What is the Appropriate Subhynotic Propofol Infusion Dose for the Prevention of Post-operative Nausea and Vomiting: A Meta-analysis of Six Randomized-controlled Trials
Background: Post-operative nausea and vomiting (PONV) is one of the most common complications after surgery and can result in various deleterious complications including wound dehiscence, aspiration, pain, discomfort, and delayed hospital discharge, which ultimately leads to increased hospital costs and increased morbidity. Propofol has been known to have direct anti-emetic properties and is one of the few anesthetic drugs to be associated with a lower incidence of PONV. We conducted a meta-analysis to evaluate the anti-emetic effect of perioperative administration of subhypnotic infusions of propofol with a goal of uncovering the most appropriate infusion rate that led to a decreased incidence of PONV.
Methods: PubMed and Cochrane databases were searched for randomized-controlled trials comparing the anti-emetic effects of propofol versus a control. The initial search yielded over twenty-five studies. Studies in which patients received a general anesthetic that was maintained with a volatile agent were included. Trials in which patients received total intravenous anesthetic (TIVA) levels of propofol were excluded as were those where patients were administered subhypnotic bolus doses of propofol, as opposed to infusions. Two independent investigators selected the studies and reviewed the research. The quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
Results: Following GRADE assessment, five trials meeting inclusion criteria were included for further analysis. A total of 224 patients received subhynotic infusions of propofol while 150 were in a control group that received either dexamethasone alone or placebo (generally 10% intralipid). Infusion doses ranged from 10mcg/kg/min to 100mcg/kg/min. Five of the studies used adult subjects, all of which underwent abdominal procedures, and two of the adult studies focused on target controlled infusions and determination of appropriate blood levels for PONV prevention. All but one of the studies demonstrated that the overall incidence of PONV in the propofol groups was lower than in the control groups, with the outlying study using a rate of 16.7mcg/kg/min in gynecologic patients.
Conclusion: The majority of the trials showed that the intraoperative administration of a subhypnotic intravenous infusion of propofol was effective at preventing post-operative nausea and vomiting in surgical patients receiving general anesthesia with maintenance volatile agent. An infusion rate of 16.7 mcg/kg/min was the most commonly used dose and showed a decreased incidence of PONV in two of the three adult trials that were studied. A 20mcg/kg/min dose was beneficial in a pediatric population, however only one study has examined this effect in this age group. In conclusion, we recommend a subhypnotic dose of at least 16.7 mcg/kg/min to help prevent the anesthetic complication of PONV.
Mossa-Basha, Nora and Soto, Roy G., "What is the Appropriate Subhynotic Propofol Infusion Dose for the Prevention of Post-operative Nausea and Vomiting: A Meta-analysis of Six Randomized-controlled Trials" (2019). Conference Presentation Abstracts. 5.