What Is Propofol? The "Michael Jackson Drug" in Anesthesia
What does Propofol Look Like?
What Is Propofol?
Propofol is a sedative/hypnotic drug used every day as a routine part of anesthesia practice. When administered properly by skilled practitioners, it is usually very safe.
Recently, it has become infamous as the "Michael Jackson Drug." In his case, propofol was inappropriately used as a sleep aid—which, in combination with other sedatives, led to his death.
Even now that time has passed since the superstar's death, we anesthesiologists still get asked about the "Michael Jackson Drug" with some frequency.
So what is propofol?
What are the guidelines for the safe use of this medication?
Who should administer it?
And, what role does it play in the administration of anesthesia?
Is Propofol Safe?
Propofol is a milky white fluid used in anesthesia. Its color and effect has led to its nickname, "milk of amnesia."
The levels of anesthesia can be thought of as a continuum from conscious, awake and alert through various stages of sedation to unconsciousness with general anesthesia.
Many of the same agents are employed in increasing amounts to achieve and sustain the desired level of anesthesia. Propofol is a very versatile drug in this regard. It can also be very dangerous and takes a high level of training and skill to titrate correctly and, most importantly, respond to the physiologic changes caused by propofol administration. For this reason, the use of propofol is restricted to medical facilities where appropriate personnel are available, along with sophisticated monitors to record vital signs and emergency rescue medications and equipment to deal with any severe events related to propofol use.
Like all medications capable of inducing profound changes in the body, there are risks and dangers with propofol use. But, in the hands of skilled anesthesia providers, it is quite safe and provides reliable and comfortable anesthesia.
Who Should Be Allowed to Administer Propofol?
This is actually a topic of some debate. Anesthesiologists, obviously, should be able to administer propofol. They are the experts, not only in giving this type of medicine, but also in rescuing patients from any serious, unintended effects. They are highly trained to deliver oxygen, either by mask or breathing tube, or through other emergency techniques in case that is needed.
But, which other physicians should be able to do this? It's a good question. Just as I (as an anesthesiologist) am not trained to perform surgery or optimally manage someone's diabetes over time, some physicians are not adequately trained to give drugs capable of inducing anesthesia or to manage the airway of patients, especially high risk patients, who might need that type of rescue.
Some emergency room doctors (who are trained properly to use it) can use propofol for sedation for brief procedures. Sometimes, propofol is used by GI doctors (gastroenterologists) during endoscopies or colonoscopies. Gastroenterologists are not specialists in airway management or resuscitation, so this may be less safe, although most gastroenterologists disagree. Procedures in other settings have also been done with propofol under less than ideal conditions.
A cardiologist administering propofol in a private home with no monitoring or rescue equipment is NOT a gray zone, however. This cannot be justified.
How is Propofol Used for Anesthesia?
Propofol is a sedative/hypnotic drug. In anesthesia, that means that a main effect of the drug is to change the level of consciousness.
Propofol acts at specific receptors in the brain, changing their activity and affecting brain function. It does this in a dose-dependent fashion, meaning the more medication you give, the more brain function changes. With propofol, it is possible to give a very small amount and you wouldn't even realize it was given. At the other end of the spectrum, a large dose can rapidly induce unconsciousness and even cause a "flat-line EEG," meaning brain activity has stopped.
Because propofol is short-acting, all of these effects rapidly terminate as the drug is metabolized in the body. The effects of lower doses go away the most quickly, but even after a bigger dose in the operating room, most people will be awake from propofol in about half an hour.
As a sedative: Propofol can be used during procedures where sedation is the intended effect. It can be given as small, divided doses or as a continuous infusion at a low dose during the procedure.
During general anesthesia: Propofol is the most commonly used drug for the initiation, or induction, of anesthesia. In this regard, it is given through an intravenous line. The dose is determined by weight and then adjusted for other factors like age and health status. It can sting or burn as it is injected, but you will be asleep in about 30 seconds, so it doesn't last long.
Expected Effects of Propofol: What It Does and Doesn't Do
In addition to the sedative or anesthetic effects of propofol, there are other consequences of propofol use that are not necessarily the desired effect, but can be expected.
- Blood pressure: Propofol causes dilation of blood vessels, which leads to decreased blood pressure.
- Heart rate: Heart rate usually goes down with propofol administration, but could potentially also be increased in certain circumstances.
- Breathing: Propofol slows and can stop breathing. The amount of air inhaled with each breath is decreased, as is the rate of breathing. This can, and often does lead to decreased oxygen levels.
- Myoclonus: Propofol can cause a temporary stiffening or involuntary movement of body parts as the patient is going to sleep. This is not terribly common or consequential.
- Anti-emetic: Propofol can help to prevent or treat nausea and vomiting. This is a big advantage over other anesthetics that cause nausea and vomiting.
- Other: Propofol may cause vivid or unusual dreams, usually of a pleasant variety (seems to me a lot of patients dream about food- maybe because they weren't allowed to eat before surgery, not scientific, just my observation).
Propofol does not, however, have any pain-preventing or pain-relieving properties.
can become dangerously low in patients with risk factors (trauma, taking blood pressure medicines, poor overall health, etc)
May go up in bleeding or dehydrated patient as a response to low blood pressure
decreases or stops
Oxygen and practioners, such as anesthesiologists, skilled in 'airway management' must be present
Use in combination with pain medicines if not under general anesthesia
Risks of Propofol
The risks are essentially related to the changes in vital signs highlighted above. There are other potential risks with propofol use, but they are beyond the scope of this article and are either rare or aren't life threatening in most cases, unless a true allergy is present.
But, as you can tell from reading about the effects of propofol on the breathing, heart rate, and blood pressure, propofol should NEVER be used in a situation like it was for Michael Jackson. Not only were his vital signs not monitored, he was not being cared for by a physician who is skilled at placing breathing tubes or supporting respiration until the propofol wears off. And, even if he was, it seems there was no emergency equipment or medications nearby.
To use propofol in the manner that it was for the singer was extremely dangerous—and, in my opinion, either stupid or arrogant.