Patient Safety Matters with Use of Propofol in Critically Ill Patients

Abstract

Despite its tendency to produce hypotension, propofol is used widely to induce general anesthesia and to facilitate endotracheal intubation in critically ill patients. Both dose reduction and routine co-administration of vasopressors have been used to offset this unfavorable hemodynamic effect in this subset of individuals. There are potential problems associated with each of these corrective measures, however, and criticism of other intravenous hypnotics used for this purpose—particularly etomidate—may be unwarranted. Choice of the appropriate pharmacology to induce anesthesia to assist with intubation should likely be based on individual clinical assessment, together with an understanding of the drug profile and realistic adverse effects.

Keywords

Patient safety / Intubation / Hypotension / Dose-reduced propofol / Etomidate

Author Contributions

B.S.: Conceptualization; Formal analysis; Project administration; Visualization; Writing—original draft; Writing—review and editing.

Ethics Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Funding

This research received no external funding.

Declaration of Competing Interest

The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References

[1] Bauer PR, De Jong A. How to make tracheal intubation in the ICU safer and more effective? Crit. Care Med. 2024, 52, 859-862. doi:10.1097/CCM.0000000000006214.

[2] Garnacho-Montero J, Gordillo-Escobar E, Trenado J, Gordo F, Fisac L, Garcia-Prielo E, et al. A nationwide, prospective study of tracheal intubation in critically ill adults in Spain: Management, associated complications, and outcomes. Crit. Care Med. 2024, 52, 786-797. doi:10.1097/CCM.0000000000006198.

[3] Garnacho-Montero J, Trenado J, Garcia-Garmendia JL.The authors reply. Crit. Care Med. 2024, 52, e411-e412. doi:10.1097/CCM.0000000000006299.

[4] Kolani Y, Russotto V. Induction agents for tracheal intubation in critically ill patients. Crit. Care Med. 2024, 53, e173-e181. doi:10.1097/CCM.0000000000006506.

[5] Karamchandani K, Jabaley C. Can propofol be safely used for tracheal intubation in critically ill patients: Does the dose matter? Crit. Care Med. 2024, 52, e409-e410. doi:10.1097/CCM.0000000000006276.

[6] Koenig Sj, Lakticova V, Narasimhan M, Doelken P, Mayo PH. Safety of propofol as an induction agent for urgent endotracheal intubation in the medical intensive care unit. J. Intensive Care Med. 2014, 30, 499-504. doi:10.1177/0885066614523100.

[7] Ho AM, Mizubuti GB. Co-induction with a vasopressor “chaser” to mitigate propofol-induced hypotension when intubating critically ill/frail patients—A questionable practice. J. Crit. Care 2019, 54, 256-260. doi:10.1016/j.jcrc.2019.09.015.

[8] Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, et al. Peri-intubation cardiovascular collapse in patients who are critically ill. Insights from the INTUBE study. Am. J. Respir. Crit. Care Med. 2022, 206, 449-458. doi:10.1164/rccm.202111-2575OC.

[9] Krause M, Nguyen A, O’Brien O, Khoche S, Schmidt U. A randomized pilot study assessing if SEDLine monitoring during induction of surgical patients is associated with reduced dosage of administered induction agents. Semin. Cardiothorac. Vasc. Anesth. 2022, 26, 260-265. doi:10.1177/10892532221130660.

[10] Ladha S, Prakash A. CON: Propofol is better than etomidate for induction in cardiac surgical patients. J. Card. Crit. Care TSS 2021, 5, 72-74. doi:10.1055/s-0041-1728957.

[11] Long B, Gottlieb M. Ketamine versus etomidate for induction of intubation in critically ill patients. Acad. Emerg. Med. 2024, 31, 937-938. doi: 10.1111/acem.14941.

[12] Smischney NJ, Nicholson WT, Brown DR, De Morales AG, Hoskote SS, Pickering B, et al. Ketamine/propofol admixture vs. etomidate for intubation in the critically ill: KEEP PACE Randomized clinical trial. J. Trauma Acute Care Surg. 2019, 87, 883-891. doi:10.1097/TA.0000000000002448.

[13] Supatanakij P, Mungjadetanadee T, Boonyok N, Suttapanit K. The effect between etomidate and ketamine on peri-intubation hypotension in elderly patients in the emergency room. Am. J. Emerg. Med. 2025, 95, 41-48. doi:10.1016/j.ajem.2025.05.021.

[14] Upadhye S, Cyganik O. Is single-dose etomidate induction safe in emergency intubation of critically ill patients. Ann. Emerg. Med. 2016, 67, 399-400. doi:10.1016/j.annemergmed.2015.10.006.

[15] Sarda BG, Raipure AM, Ruparel DH. Serum cortisol levels with etomidate induction: A speculation that needs to be reviewed. Anesth. Essays Res. 2021, 15, 312-315. doi:10.4103/aer.aer_118_21.

[16] Chamorro-Falero C, Macias-Clemente J, Morales-Domene JJ. Induction agents for tracheal intubation in critically ill patients. Crit. Care Med. 2025, 53, e1331-e1332. doi:10.1097/CCM.0000000000006631.

[17] Heo HJ, Kim G, Kim YY, Park J. Can remimzolam be safely used in cardiac tamponade? Medicine 2023, 102, e34822. doi:10.1097/MD.0000000000034822.