Written by Seth Walsh-Blackmore
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The dose of propofol to achieve a desired level of sedation decreased linearly with increasing age in this extensive retrospective review of pediatric procedural sedations.
Why does this matter?
Recommended pediatric dosing for propofol is commonly a single weight-based range for induction and maintenance of anesthesia. The physiology of an infant is different from a teenager. Does this affect the metabolism, distribution, and thus effect of propofol?
Happy Birthday! Let’s turn down the propofol.
This was a single-center retrospective cohort of 5,420 procedural sedations (PSA) using propofol in 2,368 pediatric patients (0-17 years). Opioids, most commonly alfentanil, were administered in over 80% of PSAs.
The authors built an adjusted regression model for the age (years) coefficient of induction (total in first 5 minutes) and maintenance (average infusion over 5-60 minutes) dose to meet a desired level of sedation. The model adjusted for procedure type, opiate use, sex, and ASA class. The model did not adjust for desired sedation level, using the procedure type as a surrogate. Most sedations targeted a Modified Ramsay scale of 3-4. This model yielded an age coefficient of -0.11 mg/kg (95%CI -0.12 to -0.11) for induction and -0.36 mg/kg/h (-0.39 to -0.34) for maintenance.
Simply put, children required less propofol with each additional year of age: 4-5mg/kg for infant induction down to 2-3mg/kg for teens; 200-300 mcg/kg/min for infants down to 150-200 mcg/kg/min for teens. See the figures below to appreciate the trend.
The results demonstrate an important consideration in pediatric sedation. A single weight-based pediatric dosing range may over-generalize this physiologically diverse age group. The actual dosages from the study lack generalizability to an ED or ICU setting, as these were primarily procedure suite sedations such as endoscopies and biopsies. Ketamine also appears safer than propofol for pediatric ED sedation. Though propofol exhibits unique pharmacokinetics, there are similar features to agents like benzodiazepines, so consider this for your next intranasal-versed dose.
Source
Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia. Anesth Analg. 2023 Mar 1;136(3):551-558. doi: 10.1213/ANE.0000000000006196. Epub 2023 Feb 17.
