Lesser of Two Evils? Propofol and Hypotension With the Need for Norepinephrine

Introduction: The 2018 PADIS guidelines recommend using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically intubated patients due to a shorter time to light sedation and extubation. Based on this recommendation, propofol is the initial sedative of choice in our intensive care unit (ICU). However, the use of propofol is associated with adverse hemodynamic effects. We conducted this study to look at the number of intubated patients who required norepinephrine (NE) after starting propofol and the effect on patient outcomes including new atrial fibrillation (afib), concern for septic shock, and mortality.


Methods: We conducted a retrospective electronic medical record (EMR) (Epic, Verona, WI) review of intubated patients in our 24-bed mixed medical/surgical ICU from October 1, 2023 to September 30, 2024. Based on smart pump (BD Alaris Infusion System, Franklin Lakes, NJ) data input, all patients started on a propofol infusion prior to starting a NE infusion (study group) were included in the analysis. The EMR was reviewed to look for amiodarone drips and antibiotic start times as an indicator for new afib and septic shock respectively.


Results: Of the 1169 patients intubated during the study period, 948 had propofol ordered and 187 (20%) had NE initiated after starting propofol. The median time to the start of NE was 119 minutes (IQR 21-470). A second pressor was started on 43 patients (23%), and 13 patients (7%) required a third pressor. Of the 181 patients not on amiodarone prior to admission, 18 (10%) were started on amiodarone following NE initiation. Antibiotics were started on 124 patients of the 187 study group patients. Of these, 50 (40%) started after the NE was started. Mortality was significantly increased in the study group compared to intubated patients overall (33% vs 23%, p=0.0036).


Conclusions: Propofol is the most common sedative infusion started on intubated patients in our mixed medical/surgical ICU. Of these patients, 20% required NE to sustain adequate blood pressure. Mortality was significantly increased in patients who required NE after initiating propofol. The risk of propofol precipitating the need for pressor support to be weighed against the risk of benzodiazepine induced delirium when sedating critically ill patients.