Propofol (Diprivan) | Medication Reference

Bedside Snapshot

Short-acting IV hypnotic for rapid-on/rapid-off sedation: used for induction of anesthesia, ED procedural sedation, post-intubation sedation, ICU sedation infusions, and refractory status epilepticus.
Onset: ~15–30 seconds after IV bolus; patients typically lose consciousness rapidly. Duration of a single bolus is ~3–10 minutes due to redistribution, but context-sensitive half-life increases with prolonged infusions.
Standard ICU/post-intubation sedation infusion: Often started around 5–20 mcg/kg/min (0.3–1.2 mg/kg/h) and titrated up to ~50 mcg/kg/min (3 mg/kg/h) to achieve light–moderate sedation. Doses >70–80 mcg/kg/min (4–5 mg/kg/h) and duration >48 hours increase risk of propofol-related infusion syndrome (PRIS).
ED post-intubation or short-term sedation: Titrate boluses of 10–30 mg IV (0.3–0.5 mg/kg) followed by an infusion in the 20–50 mcg/kg/min range, always paired with appropriate analgesia (propofol has no analgesic effect).
Procedural sedation (deep sedation): Initial 0.5–1 mg/kg IV over 30–60 seconds, then 0.25–0.5 mg/kg q2–3 minutes or 10–20 mg aliquots to effect. Requires full monitoring, airway-capable provider, and rescue equipment.
Major issues: Profound dose-dependent hypotension (↓SVR, mild myocardial depression), respiratory depression/apnea, pain on injection, hypertriglyceridemia, and rare but life-threatening PRIS (metabolic acidosis, arrhythmias, cardiac failure, rhabdomyolysis, renal failure).
Formulation: 10 mg/mL oil-in-water lipid emulsion (soybean oil, egg lecithin, glycerol). Supports bacterial growth → strict asepsis and discard tubing/solution per institutional policy (commonly q6–12 h).

Brand & Generic Names

Generic Name: Propofol
Brand Names: Diprivan, generic propofol emulsions

Medication Class

Short-acting intravenous anesthetic; hypnotic sedative (no intrinsic analgesia)

Pharmacology

Mechanism of Action:

Acts primarily as a positive allosteric modulator at the GABA_A receptor, enhancing inhibitory neurotransmission by increasing chloride influx and neuronal hyperpolarization
At higher concentrations, propofol may directly activate GABA_A receptors and also inhibits NMDA receptors and modulates calcium channels, contributing to its hypnotic and anticonvulsant properties
Produces dose-dependent depression of cortical activity, resulting in hypnosis and amnesia; it does not provide intrinsic analgesia, so opioids or other analgesics are required for painful stimuli
Systemic vasodilation (reduced systemic vascular resistance) and mild negative inotropy lead to decreases in blood pressure and, occasionally, bradycardia or asystole in susceptible patients

Pharmacokinetics (IV):

Onset: Loss of consciousness typically within 15–30 seconds after IV bolus
Peak Effect: ~1 minute after bolus
Duration: After single bolus ~3–10 minutes, governed largely by rapid redistribution from the central compartment to peripheral tissues
Distribution: Highly lipophilic with rapid CNS penetration; large volume of distribution; ~95–99% protein bound
Metabolism: Extensive hepatic metabolism (primarily via glucuronidation and hydroxylation) to inactive metabolites; extrahepatic metabolism (e.g., in lungs) also contributes
Elimination: Metabolites excreted primarily in urine; terminal elimination half-life ~2–24 hours, but clinical offset is much shorter after brief use
Context-Sensitive Half-Life: Remains relatively short for infusions of a few hours, but increases significantly with prolonged high-dose infusions, especially in critical illness or organ dysfunction

Indications

Induction of general anesthesia (typically 1.5–2.5 mg/kg IV in healthy adults; lower doses in the elderly, hypovolemic, or hemodynamically unstable)
Maintenance of anesthesia as a continuous infusion, usually in the OR or procedural suite
ED procedural sedation for painful procedures requiring deep sedation (e.g., cardioversion, joint reduction, large abscess I&D) by providers trained in deep sedation and airway management
Post-intubation sedation for mechanically ventilated patients in the ED and ICU, often in combination with opioid analgesia and adjunct sedatives
Ongoing ICU sedation for mechanically ventilated adults, generally targeting light sedation per PADIS/updated sedation guidelines
Refractory status epilepticus as a continuous sedative infusion to achieve EEG burst suppression (neurocritical care–directed)

Dosing & Administration

Available Forms:

IV emulsion: Standard concentration 10 mg/mL (1% propofol) in a lipid emulsion (soybean oil, egg lecithin, glycerol)
Commercial vials: Commonly 20 mL (200 mg), 50 mL (500 mg), and 100 mL (1,000 mg) vials or prefilled bottles
Ready-to-use; do not dilute with hypotonic solutions (e.g., sterile water) due to risk of hemolysis; may be diluted in compatible fluids (e.g., NS, D5W) per institutional policy for infusion

Infection Risk: Because the lipid emulsion supports bacterial growth, strict aseptic technique is required, and vials/tubing should be discarded within the manufacturer/institutional time limits (often 6–12 hours).

Dosing – Propofol (Adult, Always Follow Local Protocol):

Indication	Dose & Route	Frequency / Titration	Notes
Induction of anesthesia (healthy adult)	1.5–2.5 mg/kg IV bolus	Given over 20–30 seconds	Reduce dose in elderly, hypovolemic, or unstable patients
ED procedural deep sedation	Initial 0.5–1 mg/kg IV (or 10–20 mg increments)	Additional 0.25–0.5 mg/kg q2–3 min or 10–20 mg aliquots	Requires full monitoring and airway-capable provider; no analgesia
Post-intubation sedation (initial)	10–30 mg IV bolus (≈0.3–0.5 mg/kg)	Repeat small boluses as needed while starting infusion	Always pair with analgesia (e.g., fentanyl) and consider adjunct sedatives
ICU/post-intubation sedation infusion – typical range	5–50 mcg/kg/min (0.3–3 mg/kg/h)	Titrate by 5–10 mcg/kg/min every 5–10 min to light sedation	Avoid sustained doses >70–80 mcg/kg/min (>4–5 mg/kg/h) due to PRIS risk
Refractory status epilepticus (neurocritical care)	Loading 1–2 mg/kg IV, then 30–200 mcg/kg/min infusion	Titrate to EEG burst suppression as directed by neurology	High-dose, high-risk; typically short-term with close monitoring
Elderly, shock, or severe cardiomyopathy	Use lower doses (e.g., 0.25–0.5 mg/kg bolus; 5–20 mcg/kg/min)	Titrate slowly with hemodynamic monitoring	Consider alternative agents if profound hemodynamic instability

Maximum / Caution for Prolonged ICU Sedation:

Generally keep ≤50–70 mcg/kg/min
Reassess if >48 hours at moderate–high doses
Monitor for PRIS: acidosis, arrhythmias, rhabdomyolysis, hyperkalemia, renal failure

Contraindications

Contraindications:

Documented hypersensitivity to propofol or any component of the formulation
Allergy to eggs, egg products, soy, or soy products is listed as a contraindication in some product labeling; however, clinical cross-reactivity appears low. Many institutions treat this as a relative rather than absolute contraindication
Situations where deep sedation or general anesthesia cannot be safely provided (e.g., lack of appropriate monitoring, airway equipment, or trained personnel)

Major Precautions:

Hemodynamic instability: Propofol can cause marked hypotension and bradycardia, especially in hypovolemic, septic, or cardiogenic shock patients; preload and vasopressor support may be needed
Severe cardiac dysfunction (low EF, cardiomyopathy): Negative inotropy and vasodilation may precipitate cardiovascular collapse
Respiratory depression and apnea: Must be prepared for bag-mask ventilation, airway maneuvers, and endotracheal intubation if needed
Obesity, hepatic dysfunction, or prolonged high-dose infusion: Increased risk of drug accumulation and delayed emergence
Risk of propofol-related infusion syndrome (PRIS) with prolonged high-dose infusions, especially in critically ill patients receiving catecholamines and/or corticosteroids

PRIS Warning: Propofol-related infusion syndrome is a rare but life-threatening complication characterized by metabolic acidosis, rhabdomyolysis, renal failure, hyperkalemia, hepatomegaly, arrhythmias, and cardiovascular collapse. Risk increases with doses >70–80 mcg/kg/min for >48 hours.

Adverse Effects

Common:

Hypotension and decreased systemic vascular resistance
Bradycardia and reduced cardiac output
Respiratory depression and apnea
Pain or burning at injection site
Hypertriglyceridemia with prolonged infusion
Green or cloudy urine (benign, related to metabolites)

Serious:

Profound hypotension, bradycardia, and cardiovascular collapse
Severe respiratory depression leading to hypoxia and arrest
Propofol-related infusion syndrome (PRIS): Metabolic acidosis, rhabdomyolysis, renal failure, hyperkalemia, hepatomegaly, arrhythmias, and cardiovascular collapse
Pancreatitis associated with hypertriglyceridemia in some patients
Infection from contaminated propofol emulsion if aseptic technique is inadequate

Special Populations

Elderly Patients:

Use reduced induction doses (0.25–0.5 mg/kg) due to increased sensitivity and decreased cardiovascular reserve
Lower infusion rates (5–20 mcg/kg/min) and titrate slowly with close hemodynamic monitoring

Hemodynamically Unstable / Shock States:

Consider alternative agents (ketamine, etomidate, dexmedetomidine) for induction if severe shock or cardiomyopathy
If propofol is used, reduce doses significantly and prepare vasopressor support
Administer fluids and optimize preload before induction when possible

Hepatic / Renal Impairment:

Prolonged infusions may lead to accumulation and delayed emergence
Consider dose reduction and increased monitoring in severe hepatic dysfunction
Renal impairment does not significantly affect propofol clearance, but metabolites accumulate

Pregnancy & Lactation:

Pregnancy Category B; propofol crosses the placenta
Use in pregnancy only if clearly needed; neonatal CNS and respiratory depression possible
Excreted in breast milk; most sources recommend avoiding breastfeeding for 24 hours after administration

Pediatric:

Dosing differs from adults; consult pediatric protocols
Higher risk of cardiovascular collapse in children with hemodynamic instability

Monitoring

Clinical Monitoring:

Continuous ECG, noninvasive or invasive blood pressure, and pulse oximetry for all patients receiving IV propofol
Consider capnography during deep sedation
Frequent assessment of level of consciousness and sedation depth (e.g., RASS or similar scale)
Hemodynamics: watch for hypotension, bradycardia, and signs of low cardiac output; adjust dose and provide fluids/vasopressors as needed
Respiratory status: respiratory rate, tidal volumes, EtCO₂, and ventilator synchrony in intubated patients

Laboratory Monitoring in Prolonged or High-Dose Infusions:

Triglycerides
Creatine kinase (CK) for rhabdomyolysis
Lactate
Arterial/venous blood gases
Electrolytes (especially K⁺)
Creatinine and liver enzymes

Infection Control:

Strict attention to infusion tubing and vial hang times to prevent contamination
Follow institutional policies (commonly discard after 6–12 hours)

Clinical Pearls

No Analgesia: Propofol provides hypnosis and amnesia but no intrinsic analgesia—always pair it with an appropriate opioid or other analgesic for painful conditions. Don't rely on propofol alone for pain management.

Start Low, Go Slow in Shock: In hemodynamically fragile patients, start with lower doses and titrate slowly. Consider alternative strategies (e.g., ketamine, dexmedetomidine, or multimodal sedation) when shock or severe cardiomyopathy is present. Propofol's vasodilatory and negative inotropic effects can be devastating in unstable patients.

Prefer Infusion Over Boluses: For post-intubation sedation, prefer a modest propofol infusion (e.g., 20–50 mcg/kg/min) plus opioid analgesia rather than large intermittent boluses that cause swings in BP and depth of sedation. Smooth, titratable sedation is safer and more effective.

Watch for PRIS: If propofol requirements creep up toward 70–80 mcg/kg/min or beyond, or if the patient has been on moderate–high doses for >48 hours, screen aggressively for PRIS (check lactate, CK, electrolytes, triglycerides, ABG). Consider alternative sedatives if high doses are needed for prolonged periods. PRIS is rare but deadly.

Excellent for Neuro Checks: Propofol is excellent for neuro checks due to its rapid offset—briefly reducing the infusion often allows quick neurologic assessment, provided the patient is hemodynamically and respiratorily supported. This makes it ideal for neurocritical care patients who need frequent exams.

Pain on Injection: Propofol commonly causes pain or burning on injection. This can be minimized by using a larger vein, pre-treating with lidocaine (10–20 mg IV just before propofol), or mixing lidocaine with propofol in the syringe. The pain is transient and resolves once the patient loses consciousness.

Lipid Emulsion = Infection Risk: The lipid emulsion supports bacterial growth. Use strict aseptic technique when drawing up and administering propofol. Discard vials and tubing per institutional policy (typically 6–12 hours). Never reuse propofol syringes or vials between patients.

Green Urine is Benign: Patients on propofol infusions may develop green or cloudy urine due to phenolic metabolites. This is benign and not a sign of renal injury or infection. Reassure nursing staff and document appropriately.

References

1. Folino, T. B., & Goldberg, M. E. (2025). Propofol. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430884/
2. Secor, T., & Lim, T. Y. (2022). Propofol toxicity and propofol-related infusion syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538332/
3. Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., ... Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/CCM.0000000000003299
4. Lewis, K., Piticaru, J., Chaudhuri, D., Baumann, B., Dunlap, N., Devlin, J. W., Kho, M. E., Menon, K., Centofanti, J., Ferreyro, B. L., Chant, C., Burry, L., D'Aragon, F., Mehta, S., & Rochwerg, B. (2024). Safety and efficacy of propofol versus benzodiazepine monotherapy for the prevention and treatment of delirium: A systematic review and meta-analysis. Critical Care, 28(1), 379. https://doi.org/10.1186/s13054-024-05168-5
5. Farkas, J. (2024). Analgesia and sedation for the critically ill patient. EMCrit Project – Internet Book of Critical Care (IBCC). https://emcrit.org/ibcc/sedation/