Editing Propofol (section)

==Uses==

===Anesthesia===
To induce general anesthesia, propofol is the drug used almost exclusively, having largely replaced [[sodium thiopental]].<ref>{{Cite web |title=Discovery and development of propofol, a widely used anesthetic |url=http://www.laskerfoundation.org/awards/show/discovery-and-development-propofol-widely-used-anesthetic/ |access-date=8 September 2020 |website=The Lasker Foundation |quote=Propofol is used today to initiate anesthesia in nearly 100% of general anesthesia cases worldwide.}}</ref>

It is often administered as part of an anesthesia maintenance technique called [[total intravenous anesthesia]], using either manually programmed infusion pumps or computer-controlled infusion pumps in a process called [[target controlled infusion]] (TCI).<ref>{{Cite journal | vauthors = Gale T, Leslie K, Kluger M |date= December 2001 |title=Propofol anaesthesia via target controlled infusion or manually controlled infusion: effects on the bispectral index as a measure of anaesthetic depth |journal=Anaesthesia and Intensive Care |volume=29 |issue=6 |pages=579–584 |doi=10.1177/0310057X0102900602 |pmid=11771598 |doi-access=free }}</ref>

Propofol is also used to sedate people who are receiving mechanical ventilation but not undergoing surgery, such as patients in the [[intensive care unit]].<ref name="Lewis_2018">{{cite journal | vauthors = Lewis SR, Schofield-Robinson OJ, Alderson P, Smith AF | title = Propofol for the promotion of sleep in adults in the intensive care unit | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD012454 | date = January 2018 | issue = 1 | pmid = 29308828 | pmc = 6353271 | doi = 10.1002/14651858.CD012454.pub2 }}</ref> In critically ill patients, propofol is superior to [[lorazepam]] both in effectiveness and overall cost.<ref name="Cox-2008">{{cite journal | vauthors = Cox CE, Reed SD, Govert JA, Rodgers JE, Campbell-Bright S, Kress JP, Carson SS | title = Economic evaluation of propofol and lorazepam for critically ill patients undergoing mechanical ventilation | journal = Critical Care Medicine | volume = 36 | issue = 3 | pages = 706–714 | date = March 2008 | pmid = 18176312 | pmc = 2763279 | doi = 10.1097/CCM.0B013E3181544248 }}</ref> Propofol is relatively inexpensive compared to medications of similar use due to shorter ICU stay length.<ref name="Cox-2008" /> One of the reasons propofol is thought to be more effective (although it has a longer half-life than [[lorazepam]]) is that studies have found that benzodiazepines like [[midazolam]] and lorazepam tend to accumulate in critically ill patients, prolonging sedation.<ref name="Cox-2008" />

Propofol has also been suggested as a [[sleep aid]] in critically ill adults in an ICU setting; however, the effectiveness of this medicine in replicating the mental and physical aspects of sleep for people in the ICU is not clear.<ref name="Lewis_2018" />

Propofol can be administered via a [[Intravenous therapy|peripheral IV]] or [[Central venous catheter|central line]]. Propofol is often paired with [[fentanyl]] (for pain relief) in intubated and sedated people.<ref name="Isert_1996">{{cite journal |vauthors=Isert PR, Lee D, Naidoo D, Carasso ML, Kennedy RA |date=June 1996 |title=Compatibility of propofol, fentanyl, and vecuronium mixtures designed for potential use in anesthesia and patient transport |journal=Journal of Clinical Anesthesia |volume=8 |issue=4 |pages=329–336 |doi=10.1016/0952-8180(96)00043-8 |pmid=8695138}}</ref> The two drugs are molecularly compatible in an IV mixture form.<ref name="Isert_1996" />

Propofol is also used to deepen anesthesia to relieve [[laryngospasm]]. It may be used alone or followed by [[succinylcholine]]. Its use can avoid the need for paralysis and in some instances the potential side-effects of succinylcholine.<ref name= "Gavel_2014">{{cite journal | vauthors = Gavel G, Walker RW | title = Laryngospasm in anaesthesia | journal = Continuing Education in Anaesthesia Critical Care & Pain | volume = 14 | issue = 2 | date = April 2014 | pages = 47–51 | doi = 10.1093/bjaceaccp/mkt031 | doi-access = free }}</ref>

===Routine procedural sedation===
Propofol is safe and effective for gastrointestinal endoscopy procedures (colonoscopies etc.). Its use in these settings results in a faster recovery compared to [[midazolam]].<ref name="McQuaid-2008">{{cite journal |vauthors=McQuaid KR, Laine L |date=May 2008 |title=A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures |journal=Gastrointestinal Endoscopy |volume=67 |issue=6 |pages=910–923 |doi=10.1016/j.gie.2007.12.046 |pmid=18440381}}</ref> It can also be combined with [[opioids]] or [[benzodiazepines]].<ref>Canadian National Formulary 2010</ref><ref>{{cite book |title=Appleton & Lange's 1999 drug guide |vauthors=Shannon MT, Wilson BA, Stang CL |date=1999 |publisher=Appleton & Lange |isbn=978-0-8385-0371-3 |location=Stamford, CT}}</ref><ref>Numorphan® (oxymorphone) package insert (English), Endo 2009</ref> Because of its rapid induction and recovery time, propofol is also widely used for sedation of infants and children undergoing [[MRI]] procedures.<ref>{{cite journal |vauthors=Machata AM, Willschke H, Kabon B, Kettner SC, Marhofer P |date=August 2008 |title=Propofol-based sedation regimen for infants and children undergoing ambulatory magnetic resonance imaging |journal=British Journal of Anaesthesia |volume=101 |issue=2 |pages=239–243 |doi=10.1093/bja/aen153 |pmid=18534971 |doi-access=free}}</ref> It is also often used in combination with [[ketamine]] with minimal side effects.<ref>{{cite journal |vauthors=Yan JW, McLeod SL, Iansavitchene A |date=September 2015 |title=Ketamine-Propofol Versus Propofol Alone for Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis |journal=Academic Emergency Medicine |volume=22 |issue=9 |pages=1003–1013 |doi=10.1111/acem.12737 |pmid=26292077 |doi-access=free}}</ref>

===COVID-19===
{{anchor|COVID-19}}
In March 2021, the U.S. [[Food and Drug Administration]] (FDA) issued an [[emergency use authorization]] (EUA) for ''Propofol‐Lipuro'' 1% to maintain sedation via continuous infusion in people older than sixteen with suspected or confirmed COVID-19 who require mechanical ventilation in an [[intensive care unit]] ICU setting.<ref>{{Cite web |title=Propofol-Lipuro 1% (propofol) Injectable emulsion for infusion – 1,000 mg in 100 ml (10 mg /ml) : Fact Sheet for health Care Providers |url=https://www.bbraunusa.com/content/dam/b-braun/us/website/company/covid-files/210319_Propofol_EUA_Submission_to_FDA_hcp.pdf |access-date=5 March 2022 |website=Bbraunusa.com |archive-date=14 May 2021 |archive-url=https://web.archive.org/web/20210514065329/https://www.bbraunusa.com/content/dam/b-braun/us/website/company/covid-files/210319_Propofol_EUA_Submission_to_FDA_hcp.pdf |url-status=dead }}</ref><ref>{{Cite web |title=Letter RE: Emergency Use Authorization 096 |url=https://www.fda.gov/media/146680/download |access-date=5 March 2022 |website=Fda.gov}}</ref><ref>{{Cite web |title=Fact Sheet for Health Care Providers: Emergency Use Authorization (EUA) of Propofol-Lipuro 1% Injectable Emulsion for Infusion |url=https://www.fda.gov/media/146681/download |access-date=5 March 2022 |website=Fda.gov}}</ref><ref name="FDA EUA">{{Cite web |title=Emergency Use Authorization |url=https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization |access-date=17 April 2021 |website=U.S. [[Food and Drug Administration]] (FDA)}}</ref> During the public health emergency, it was considered unfeasible to limit Fresenius Propoven 2% Emulsion or Propofol-Lipuro 1% to patients with suspected or confirmed COVID-19, so it was made available to all ICU patients under mechanical ventilation.<ref name="FDA EUA" /> This EUA has since been revoked.<ref>{{cite web |url=https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization-archived-information |title=Emergency Use Authorization--Archived Information |website=FDA |archive-url=https://web.archive.org/web/20231216135744/https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization-archived-information |archive-date=December 16, 2023 |url-status=dead}}</ref>

===Status epilepticus===
[[Status epilepticus]] may be defined as seizure activity lasting beyond five minutes and needing anticonvulsant medication. Several guidelines recommend the use of propofol for the treatment of refractory status epilepticus.<ref>{{cite book |title=Harrison's Principles of Internal Medicine |vauthors=Rao VR, Lowenstein DH |date=2022 |publisher=McGraw Hill |isbn=978-1-264-26851-1 |veditors=Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J |edition=21st |chapter=Seizures and epilepsy. |chapter-url=https://accessmedicine.mhmedical.com/content.aspx?bookid=3095&sectionid=265447874}}</ref>
===Other uses===
====Assisted death in Canada====
A lethal dose of propofol is used for [[Euthanasia in Canada|medical assistance in dying in Canada]] to quickly induce deep coma and death, but [[Rocuronium bromide|rocuronium]] is always given as a [[paralytic]] ensuring death, even when the patient has died as a result of initial propofol overdose.<ref name="divisionsbc1">{{cite web |date=May 2017 |title=Medical Assistance in Dying (MAiD): Protocols and Procedures Handbook |url=https://divisionsbc.ca/sites/default/files/51936/Medical%20Assistance%20in%20Dying%20(MAID)%20Protocols%20and%20Procedures%20Handbook%20Comox%20Valley%202017%20-%202nd%20edition_0.pdf |work=Divisions of Family Practice |edition=2nd |vauthors=Reggler J, Daws T |location=Comox Valley, British Columbia}}</ref>

====Capital punishment====
The use of propofol as part of an execution protocol has been considered, although no individual has been executed using this agent. This is largely due to European manufacturers and governments banning the export of propofol for such use.<ref>{{cite journal | vauthors = Kim E, Levy RJ | title = The role of anaesthesiologists in lethal injection: a call to action | journal = Lancet | volume = 395 | issue = 10225 | pages = 749–754 | date = February 2020 | pmid = 32014115 | pmc = 7416913 | doi = 10.1016/S0140-6736(19)32986-1 }}</ref><ref>{{Cite news |date=15 November 2013 |title=Lethal injection: Secretive US states resort to untested drugs  |work=BBC News |url=https://www.bbc.com/news/world-us-canada-24935868 |access-date=8 November 2023}}</ref>

====Recreational use====
Recreational use of the drug via self-administration has been reported<ref>{{cite journal | vauthors = Riezzo I, Centini F, Neri M, Rossi G, Spanoudaki E, Turillazzi E, Fineschi V | title = Brugada-like EKG pattern and myocardial effects in a chronic propofol abuser | journal = Clinical Toxicology | volume = 47 | issue = 4 | pages = 358–363 | date = April 2009 | pmid = 19514884 | doi = 10.1080/15563650902887842 | hdl = 11392/2357145 }}</ref><ref>{{Cite news | vauthors = Belluck P |date=6 August 2009 |title=With High-Profile Death, Focus on High-Risk Drug |work=[[The New York Times]] |url=https://www.nytimes.com/2009/08/07/us/07propofol.html |url-status=live |access-date=7 August 2009 |archive-url=https://web.archive.org/web/20111111023529/http://www.nytimes.com/2009/08/07/us/07propofol.html |archive-date=11 November 2011 }}</ref> but is relatively rare due to its potency and the level of monitoring required for safe use. Critically, a steep [[dose-response curve]] makes recreational use of propofol very dangerous, and deaths from self-administration continue to be reported.<ref>{{cite journal | vauthors = Iwersen-Bergmann S, Rösner P, Kühnau HC, Junge M, Schmoldt A | title = Death after excessive propofol abuse | journal = International Journal of Legal Medicine | volume = 114 | issue = 4–5 | pages = 248–251 | year = 2001 | pmid = 11355404 | doi = 10.1007/s004149900129 }}</ref><ref>{{cite journal | vauthors = Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis M | title = Lethal self administration of propofol (Diprivan). A case report and review of the literature | journal = Forensic Science International | volume = 167 | issue = 1 | pages = 56–58 | date = March 2007 | pmid = 16431058 | doi = 10.1016/j.forsciint.2005.12.027 }}</ref> The short-term effects sought via recreational use include mild euphoria, hallucinations, and disinhibition.<ref>{{cite book | veditors = Sweetman SC | title = Martindale: The Complete Drug Reference | date = 2005 | edition = 34th | location = London | publisher = Pharmaceutical Press| pages = 1305–1307 | isbn = 978-0-85369-550-9 }}</ref><ref>{{cite book | vauthors = Baudoin Z | chapter = General anesthetics and anesthetic gases. | veditors = Dukes MN, Aronson JK | title = Meyler's Side Effects of Drugs | date = 2000 | edition = 14th | location = Amsterdam | publisher = Elsevier Science | page = 330 | isbn = 978-0-444-50093-9 }}</ref>

Recreational use of the drug has been described among medical staff, such as [[anesthetist]]s who have access to the drug.<ref name="Roussin">{{cite journal | vauthors = Roussin A, Montastruc JL, Lapeyre-Mestre M | title = Pharmacological and clinical evidences on the potential for abuse and dependence of propofol: a review of the literature | journal = Fundamental & Clinical Pharmacology | volume = 21 | issue = 5 | pages = 459–466 | date = October 2007 | pmid = 17868199 | doi = 10.1111/j.1472-8206.2007.00497.x }}</ref><ref>{{cite journal | vauthors = Ward CF | title = Propofol: dancing with a "White Rabbit." | journal = California Society Anesthesiology Bulletin | date = 2008 | volume = 57 | issue = Spring | pages = 61–63 | url = https://csahq.org/docs/default-source/news-and-events-docs/csa-bulletin-docs/spring-2008/propofol_57_2.pdf | archive-url = https://web.archive.org/web/20170908190922/https://csahq.org/docs/default-source/news-and-events-docs/csa-bulletin-docs/spring-2008/propofol_57_2.pdf | archive-date=8 September 2017 | access-date = 24 November 2014 }}</ref> It is reportedly more common among anesthetists on rotations with short rest periods, as usage generally produces a well-rested feeling.<ref name="BMJ2009">{{cite journal | vauthors = Charatan F | title = Concerns mount over misuse of anaesthetic propofol among US health professionals | journal = BMJ | volume = 339 | pages = b3673 | date = September 2009 | pmid = 19737827 | doi = 10.1136/bmj.b3673 }}</ref> Long-term use has been reported to result in addiction.<ref name=Roussin/><ref>{{cite journal | vauthors = Bonnet U, Harkener J, Scherbaum N | title = A case report of propofol dependence in a physician | journal = Journal of Psychoactive Drugs | volume = 40 | issue = 2 | pages = 215–217 | date = June 2008 | pmid = 18720673 | doi = 10.1080/02791072.2008.10400634 }}</ref>

Attention to the risks of [[off-label use]] of propofol increased in August 2009, after the release of the Los Angeles County coroner's report that musician [[Michael Jackson]] had [[Death of Michael Jackson|died]] from a mixture of propofol and the [[benzodiazepine]] drugs [[lorazepam]], [[midazolam]], and [[diazepam]] on 25 June 2009.<ref>{{Cite news | vauthors = Moore S |date=28 August 2009 |title=Jackson's Death Ruled a Homicide |work=[[The New York Times]] |url=https://www.nytimes.com/2009/08/29/us/29jackson.html |url-status=live |archive-url=https://web.archive.org/web/20131114065934/http://www.nytimes.com/2009/08/29/us/29jackson.html?hp |archive-date=14 November 2013 }}</ref><ref name="washingtonpost.com">{{Cite news | vauthors = Surdin A |date=25 August 2009 |title=Coroner Attributes Michael Jackson's Death to Propofol |newspaper=The Washington Post |url=https://www.washingtonpost.com/wp-dyn/content/article/2009/08/24/AR2009082402193.html |url-status=live |access-date=22 May 2010 |archive-url=https://web.archive.org/web/20121109132226/http://www.washingtonpost.com/wp-dyn/content/article/2009/08/24/AR2009082402193.html?hpid=moreheadlines |archive-date=9 November 2012 }}</ref><ref name="artsbeat.blogs.nytimes.com">{{Cite news | vauthors = Itzkoff D |date=24 August 2009 |title=Coroner's Findings in Jackson Death Revealed |work=The New York Times |url=http://artsbeat.blogs.nytimes.com/2009/08/24/coroners-findings-in-jackson-death-revealed/?hp |url-status=live |access-date=22 May 2010 |archive-url=https://web.archive.org/web/20100611151136/http://artsbeat.blogs.nytimes.com/2009/08/24/coroners-findings-in-jackson-death-revealed/?hp |archive-date=11 June 2010 }}</ref><ref>{{Cite magazine |date=25 August 2009 |title=Jackson's Death: How Dangerous Is Propofol? |url=http://www.time.com/time/arts/article/0,8599,1918363,00.html |url-status=dead |magazine=Time |archive-url=https://web.archive.org/web/20100725002645/http://www.time.com/time/arts/article/0,8599,1918363,00.html |archive-date=25 July 2010 |access-date=22 May 2010 }}</ref> According to a 22 July 2009 search warrant affidavit unsealed by the district court of Harris County, Texas, Jackson's physician, [[Conrad Murray]], administered 25 milligrams of propofol diluted with [[lidocaine]] shortly before Jackson's death.<ref name="washingtonpost.com" /><ref name="artsbeat.blogs.nytimes.com" /><ref>{{Cite web |title=Michael Jackson search warrant |url=https://www.scribd.com/doc/19058649/Michael-Jackson-search-warrant |url-status=live |archive-url=https://web.archive.org/web/20160305092954/https://www.scribd.com/doc/19058649/Michael-Jackson-search-warrant |archive-date=5 March 2016 |access-date=12 August 2015 |publisher=[[Scribd]] }}</ref>