Is Propofol a Friend or a Foe of the Pediatric Intensivist? Description of Propofol Use in a PICU*

Koriyama, Hiromi; Duff, Jonathan P.; Guerra, Gonzalo Garcia; Chan, Alice

doi:10.1097/pcc.0000000000000021

Cited by 32 publications

(26 citation statements)

References 18 publications

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“…Propofol infusions of doses greater than 4mg/kg/hr for more than 48 hours should be avoided [191, 192, 125]. However, it should be borne in mind that in critically ill children, development of PRIS has been reported even after 3–5 hours of high-dose propofol anesthesia and rates as low as 1.4 mg kg −1 h −1 [193].…”

Section: ) Propofol and Mitochondriamentioning

confidence: 99%

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

2015

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Propofol is an intravenous agent used commonly for induction and maintenance of anesthesia, procedural and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially gamma-aminobutyric acid A receptor. Approved for use in the United States by the Federal Drugs and Administration (FDA) in 1989, its use for induction of anesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not “little adults”, in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exist despite the FDA mandating addition of antimicrobial preservative, calling for manufacturers’ directions to discard open vials after six hours. While propofol has advantages over inhalation anesthesia like less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research.

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Section: ) Propofol and Mitochondriamentioning

confidence: 99%

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

2015

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“…The incidence of PRIS is~1 % in adult patients [40]. There are no valid data for children, but propofol use in children in pediatric intensive care units (PICUs) appeared to be safe when doses did not exceed 4 mg/kg/h and use was restricted to <24 h [41,42]. Patients should be monitored closely for the presence of elevated triglycerides and lactic acidosis [43].…”

Section: Pathophysiologymentioning

confidence: 99%

“…Usually, aminoglycoside-induced RFS is seen in patients with impaired renal function, but some reports of patients with normal kidney function exist [143]. Gentamicin enters the cell through the megalin-cubulin system [41]. Intracellular gentamicin can decrease the function of mitochondrial ribosomes [144] and interfere with the conversion of ADP to ATP [145].…”

Section: Aminoglycosides and Tetracyclinesmentioning

confidence: 99%

Drug-induced acid-base disorders

et al. 2014

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The incidence of acid-base disorders (ABDs) is high, especially in hospitalized patients. ABDs are often indicators for severe systemic disorders. In everyday clinical practice, analysis of ABDs must be performed in a standardized manner. Highly sensitive diagnostic tools to distinguish the various ABDs include the anion gap and the serum osmolar gap. Drug-induced ABDs can be classified into five different categories in terms of their pathophysiology: (1) metabolic acidosis caused by acid overload, which may occur through accumulation of acids by endogenous (e.g., lactic acidosis by biguanides, propofol-related syndrome) or exogenous (e.g., glycol-dependant drugs, such as diazepam or salicylates) mechanisms or by decreased renal acid excretion (e.g., distal renal tubular acidosis by amphotericin B, nonsteroidal antiinflammatory drugs, vitamin D); (2) base loss: proximal renal tubular acidosis by drugs (e.g., ifosfamide, aminoglycosides, carbonic anhydrase inhibitors, antiretrovirals, oxaliplatin or cisplatin) in the context of Fanconi syndrome; (3) alkalosis resulting from acid and/or chloride loss by renal (e.g., diuretics, penicillins, aminoglycosides) or extrarenal (e.g., laxative drugs) mechanisms; (4) exogenous bicarbonate loads: milk-alkali syndrome, overshoot alkalosis after bicarbonate therapy or citrate administration; and (5) respiratory acidosis or alkalosis resulting from drug-induced depression of the respiratory center or neuromuscular impairment (e.g

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“…[41][42][43] Recent studies by Koriyama et al and by Krussell et al showed that the use of continuous infusion of propofol limited to 4 mg/kg/h for less than 48 hours is safe, with no cases of propofol infusion syndrome reported in children. 44,45 Another sedative agent indicated for adult use, with benefits over benzodiazepines, is dexmedetomidine, an alfa-2 agonist with sedative and analgesic properties. Riker et al demonstrated a decrease in duration of mechanical ventilation and a reduction in the prevalence of delirium in adults, when comparing the use of dexmedetomidine to benzodiazepines.…”

Section: Resultsmentioning

confidence: 99%

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Motta

Luglio²,

Delgado

et al. 2016

Rev. Assoc. Med. Bras.

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Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

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Is Propofol a Friend or a Foe of the Pediatric Intensivist? Description of Propofol Use in a PICU*

Cited by 32 publications

References 18 publications

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

Drug-induced acid-base disorders

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

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