A study suggests avoiding propofol for intraprocedural sedation during catheter-directed interventions (CDIs) for intermediate-risk pulmonary embolism (PE) because it can have detrimental effects. Propofol is the most commonly used parenteral anaesthetic agent in the USA, extensively used for minor and outpatient surgical procedures because of its rapid onset and reversal of action, and in intensive care units for maintenance of coma.
The single-centre, retrospective study is reported in the May 2021 issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
Over the past decade, using CDIs to treat intermediate-risk PE has increased because of the presumed similar therapeutic benefits compared with systemic thrombolysis, in addition to a better safety profile. These procedures are performed using intravenous anaesthetics with sedative and hypnotic properties, usually in conjunction with opioids for adequate pain control.
According to corresponding author Efthymios Avgerinos (University of Pittsburgh Medical Center, Pittsburgh, USA), researchers sought to assess “whether using propofol during CDIs for submassive PE is associated with in-hospital intra- or post-procedural major adverse events”.
The research team studied consecutive patients who had undergone CDIs for acute intermediate-risk submassive PE from 2009 to 2019. Submassive PE was defined as right ventricular strain without systemic hypotension. The primary endpoint was any major adverse event defined by postoperative intubation, progression to massive PE, the need for surgical conversion or in-hospital death.
Patient characteristics of the 340 patients studied included age 59±15 years, and 174 men (51%).
The procedures involved:
- standard thrombolysis (85),
- ultrasound assisted thrombolysis (229), and
- suction catheter embolectomy (26).
Thirty-six patients (11%) received propofol during their procedure; the remaining received midazolam plus a narcotic.
Overall, 18 of the 340 patients experienced at least one major adverse event including:
- 10 intubations,
- 11 decompensations,
- 2 surgical conversions, and
- 3 deaths.
The patients receiving propofol had a higher major adverse event rate (14%) versus the non-propofol group (4%, p=0.015). Propofol was a predictive factor for adverse events with an odds ratio of 3.8 (p=0.03).
“Propofol has increased in popularity after demonstrating satisfactory amnestic effects in addition to a fast recovery profile. The results of our study demonstrate a high safety profile for CDIs for acute submassive PE, yet a detrimental effect from the use of this drug,” said Avgerinos.
“Although we hypothesise that the mechanism for this adverse effect is blood pressure fluctuations (mainly hypotension) combined with a failing right ventricle, the exact pathophysiology is unknown,” said Avgerinos.
A limitation of this study is the lack of standardisation of anaesthetic care, as the anaesthesia team provided the sedation in the operating room while the operating physician provided that care when the procedure was done in an interventional suite. Nonetheless, propofol should be used with caution in caring for critically ill patients, especially with PE, the study concluded.