Propofol use in newborns and children: is it safe? A systematic review

Propofol Sedation Washouts in Critically Ill Infants: A Case Series

Medically complex infants are experiencing longer hospital stays, more invasive procedures, and increasingly involved therapeutic interventions that often require long-term analgesia and sedation. This is most commonly achieved with continuous intravenous infusions of opioids and benzodiazepines. There are times when patients develop a tolerance for these medications or the clinical scenario necessitates a rapid wean of them. A rapid wean of either class of medication can lead to increased signs of pain and agitation or withdrawal symptoms. As a result, when a rapid wean is needed or there has been a failure to control symptoms with conventional measures, alternative therapies are considered. Propofol, a sedative hypnotic typically used for general anesthesia and procedural sedation, is one such medication. It has effectively been used for short-term sedation in adults and children to facilitate weaning benzodiazepines and opioids. There is a paucity of data on the use of propofol in infants for this purpose. Here we describe the use of propofol to rapidly wean high-dose sedation and analgesia medications, a propofol sedation washout, in 3 infants. The washouts proved to be safe and efficacious. Based on institutional experience and a literature review, considerations and recommendations are made for propofol sedation washouts in infants.

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial

Background and Aims

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children.

Methods

A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia.

Results

Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05).

Conclusion

The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high.

Clinical Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000040500.

Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia

BACKGROUND

Procedural sedation and analgesia (PSA) for diagnostic and minimally invasive therapeutic procedures has become common practice in children of all ages. Based on our clinical experience, we suspected an inverse relation between age and dosage. However, a schedule for age-stratified propofol induction and maintenance dosage for PSA was not available and could be helpful to many anesthesiologists as a reference.

METHODS

We performed a retrospective cohort study of children who received procedural sedation at the Wilhelmina Children's Hospital (WKZ), a tertiary pediatric hospital part of the University Medical Center Utrecht (UMCU), between June 2007 and December 2020. We studied whether the induction (mg·kg -1 ) and maintenance (mg·kg -1 ·h -1 ) dosage is age-dependent using linear regression models.

RESULTS

A total of 6438 pediatric procedures were retrieved from Anesthesia Information Management Systems (AIMS). A total of 5567 records were available for induction dose analysis and 5420 records for analysis of the maintenance dose. After adjustment for sex, American Society of Anesthesiologists (ASA) physical status classification, opioid administration, and diagnostic or interventional, we obtained a coefficient of -0.11 (95% confidence interval [CI], -0.12 to -0.11) for age (years) from a multivariable linear regression model for propofol induction dosage (mg·kg -1 ) and a coefficient of -0.36 (95% CI, -0.39 to -0.34) for age (years) for propofol maintenance dosage.

CONCLUSIONS

We found a noteworthy inverse age-effect on propofol dosage for both induction and maintenance of pediatric procedural sedation. Furthermore, our study revealed that remarkably higher propofol sedation doses were needed for infants and toddlers than previously expected and reported.

Ecological risk assessment of environmentally relevant concentrations of propofol on zebrafish (Danio rerio) at early life stage: Insight into physiological, biochemical, and molecular aspects

Propofol is an intravenous anesthetic injection extensively used in clinic, which has been proved to be neurotoxic in humans. Improper use and disposal of propofol may lead to its release into the aquatic environment, but the potential ecological risk of propofol to aquatic organisms remains poorly understood. For this study, we comprehensively explored the ecotoxicological effects and potential mechanisms of propofol (0.04, 0.2 and 2 mg L^-1) on 120 hpf zebrafish (Danio rerio) embryos from physiological, biochemical, and molecular perspectives. The results showed that propofol has moderate toxicity on zebrafish embryos (96 h LC₅₀ = 4.260 mg L^-1), which could significantly reduce the hatchability and delay the development. Propofol can trigger reactive oxygen species (ROS) generation, lipid peroxidation (Malondialdehyde, MDA) and DNA damage (8-hydroxy-2-deoxyguanosine, 8-OHdG). The glutathione peroxidase (GPX) activity of zebrafish embryos in 0.04 and 0.2 mg L^-1 propofol treatment group was activated in response to oxidative damage, while activities of superoxide dismutase (SOD), catalase (CAT) and GPX in zebrafish treated with 2 mg L^-1 was significant inhibited compared with the control group (p＜0.05). Moreover, the expression of antioxidant genes and related pathways was inhibited. Apoptosis was investigated at genes level and histochemistry. Molecular docking confirmed that propofol could change in the secondary structure of acetylcholinesterase (AChE) and competitively inhibited acetylcholine (ACh) binding to AChE, which may disturb the nervous system. These results described toxic response and molecular mechanism in zebrafish embryos, providing multiple aspects about ecological risk assessment of propofol in water environment.

Evaluation of the biological response of propofol in zebrafish (Danio rerio): Focusing on biochemical, transcriptional, and molecular level

Propofol, one of the most widely used intravenous anesthetic in clinical practice, has been reported to impair cognitive and memory function. However, the toxicological effects of propofol on aquatic organisms are still poorly understood. This study explored the toxic effects of chronic propofol exposure (0.008, 0.04, and 0.2 mg L^-1) on adult zebrafish from biochemical, transcriptional, and molecular level after 7, 14, 21 and 28 days of exposure. Results indicated that the reactive oxygen species (ROS) levels were significantly upregulated during the 28 days exposure period, and excessive ROS caused lipid peroxidation, resulting in increased malondialdehyde (MDA) contents in the zebrafish brain. In order to relieve the oxidative damage induced by the excessive ROS, the activities of antioxidant enzymes (superoxide dismutase (SOD), catalase (CAT)) were significantly activated, and detoxification enzyme (glutathione S-transferase, GST) activities showed an "activation-inhibition" trend. However, the antioxidant enzymes and detoxification enzyme system could not eliminate the excessive ROS in time and thus caused DNA damage in zebrafish brain. The olive tail moment (OTM) values displayed a "dose-response" relationship with propofol concentrations. Meanwhile, the transcription of related genes of Nrf2-Keap1 pathway was activated. Further molecular simulation experiments suggested that propofol could directly combine with SOD/CAT to change the activity of its biological enzyme. These findings indicated that zebrafish could regulate antioxidant capacity to combat oxidative stress at the early exposure stage, but the activity of antioxidant enzymes were significantly inhibited with the increase of propofol exposure time. Our results are of great importance for understanding toxicological effects of propofol on aquatic organisms.

[Safe and Appropriate Pharmacotherapy in Paediatric Anaesthesia]

Safe and appropriate pharmacotherapy in children requires knowledge of age-group-specific features regarding pharmacology and drug dosing. In addition, aspects of medication safety must be considered. This review highlights basic principles and discusses key facts; further research in paediatric databases is recommended (www.kinderformularium.de).

Application of Dexmedetomidine combined with Propofol Intravenous Anesthesia in Laparoscopic Day Surgery in Pediatric Urology

Objectives

To evaluate the sedative and analgesic effects of dexmedetomidine combined with propofol intravenous anesthesia in laparoscopic day surgery in pediatric urology.

Methods

Eighty male children with cryptorchidism and hydrocele who underwent laparoscopic daytime surgery in our hospital from January 2019 to January 2021 were selected and randomly divided into two groups: the experimental group and the control group. Children in the experimental group ranged in age from 5.7 to 11.3, with an average of 8.52±2.17 years old, while those in the control group ranged in age from 5.3 to 12.0, with an average of 8.60±2.07 years old. There were 12 cases of cryptorchidism and 28 cases of hydrocele in the experimental group, and 14 cases of cryptorchidism and 26 cases of hydrocele in the control group. Children in the control group received conventional propofol intravenous combined anesthesia, while those in the experimental group were given dexmedetomidine (2-5 ug/kg) intranasally on the basis of conventional propofol intravenous anesthesia. The anesthetic effect, analgesic effect, serum levels of inflammatory cytokines before and after surgery and adverse drug reactions in the two groups were compared and analyzed.

Results

The awakening time, extubation time and retention time in the resuscitation room of the experimental group were shorter than those of the control group, with a statistically significant difference (P<0.05); The VAS pain scores of the experimental group were significantly lower than those of the control group at 15minutes, 12hour and 24hour after awakening, with a statistically significant difference (P<0.05). In addition, the levels of TNF-a, CRP, IL-6 and other inflammatory factors in the control group were significantly higher compared with those in the experimental group 24h after surgery, with a statistical significance (TNF-a, P=0.02; CRP, P=0.00; IL-6, P=0.03); The incidence of adverse drug reactions in the experimental group was 17.5%, while that in the control group was 12.5%, which was not statistically significant (P=0.53).

Conclusion

Dexmedetomidine combined with intravenous propofol anesthesia may be helpful to shorten the extubation time, the recovery time and the stay time in the anesthesia resuscative room, improve the analgesic effect, and may reduce the inflammatory response and the expression of serum inflammatory cytokines, with no significant increase in side effects.

Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis

BACKGROUND

To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

METHODS

We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

RESULTS

In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol.

CONCLUSIONS

The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.

Wide range of perioperative drugs and doses used in inguinal hernia repairs for premature infants

OBJECTIVE

Characterize the types and doses of commonly administered perioperative drugs in inguinal hernia (IH) repair for premature infants.

STUDY DESIGN

Single-center, retrospective cohort study.

RESULTS

In total, 112 premature infants underwent IH repair between 2010 and 2015. Twenty-one drugs were used during IH repair, with each infant receiving a median seven drugs. Acetaminophen (88%), bupivacaine (84%), cisatracurium (74%), sevoflurane (72%), and propofol (71%) were the most commonly used agents. Thirty-two infants underwent additional procedures with IH repair. Additional procedures were not associated with a higher number of perioperative drugs, however infants with additional procedures were exposed to higher cumulative doses of cisatracurium (p < 0.001) and fentanyl (p = 0.002).

CONCLUSION

There is wide variability in the drugs and doses used for a common surgical procedure in this population, even within a single center. Future research should focus on the safety and efficacy of the most commonly used perioperative drugs described in this study.