Somnus is developing rapid, point-of-care propofol measuring technologies but is there another drug that could be used instead? Traditionally, benzodiazepines such as midazolam were the mainstay of sedation for intensive care unit (ICU) patients and those undergoing invasive procedures. These drugs take longer to wear off and, in the ICU patient, are significantly associated with an increased risk of delirium. They are no longer first choice sedatives.
Propofol has been in use for over 30 years and is, alongside a drug called dexmedetomidine, the recommended drug for sedation, but how do the two compare? Two recent studies have shown that propofol is still preferable.
The SPICE III trial is the biggest randomised controlled trial to compare dexmedetomidine with propofol1. It included approximately eight times as many patients as other trials and enrolled 3,904 people, with mortality at 90 days as the primary outcome. Results from the study revealed no difference in 90- and 180-day mortality, nor in cognitive function (confusion or delirium). However, more than 70% of patients in the dexmedetomidine arm received propofol or midazolam to reach goal sedation in the first 48 h following randomisation, and more than 50% of the dexmedetomidine cohort continued to receive propofol at the study day 10. The conclusion is that dexmedetomidine was frequently unable to achieve target sedation by itself and had no better outcomes than propofol.
A more recent study compared the effectiveness of propofol and dexmedetomidine for nasotracheal intubation under conscious sedation2. The primary outcome measure was the intubation score with secondary measures including time to successful intubation, number of attempts at intubation, the quality of the view at intubation, haemodynamic stability, and patient satisfaction.
The results showed that intubating conditions were significantly better with propofol, as were the haemodynamic measurements, intubation view, and patient reaction. The time taken to achieve the desired level of sedation was four times longer with dexmedetomidine. The authors concluded that propofol is the recommended sedative for awake video laryngoscopy intubation.
These studies show that propofol remains the gold standard intravenous sedative against which other drugs are compared. Our aim is to use propofol concentration monitoring to personalise its administration to individual patients and make its use even safer.
- Shehabi Y, et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019 Jun 27;380(26):2506-2517. doi: 10.1056/NEJMoa1904710.
- Vishnoi, Gunjan; et al. Comparison of propofol versus dexmedetomidine sedation for awake C-MAC® D-Blade video laryngoscopic nasotracheal intubation in patients with difficult airway: A randomised clinical study. Indian Journal of Anaesthesia 2024 Aug 68(8): 699-705. DOI:10.4103/ija.ija_923_23
