In this episode, I’ll discuss the prediction of hypotension from propofol when used as an ICU sedative.
Hypotension from ICU sedatives like propofol and dexmedetomidine can complicate patient management. I discussed predicting hypotension from dexmedetomidine back in Episode 563.
Hypotension from propofol in the ICU can also be reasonably predicted by several factors.
The first is IVC collapsibility. This is assessed by bedside ultrasound where the inferior vena cava is looked for the percent that collapses on inspiration. Patients with an IVC collapsibility of more than 43%, as assessed by bedside ultrasonography, are more likely to develop significant hypotension after induction with propofol. This test has a positive predictive value of 94%. This data is from a study that was performed on OR patients, however, not specifically those in the ICU. In general, IVC collapsibility values >50% suggest hypovolemia, so from this study it may be inferred that hypovolemia is a risk factor for hypotension from propofol.
Whether bedside ultrasound is performed in your ICU is likely provider-dependent. This tool is growing in popularity and in my experience, newer physicians are more inclined and more comfortable with bedside ultrasound as a diagnostic procedure.
A study of 200 trauma patients analyzed risk factors for hypotension from propofol and found 3 that predicted hypotension:
- Age greater than 55 years (Odds Ratio 3.6)
- Obesity (OR 2.7)
- Lower baseline blood pressure (OR 1.6 per 10-mm Hg decrease)
It should be noted that the context of this study was hypotension from using propofol as induction for intubation, not continuous sedation.
Finally, a retrospective study of 237 neurocritical patients examined predictors of hypotension from propofol sedation. Low baseline MAP and need for renal replacement therapy were identified as risk factors for hypotension from propofol.
This study also found that frequent dose titrations of propofol is associated with hypotension. Frequent dose titrations was also identified as a risk factor for hypotension from dexmedetomidine in Episode 563. ICU pharmacists can proactively look for frequent dose titration of ICU sedatives and provide nurse education on the ideal titration frequency to prevent associated hypotension.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on Predicting Clinical Deterioration in ICU patients. This is in addition to hundreds of other trainings and resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
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