.

Propofol is an anesthetic only, right? I know it has largely replaced barbiturates, and that it can cause respiratory arrest in high doses.

But can it kill on its own?
Or is death the result of respiratory arrest?
If a patient is being monitored correctly (pulse ox and 3-lead EKG minimum), and there is an ambu bag nearby, is there any excuse for a patient dying of propofol overdose?



Thanks for the help.

I tested your question. I left 20 mL, 50 mL, and 100 mL vials of propofol near where the circulating nurse sits during a 12 hour ENT free flap case. I didn't warn anybody about them, but I kept my distance. I whispered to them some insults that I had "overheard" from the circulating nurse. I even told the vials that it was either them or her. I saw the 50 mL vial give her a death stare, but it never attacked her nor anyone else. though it had plenty of opportunity.

So, to answer your question, propofol cannot kill on its own.

But I suspect if you threw the 100 mL vial hard enough at someone's head, you could cause some damage.

 

[deuist]

If a patient is being monitored correctly (pulse ox and 3-lead EKG minimum), and there is an ambu bag nearby, is there any excuse for a patient dying of propofol overdose?

Yes, because a pulse ox is not appropriate for monitoring during sedation. It measures oxygen, but not ventilation. You need to add on end-tidal CO2 (capnography) for the true minimum.

 

[IlDestriero]

Yes, because a pulse ox is not appropriate for monitoring during sedation. It measures oxygen, but not ventilation. You need to add on end-tidal CO2 (capnography) for the true minimum.

And blood pressure.