Propofol: guilt by association

Monday, August 24, 2009

The LA Times reports that “county coroner’s officials found lethal levels of the powerful anesthetic propofol after examining Michael Jackson’s body, according to a search warrant affidavit”. Guilt by association: not the doctor who administered but for the propofol. Here is a perfectly fine anesthetic agent, minding its own business, being scrutinized just because it was in the wrong place at the wrong time.

Actually, propofol should never be carried by a doctor making a house call. It’s meant for hospital use in the intensive care unit or the operating room, for patients who are intubated and on a ventilator. It’s meant for the emergency room when people have to be sedated for a few seconds to undergo a painful procedure like a cardiac shock or to fix a joint dislocation. The drug is meant to be given by physicians trained in critical care with equipment available to deal with any complications that might occur. It is not meant to be used as a sleeping pill.

Every medication has the opportunity to make a positive contribution to a patient’s care but every medication also has a risk-reward balance sheet. Drug side effects and complications have to be respected. Over the counter medications risk major problems if they are abused, even if no doctor’s prescription is required. Tylenol is a great pain killer but take too much and it’s a liver killer too. Aspirin may be a wonder drug preventing heart attack and stroke but take too much and there is risk of kidney failure and fluid accumulation in the lungs.

But back to propofol. The medication has become on of the drugs of choice to sedate patients. An initial bolus is injected intravenously and the patient drifts off to sleep and lasts 3-5 minutes before wearing off…just enough time to do something painful. If longer amounts of sedation are required, then the propofol is continuously infused in the IV line. The issue with propofol is that it can make the patient’s brain forget to breathe. It’s not a side effect or complication; it’s just what it does. That issue requires a person with the skills to breathe for the patient, to stand guard at all times. Propofol is a sedating drug, and excess sedation may occur if used in combination with drugs like valium. The more sedation, the more likely the patient will quick breathing.

The body lives within a very narrow range of normal. Once a patient quits breathing, the body switches to anaerobic metabolism, lactic acid levels build, and organs quickly fail.

So back to the guilt by association. According to a variety of news reports, Jackson’s physician began injecting the sedative drugs Valium, Ativan and Versed intravenously. When they failed to make him fall asleep, he added the propofol and then left the patient’s side to make a few phone calls. When he returned, Jackson was dead.

Somehow, the story lead has become the dangers of propofol. Perhaps the story should have concentrated on how a drug meant for a critical care unit crammed with high tech monitoring equipment, was being injected into the arm of a patient lying in his bed at home.

Realistically, propofol is a great drug, used routinely and safely in the hospital setting, but patients and family will come to recognize and perhaps fear the drug that killed Michael Jackson. And it will take a fair amount of bedside education to convince those patients that a safe drug isn’t guilty as charged.

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