Safety of Short-Term Continuous Propofol Infusion for Severe Pediatric Traumatic Brain Injury

Introduction: Propofol may be a practical short-term continuous sedative after severe traumatic brain injury (TBI) to facilitate serial neurologic assessments and treat intracranial hypertension. Although the 2020 Brain Trauma Foundation adult guidelines support using propofol infusions to treat intracranial hypertension, the 2019 pediatric guidelines do not recommend “prolonged continuous infusion of propofol” due to concern for propofol related infusion syndrome (PRIS). However, 2022 Society for Critical Care Medicine Guidelines on Prevention and Management of Pain, Agitation Neuromuscular Blockade and Delirium (PANDEM) support continuous propofol as a safe sedative in pediatrics below 67mcg/kg/minute for up to 48 hours. Our objective is to describe the safety of propofol as a short-term continuous sedative following severe pediatric TBI in our quaternary pediatric academic center.


Methods: We analyzed patients younger than 18 years who received at least 12 hours of continuous propofol with severe traumatic brain injury (GCS ≤8) from 2019 to 2025. Lactate, triglyceride and creatinine kinase (CK) were included if assessed during the infusion.


Results: Nineteen pediatric patients (14 male) with severe TBI (6wk to 18y) received propofol for at least 12 hours, with a median time of 20.4h (IQR 15-32, maximum 72.5), median dose of 63mcg/kg/min (51-99) and total dose of 60.4mg/kg (10-146). Ten patients received propofol to achieve deep sedation or acutely manage intracranial hypertension, of which 7 patients had intracranial pressure monitoring. Lactate, triglycerides or CK were measured in 14 patients and none demonstrated progressively increasing values. Propofol was not stopped in any patients due to clinical or laboratory signs of PRIS. All patients survived; six patients were discharged to home and the remainder to rehabilitation.


Conclusions: Although 2019 pediatric severe TBI guidelines discourage propofol use due to concern for PRIS, we describe 19 pediatric patients who received continuous propofol sedation following severe TBI without exhibiting clinical or laboratory concerns for PRIS and all patients survived. In light of PANDEM guidelines, pediatric severe TBI guidelines warrant reassessment of the safety of propofol for acute management after TBI.