Sepsis/InfectionEffects of propofol on vasopressor use in patients with sepsis and severe sepsis: A pilot study☆
Introduction
Propofol is an intravenous γ-amino butyric acid agonist used for continuous sedation in intensive care unit (ICU) patients [1], [2]. Advantages of propofol include ease of titration, fast onset and offset of action, and favorable pharmacokinetic properties [2]. The pharmacokinetic properties of propofol are beneficial as they allow for rapid awakenings and a reduced risk of drug accumulation, especially in patients with hepatic and renal dysfunction. Furthermore, recent literature has demonstrated that propofol is associated with a decreased length of mechanical ventilation compared to benzodiazepines, making it a preferred agent for patients requiring continuous sedation [3].
Although commonly used in ICU patients, propofol does have several significant disadvantages, including the development of hypotension secondary to a reduction in vascular sympathetic tone [2], [3]. Based on previous studies, the development of hypotension during propofol administration occurs in approximately 25% to 30% of ICU patients receiving the drug [1], [4]. As a result of this potential risk, clinicians may prefer alternative sedatives over propofol in patients at risk for developing hypotension [5], [6]. It is well known that critically ill patients with sepsis have an increased risk of hypotension and require early resuscitation to maintain hemodynamic stability and perfusion of critical vascular beds [7], [8]. Failure to maintain hemodynamic stability can result in progression to shock, resulting in potential increases in mortality as high as 46% [9], [10], [11], [12], [13]. Therefore, avoiding factors that may amplify hypotension and the progression to septic shock is critical to patient care.
Risk factors for progression to septic shock have been previously identified and include increased age, hyperthermia, increased shock index, pulmonary disease, and site of infection [9], [11]. Although some medications have been postulated to increase the risk of death in septic patients, definitive literature confirming this risk is lacking [14], [15]. Etomidate has been hypothesized to influence the progression to septic shock by causing adrenal suppression, although data from multiple studies have failed to demonstrate an effect on hemodynamics or other clinical outcomes [16], [17], [18]. Although hypotension has been widely reported with propofol administration, it has not been described in the setting of sepsis as a risk factor for progression to shock. As propofol remains the most commonly used sedative in the ICU and has the potential to cause clinically relevant hypotension in septic patients, the purpose of this investigation was to determine the effects of continuous intravenous (CIV) propofol administration on the need for vasopressor support in patients with sepsis and severe sepsis.
Section snippets
Materials and methods
This was a multicenter, retrospective, pilot study of patients with sepsis or severe sepsis who required mechanical ventilation. Patients were enrolled from 2 separate urban teaching hospitals. Patients discharged between the years 2011 and 2014 were identified through corporate patient financial services using the International Classification of Diseases, Ninth Revision, Clinical Modification, codes for sepsis and mechanical ventilation. Patients were included if they were at least 18 years of
Results of unmatched analysis
Over a 4-year period, 1337 patients were identified by International Classification of Diseases, Ninth Revision, codes and screened for enrollment. A total of 1058 patients were excluded, leaving 279 for evaluation. One-hundred forty-nine patients were included in the CIV propofol group; and 130 patients, in the non-CIV propofol group (Fig. 1). Primary reasons for exclusion were that patients were not septic within 2 hours of intubation, immunosuppressed, or intubated before arrival. Baseline
Discussion
To our knowledge, this is the first investigation evaluating the effects of CIV propofol on vasopressor requirements in septic patients. We compared CIV propofol administration in mechanically ventilated patients with sepsis and severe sepsis and found no differences in vasopressor support or change in MAP within 48 hours after intubation in a matched cohort. Despite its well-known ability to lower blood pressure, our results demonstrated that CIV propofol may be safe in patient populations
Conclusion
In this multicenter, retrospective propensity-matched pilot study, CIV propofol did not increase vasopressor requirements within 48 hours after intubation. Furthermore, CIV propofol was not associated with significant differences in duration of mechanical ventilation, ICU or hospital length of stay, or all-cause mortality. Because this was a pilot study, further prospective studies would be useful to evaluate the hemodynamic effects associated with CIV propofol in septic patients.
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All authors of this study have no direct or indirect conflicts of interest to disclose. No funding was obtained for the conduction of this study. The results of this study have not been presented previously.