In this episode, I’ll discuss the management of suspected propofol dependence with phenobarbital in an adult patient with COVID-19.
There is limited published information on propofol withdrawal syndrome. Authors recently published a case report of their experience treating a patient with suspected propofol dependence with phenobarbital in the American Journal of Health-System Pharmacy.
The patient in the case was a 64-year-old male who required ICU admission and mechanical ventilation with sedation for the management of acute respiratory distress syndrome due to COVID-19 pneumonia.
To tolerate the ventilator, the patient required high and prolonged doses of fentanyl and propofol with additional periods of also requiring midazolam and dexmedetomidine.
In total the patient was on propofol for 17 days, fentanyl for 19 days, midazolam for 12 days, and dexmedetomidine for 15 days.
When lung function improved the team started to wean the patient from propofol sedation to perform breathing trials however every attempt at this failed due to symptoms such as tachypnea, tachycardia, and hypertension. These symptoms resolved when the previous dose of propofol was resumed which led the clinicians to believe the patient was experiencing a withdrawal syndrome from propofol.
To treat this syndrome the authors chose phenobarbital in hopes it would alleviate the withdrawal symptoms and allow the patient to be weaned from the ventilator. The authors described the response to phenobarbital as follows:
Phenobarbital was trialed for possible propofol withdrawal syndrome, allowing for a dose reduction of 10 μg/kg/min within 2 hours of the first dose without any corresponding symptoms. The patient continued to receive intermittent doses of phenobarbital for another 36 hours until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission.
Previous reports of propofol withdrawal syndrome did not have a positive outcome or involve the use of phenobarbital so until better evidence is available, clinicians who encounter a patient with this rare syndrome may consider using phenobarbital based on this case report.
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