Propofol, a commonly used intravenous anesthetic agent, is an integral part of modern anesthesia practice due to its rapid onset, short duration of action, and favorable recovery profile. using it, healthcare providers should consider its effects on hemodynamic stability, primarily due to its vasodilatory properties. These effects can result in significant reductions in systemic vascular resistance (SVR), mean arterial pressure (MAP), and cardiac output. Despite these challenges, propofol remains a preferred agent, especially when combined with strategies to mitigate its hemodynamic effects (1).
The underlying mechanism of propofol’s impacts on hemodynamic stability is its direct action on the sympathetic nervous system, resulting in decreased vascular tone and impaired baroreceptor reflexes. These effects are particularly pronounced in patients with cardiovascular comorbidities, the elderly, or those with reduced intravascular volume. Studies suggest that these patients are at increased risk for hypotension and bradycardia during propofol-induced anesthesia (2).
Adjunctive pharmacological strategies have been explored to reduce the hemodynamic instability associated with propofol. One such approach is the use of dexmedetomidine, an alpha-2 adrenergic agonist. A randomized controlled trial comparing dexmedetomidine–propofol combinations with fentanyl–propofol regimens demonstrated superior hemodynamic stability with dexmedetomidine. This was attributed to dexmedetomidine’s sympatholytic properties and ability to attenuate stress-induced increases in heart rate and blood pressure during surgery (2). In addition, the combination of ketamine and propofol (ketofol) has been shown to maintain hemodynamic stability more effectively than propofol alone. The sympathomimetic effects of ketamine offset the depressant effects of propofol, making this combination particularly useful in high-risk patients (3).
Newer anesthetic agents, such as remimazolam, have also been evaluated for their potential to provide improved hemodynamic stability compared to propofol. In a prospective randomized controlled trial, remimazolam demonstrated more stable MAP and heart rate during cerebrovascular surgery, suggesting that it may be a promising alternative to propofol in select populations (4). While these newer agents offer many benefits, the widespread use of propofol continues due to its well-established efficacy, low cost, and predictable pharmacokinetic profile.
Titration and dose adjustments are critical for minimizing the hemodynamic effects of propofol. Careful monitoring and preloading with intravenous fluids can help prevent significant hypotension. For example, in pediatric sedation, the use of preemptive fluid boluses has been highlighted as a quality improvement measure to increase the safety of propofol use (2).
Although propofol is associated with dose-dependent hemodynamic instability, its effects can be mitigated by careful patient selection, adjunctive therapies, and dosing strategies. Ongoing research into alternative agents and combination regimens will continue to refine its role in anesthesia practice, ensuring both safety and efficacy for a wide range of clinical applications.
References
- Koo CH, Lee SU, Kim HG, et al. Effect of remimazolam on intraoperative hemodynamic stability in patients undergoing cerebrovascular bypass surgery: a prospective randomized controlled trial. Korean J Anesthesiol. Published online January 23, 2025. doi:10.4097/kja.24538
- Chandar Chinnarasan V, Bidkar PU, Swaminathan S, et al. Comparison of dexmedetomidine versus fentanyl-based total intravenous anesthesia technique on the requirement of propofol, brain relaxation, intracranial pressure, neuronal injury, and hemodynamic parameters in patients with acute traumatic subdural hematoma undergoing emergency craniotomy: A randomized controlled trial. Surg Neurol Int. 2024;15:462. Published 2024 Dec 13. doi:10.25259/SNI_892_2024
- Chhabra R, Gupta R, Singh M, et al. Comparison of Intraoperative Propofol-Dexmedetomidine and Ketofol-Dexmedetomidine Infusions on Recovery from Anesthesia in Patients Undergoing Endoscopic Trans-Sphenoidal Pituitary Surgeries: A Randomized Controlled Trial. World Neurosurg. Published online January 17, 2025. doi:10.1016/j.wneu.2025.123678
- Guymon AL, Moore MM, Nelson LE, Ali M. Do We Need a Fluid Bolus? The Necessary Refinement of Pediatric Propofol Sedation – a Quality Improvement Project. S D Med. 2024;77(12):557-560.
