Volume 22, Number 6—June 2016
CME ACTIVITY - Synopsis
Infectious Disease Risk Associated with Contaminated Propofol Anesthesia, 1989–20141
|Propofol formulation||Settings||Advantages||Disadvantages||FDA approval|
|Propofol with EDTA
||This mixture with propofol at 0.005% wt/vol concentration has demonstrated microbial growth to be retarded to >1 log CFUs (36), of nearly 20 microorganisms, including 7 Gram-positive bacteria, 10 Gram-negative bacteria, and 3 yeasts (18). Further, incidence of propofol-related infection declined from 39 to 9 infections per year in the USA, after the introduction of EDTA into clinical use in 1996 (18).
||Decreases serum ionized calcium levels, although statistically significant, has apparently no clinical effect (time to complete recovery, p = 0.77 ). Also, EDTA is nephrotoxic at high doses (2–3 g/d). Concern that use of an antimicrobial may cause health personnel to relax on aseptic handling practices (1).
||Because of water solubility, eliminates some of the known lipid emulsion-associated disadvantages of propofol, including the risk for infection (38).
||Minor side effects (e.g., paresthesia, hypotension). The prolonged onset of action of fospropofol (≈4–13 min, because of it must first undergo metabolism to propofol) compared with the prodrug propofol (≈40 s). Allergies caused by the accumulation of a phosphate-ester component (38).
|Propofol and lidocaine
||Experimentally causes loss of viability of several strains (29).
||Has no sufficient retarding effect. Possibilities of micelle formation exist.
||At low concentrations of >2%, has been used as a preservative agent.
||Toxicity and presumed instability.
||Reduces the pain of propofol injection and has preservative properties.
||Has a labeled pH of 4.5–6.4, which is different from the required pH for propofol (6–8.5) (1).
||Use of the 0.45 µm-rated filter is purported to provide protection from accidental microbial contamination, particulate contamination and entrained air while maintaining the integrity of the emulsion (40).
||High costs, not currently available.
|Nonlipid propofol nanoemulsion||Nonlipophilic preparation||Replaces soybean lecithin with polyethylene glycol 660 hydroxystearate as propofol carrier (40).||High costs, not currently available.||No|
*FDA, US Food and Drug Administration.
†Approved for use by the FDA only for monitored anesthesia care; however, a decision from the US Drug Enforcement Agency could be scheduled (38).
1Part of this work was presented at the XXXI Colombian Congress of Anesthesiology and Critical Care, Cali, Columbia, July 2015.