Why we use it
Propofol is a phenol-based IV anesthetic that produces rapid onset of unconsciousness and equally rapid recovery once the infusion stops. It potentiates GABA-A receptors — broadly, it turns down the brain. For EP, its main appeal is predictable depth, easy titration, and clean wake-up, which is exactly what we want for long ablation cases.
Indication in the lab
- General anesthesia or deep sedation for AF ablation
- VT ablation (especially when hemodynamic support and ventilatory control are needed)
- Long pediatric cases
- Patients who can’t tolerate or cooperate with moderate sedation
- Cardioversion (single-dose bolus, anesthesia-administered)
This drug is not part of our nurse-administered sedation toolkit. Per our policy and state regulations, propofol is given by an anesthesiologist, CRNA, or in some states by a physician credentialed for deep sedation.
Dose and route
- Induction bolus: 1–2 mg/kg IV (lower in elderly, hypovolemic, frail).
- Maintenance infusion: 25–150 mcg/kg/min, titrated to depth.
- Cardioversion dose: 0.5–1 mg/kg slow IV.
- Always via dedicated IV line with a clean carrier flow — propofol is incompatible with several drugs and precipitates readily.
Onset and duration
- Onset: 30–60 seconds.
- Single-bolus duration: 5–10 minutes.
- Infusion: depth tracks rate within a few minutes; recovery within 10–20 minutes of stopping in most patients.
Monitoring
While propofol is anesthesia-administered, the entire team shares responsibility for noticing trouble.
- Continuous ECG, SpO2, EtCO2, NIBP (or arterial line for VT)
- Visible chest rise and ventilator settings
- Temperature on long cases
- BIS or other depth-of-anesthesia monitor at anesthesia’s discretion
Side effects to watch for
- Hypotension — almost universal, more pronounced with bolus dosing. Expect a 10–30% drop in MAP.
- Apnea — expected at induction doses; the patient needs an airway plan, not a “wait and see.”
- Injection pain — common in peripheral IVs; lidocaine pretreatment helps.
- Bradycardia — occasional, particularly with concurrent opioids or vagal stimulation during transseptal.
- Hypertriglyceridemia in long infusions — anesthesia tracks labs in extended cases.
- Propofol infusion syndrome — metabolic acidosis, rhabdomyolysis, cardiac failure. Very rare in EP; risk rises with prolonged high-dose use, particularly in younger patients.
Practical lab notes
- The emulsion supports microbial growth — once spiked, discard within 12 hours per manufacturer/USP guidance. We use a fresh bottle for each long case.
- Egg / soybean allergy: historically a contraindication; modern guidance is more nuanced. Always flag and let anesthesia decide.
- Look greenish? Some patients metabolize propofol to compounds that color urine green — harmless but worth noting so we don’t chase it.
Reversal
There is no antidote. Management of overdose is supportive:
- Airway and ventilation
- IV fluids and pressors (phenylephrine or norepinephrine) for hypotension
- Time — the drug redistributes quickly
Common pitfalls
- Treating propofol like midazolam — it isn’t. Depth changes fast.
- Bolusing into an arm with the BP cuff inflating, then watching pressure crash.
- Forgetting to switch the infusion off at the end of mapping so anesthesia can wake the patient on schedule.
- Reusing a spiked vial between cases.