LETTERS TO THE EDITOR DOI: https://doi.org/10.5114/ait.2020.

100477

Risk of propofol use for sedation in COVID-19 patients

Department of Cardiovascular Surgery, Okamura Memorial Hospital, Shizuoka, Japan

Dear Editor, When propofol was introduced in Anaesthesiol Intensive Ther 2020; 52, 4: 354–355
The spread of coronavirus disease the United States, surgical-site infec-
(COVID-19) has led to an increasing tion (SSI) cases increased nationwide.
number of severe cases, with many In June 1990, the Centers for Disease
patients needing ventilation. In such Control and Prevention reported that
cases, continuous sedation is required, propofol use increases the risk for SSIs
and based on recent literature, ICU because of bacterial contamination of
mortality is around 20–30% [1]. lipid emulsions [4]. A recent study re-
Sedatives currently used in clinical ported that the number of SSI cases in
practice include midazolam, propofol, patients undergoing gastroenterolog-
and dexmedetomidine. Propofol has ical surgery was significantly higher
several properties that make it a po- with propofol use than with sevoflu-
tentially superior choice for sedation rane use. Therefore, it was concluded
of intubated ICU patients. Sedation that surgical contamination was not
with propofol can be rapidly com- the cause of the SSIs [5]. Following the
menced and terminated, even after switch in the treatment from inhaled
prolonged administration, allowing sevoflurane anaesthesia to total intra-
for greater control over the level of venous propofol anaesthesia at our
sedation and faster weaning from me- hospital, clinicians noticed a sudden
chanical ventilation. However, propo- and significant increase in the number
fol has several drawbacks that should of SSIs in patients who underwent
be considered, especially in COVID-19 open-heart surgery. After experienc-
patients. ing difficulties in infection control for
In 2015, Schläpfer et al. [2] conduct- 2–3 years, the results were presented
ed a study using a rat sepsis model. at the Annual Meeting of the Japanese
They reported that all rats anaesthe- Association for Thoracic Surgery in
tised with propofol died within 24 2014 [6]. The COVID-19 pandemic puts
hours, unlike those treated with other these findings in a new light.
anaesthetics. If the infusion rate or the With COVID-19 becoming more
total dose is too high, intravenously widespread and severe, an increasing
infused lipid emulsions might inhibit number of patients are experienc-
the function of the reticuloendothelial ing thromboembolic disorders such
system, resulting in immunosuppres- as deep vein thrombosis, lower limb
sion [3]. Intravenously administered ischaemia, and pulmonary microem-
lipid emulsions bind to serum proteins, bolism [7]. Infection, thromboembo-
thereby forming lipoproteins. If the lism, acute respiratory distress syn-
dose is too high, the fat droplets that drome, and myocardial damage can
do not form lipoproteins are treated by also occur as adverse drug reactions
the body’s immune system as foreign with lipid emulsions. These adverse
substances and are phagocytosed by drug reactions resemble the currently
reticuloendothelial cells. This response reported complications of COVID-19
CORRESPONDING AUTHOR:
might lead to a diminished immune that could make the disease more se-
Kenji Yamamoto, MD, PhD, Okamura Memorial Hospital,
reaction to other foreign substances vere. In the absence of a revolutionary 293-1 Kakita, Shimizu-cho, Sunto-gun, Shizuoka,
such as bacteria and viruses. drug treatment for COVID-19, patients Japan, e-mail: [email protected]

354
 Risk of propofol use for sedation in COVID-19 patients

placed on ventilator support might re- 3. Hayes BD, Gosselin S, Calello DP, et al. Systematic
review of clinical adverse events reported after
quire long-term sedation. Under these acute intravenous lipid emulsion administration.
circumstances, the total dose of the Clin Toxicol 2016; 54: 365-404. doi: 10.3109/
administered sedative will be far high- 15563650.2016.1151528
4. Centers for Disease Control (CDC). Postsurgical
er than that used for intraoperative an- infections associated with an extrinsically contami-
aesthesia. Propofol infusion syndrome nated intravenous anesthetic agent – California, Il-
linois, Maine, and Michigan, 1990. MMWR Morb
is a rare syndrome that affects patients Mortal Wkly Rep 1990; 39: 426-427, 433.
undergoing long-term treatment with 5. Shimizu K, Hirose M, Mikami S, et al. Effect of an-
a high dose of this anaesthetic and esthesia maintained with sevoflurane and propofol
on surgical site infection after elective open gastro-
sedative drug (> 4 mg kg-1 h-1 for more intestinal surgery. J Hosp Infect 2010; 74: 129-136.
than 24 hours). It can lead to cardiac doi: 10.1016/j.jhin.2009.10.011.
6. Yamamoto K, Enomoto S, Yamada T. Propofol
failure, myopathy, metabolic acidosis, increases SSI after cardiac surgery. Gen Thorac
and kidney failure, and is often fatal Cardiovasc Surg 2014; 62 (Suppl): 240.
[8, 9]. Therefore, these complications 7. Helms J, Tacquard C, Severac F, et al. High risk of
thrombosis in patients with severe SARS-CoV-2
must also be considered when treat- infection: a multicenter prospective cohort study.
ing COVID-19 patients. Intensive Care Med 2020; 46: 1089-1098. doi:
10.1007/s00134-020-06062-x.
The extent of propofol use in dif-
8. Lönnqvist PA, Bell M, Karlsson T, Wiklund L,
ferent countries is unknown. Differ- Höglund AS, Larsson L. Does prolonged propofol
ences in propofol use among individ- sedation of mechanically ventilated COVID-19
patients contribute to critical illness myopathy?
ual cases are also conceivable. Can the Br J Anaesth 2020; 125: e334-e336. doi: 10.1016/j.
abnormally high fatality rate in severe bja.2020.05.056.
COVID-19 cases be partially explained 9. Lucchetta V, Bonvicini D, Ballin A, Tiberio I. Pro-
pofol infusion syndrome in severe COVID-19. Br
by excessive administration of lipid J Anaesth 2020. doi: 10.1016/j.bja.2020.08.020.
emulsions?
As COVID-19 spreads, more pa-
tients are experiencing thromboem-
bolic disorders [7], which can also oc-
cur as adverse drug reactions with
lipid emulsions. These adverse drug
reactions resemble many of the com-
plications of COVID-19 and further
complicate cases. Patients placed
on ventilator support might require
long-term sedation and a potentially
high dose of anaesthesia over time.
Therefore, the immunosuppressive
risk associated with propofol use due
to its lipid emulsion content should be
considered when choosing sedatives
for such patients.

ACKNOWLEDGEMENTS
1. Assistance with the article: I would
like to thank Editage (www.editage.
com) for English language editing.
2. Financial support and sponsorship:
none.
3. Conflicts of interest: none.

REFERENCES
1. Quah P, Li A, Phua J. Mortality rates of patients
with COVID-19 in the intensive care unit: a sys-
tematic review of the emerging literature. Crit Care
2020; 24: 285. doi: 10.1186/s13054-020-03006-1.
2. Schläpfer M, Piegeler TO, Dull R, et al. Propofol
increases morbidity and mortality in a rat model of
sepsis. Crit Care 2015;19: 45. doi: 10.1186/s13054-
015-0751-x.

355