Supply Disruption Alert: Propofol for infusion and injection
4 February 2021
The NHS Central Alerting System has published a Supply Disruption Alert (SDA) about limited supplies of propofol. The current surge in COVID-19 and consequent increase in cases requiring admission to critical care has created a significantly increased demand for propofol.
The SDA’s recommendation is that the use of propofol be restricted to sedation in critical care, induction of anaesthesia, and for target-controlled infusion for procedural sedation, with its use for total intravenous anaesthesia (TIVA) being limited to those patients for whom there is a clear indication.
The Association of Anaesthetists, the Society for Intravenous Anaesthesia and the Royal College of Anaesthetists suggest that the circumstances in which there may be no realistic alternative to propofol TIVA include:
Patients at risk of malignant hyperthermia;
Airway procedures during which maintenance of anaesthesia by inhaled agents is not practical;
When using intra-operative neurophysiological monitoring that is adversely affected by the use of inhalational anaesthetic drugs;
Transfers within or between hospitals;
Patients at risk of malignant cardiac arrhythmias known to be triggered by inhalational anaesthetic drugs, e.g. long QT syndrome;
Some patients with life-limiting neuromyopathies;
A history of severe postoperative nausea and vomiting (PONV), which we interpret as being limited to those patients with a history of PONV that was so severe as to delay hospital discharge significantly or to be a reason for re-admission.
NOTES
Pharmacy procurement may mean that the presentation of propofol may differ in container volume (20-ml, 50-ml and 100-ml) and drug concentration (1% and 2%) to that with which users are familiar. Care should be taken to ensure that the appropriate volume and concentration are used.
When switching to the use of multiple 20-ml glass ampoules for critical care infusion, care should be taken to use strict infection control precautions given the increased risk of contamination.
Although some data suggest that avoidance of the use of inhalational anaesthetic drugs may be associated with a lower recurrence of some cancers after surgery, the evidence is not conclusive, and anaesthetists should consider preserving propofol stocks for critical care by avoiding TIVA.
If TIVA is being used on a patient in one of the above categories, the use of propofol can be minimised by the concurrent administration of high-dose remifentanil or alpha-2 adrenergic receptor agonists.
Practitioners should exercise great caution if these recommendations lead them to consider the use of drugs or techniques with which they are not familiar.
ENDS