Patient needs daily dressing we are using propofol for sedation and US guided PNB no opioids. He had weird symptoms like mood swings as he called! It will resolved only if we give few mls of propofol. What could be the possibilities and options?
How much propofol are you using for the dressing changes?
Are you using target controlled infusions for sedation?
Any other adjuncts such as NSAIDs or Clonidine etc?
Its certainly possible that your patient has developed some habituation to the sedative/euphoric effects of low dose(I.e sub general anaesthetic) propofol but more information about the doses used and how long the patient has been undergoing the procedures may be useful.
We have anesthetized children at St Jude daily (x30-45 days) for radiation therapy for decades (250mcg/kg/min x15-60 minutes) without any suspicion of physical addiction. We have used propofol almost exclusively for at least the past 10 years. There certainly are kids who enjoy the feeling of the “white milk” and look forward to it each day but we haven’t suspected physical addiction.
Although it has been reported to have potential for abuse and addiction (first report in 1992), it is probably very rare. I have experience of one case management (although I can't say he become addicted - most probably not) where there was a mini truck run-over history and the boy suffered massive injury on both the lower limb along others. He needed heavy analgesics and sedation for daily dressing for more than 3 months with multiple surgeries in between. He would wait for the anesthesiologist eagerly and don't even allow orthopedics resident to touch the limb till our team arrives. His face filled with smile when he saw us with syringes. But, he never said specifically that, give me the white one. Moreover, we used to change the drugs between propofol + fentanyl to Ketamine + midazolam etc.
However, literature do suggest the potential. one article (Article Neurobiology of Propofol Addiction and Supportive Evidence: ...
) in this aspect may help you to some extent. But, at this point it is clear that we need more evidence and suspicion / vigilance should be continued.
@Ian Ewart! We don’t have TCA! But we have been using propofol in anesthetic dose but demand is increasing. Thus we using ketamine, midazolam or dexmitomedine in combination with propofol. Patient complains pain/discomfort in recovery room! Only few mls of propofol worked. Thus we did spinal anesthesia for few days ; his discomfort still remain! Thus we suspect propofol addiction but couldn’t find criteria for it as such!!!
Hi there.....as myself and others have said,propofol addiction is uncommon at best,although there has been at least one very high profile case.
The addition of drugs such as ketamine and midazolam may account in part at least for the symptoms that your patient describes,maybe in psychological terms rather than physical symptoms of addiction.
The fact that spinal anaesthesia did not produce the desired result may add to that conclusion.
It is interesting to know that under spinal Anaesthesia the patient was complaining of discomfort every time...may I know the modified Bromage scale value at the time of complaint under spinal? If motor blockade was good and still patient complaint discomfort due to pain...and subsided with few ml of propofol every time...it is indeed a suspicious point. Have you tried other drug other than propofol in this context (discomfort due to pain under spinal Anaesthesia)? If yes, was other drug effective like propofol? It will be nice to know...
The effect of spinal Anesthesia was adequate—- unable to move feet and knee even hip. But sti he complains of sensation in his amputated limb. We have us dexmed for sedation and make him sleep. As surgery (about 30mins) was over then dexmed off. He used to have same complain as soon as he awake up. Till we give Some mls of propofol. We have tried other drus like midazolam, haloperidol or tramadol etc; seems to be failed even with dose in upper limit. Even opioids dont work. Besides patient is so afraid of opioids ( someone told him of addiction) he refused to take..
Still interesting issue was patient didn’t had realized it is propofol. He would shout, ask nurses to give something and call doctors desparately untill someone give few mls of propofol.
We stopped giving him propofol now!!!
Really interesting. Please report as it is likely to increase our scientific knowledge. Thanks for sharing your experience
I think you should report this. Though it might be difficult to define addiction in case of propofol, i guess some editors would accept this. www.jsan.org.np would be a good venue for your work.
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