JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Since its introduction in 1986, propofol (2, 6-diisopropylphenol), a sedative-hypnotic agent chemically distinct from other intravenous induction agents, has been used for the induction andmaintenance of general anesthesia and“conscious sedation” in greater than 80% of cases, virtually replacing sodium thiopental and all other short-ac ting barbiturates as induction agents. 1 Chemically the drug is a substituted isopropylphenol. Unrestricted as a controlled substance, propofol’s abuse potential emerged quickly and was publicized by the death of pop singer, Michael Jackson, in 2009. In order to assess the epidemiological features of fatal propofol abuse, a descriptive analysis of the scientific literature was conducted using Internet search engines to meet the following objectives: (1) to assess, describe, and analyze the descriptive epidemiology and outcomes of propofol abuse; (2) to stratify deaths from propofol abuse as accidental, suicidal, or homicidal; and (3) to compare blood levels in fatal propofol overdose cases and to stratify levels in therapeutic (2-2.5 mg/kg) anesthesia induction-dose ranges versus supra-therapeutic dose ranges.
TABLE 1: The demographic features of all fatal propofol abuse cases. NR: Not Reported; NA: Not Applicable; ICU: Intensive Care Unit
METHODS
To meet the objectives of the present investigation, Internet search engines including PubMed, Medline, Ovid, Google®, Google Scholar®, and Cochrane were queried with the key words as medical subject headings to identify peer-reviewed scientific articles on fatal propofol abuse in the U.S. since 1986. 2-10 The key words included: anesthetics, intravenous, propofol (Diprivan®); drug abuse, and addiction. Data sources reviewed included case reports, case series, observational and longitudinal studies, active and passive surveillance investigations, and analytical toxicology reports. Well-documented cases of fatal propofol abuse were stratified as unintentional or accidental deaths and as intentional deaths by suicides or homicides. 2-10 Demographic characteristics of all decedents were described including age, gender, occupation, and propofol blood levels, if available. Continuous variables were compared for differences by unpaired, two-tailed t-tests with statistical significance indicated by p-values less than 0.05. Since this study was an epidemiological analysis of previously peer-reviewed scientific publications, Institutional Review Board (IRB) approval was not required and was waived.
TABLE 2: Fatal cases in which postmortem propofol blood levels drawn from the heart or the femoral artery.
RESULTS
Of 21 fatal cases of propofol abuse, eighteen (86%) occurred in healthcare workers, mostly anesthesiologists and nurse anesthetists (n=14, 67%). One case occurred in a layman who purchased propofol on the Internet. Seventeen deaths (81%) were accidental; two were suicides (9.5%) and two were homicides (9.5%). The demographic features of all fatal propofol abuse cases are described in Table 1. 2-10 Fatal cases in which postmortem propofol blood levels drawn from either the heart or the femoral artery were reported (n=12, 57%) are compared in the Table 2. Blood levels in intentional death cases were significantly greater than in accidental death cases (p < 0.0001); all of which reflected initial therapeutic induction doses of propofol in the ranges of 2.0-2.5 mg/kg. When reported, ethanol
30 J La State Med Soc VOL 169 MARCH/APRIL 2017
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