Paediatric total intravenous anaesthetic use: a nationwide study
Authors: Hill M. , Peat W. , Courtman S. 
Published: May 2007

Introduction:  Propofol is widely used for induction and maintenance of anaesthesia in paediatric patients.

Following the initial reports of deaths following prolonged high dose infusions on intensive care (1), the propofol infusion syndrome was described (2). The exact cause of this is still uncertain but consistent biochemical abnormalities have been described (3, 4). Initially the cases were all in children on intensive care units, but more recently cases have been reported in adults. Of greater concern to paediatric anaesthetists are the reports of deaths following propofol infusions in theatre (5, 6). We set out to define the current use of propofol infusions by Paediatric Anaesthetists within the UK.

Methods:  A list of names and addresses of paediatric anaesthetists was composed by contacting anaesthetic departments at the hospitals by telephone and asking for the names of their paediatric anaesthetists. An 18 question survey with an enclosed stamped, addressed envelope was posted to 388 consultant paediatric anaesthetists in 51 hospitals throughout the UK. The survey was re‐submitted once to consultants who had not initially replied. The results were tabulated onto a database and analysed.

Results:  We received a total of 242 replies (63% of surveyed population), 240 of which regularly anaesthetised children. Within the last year 13% had used propofol infusions on children under 1, 31% in children 1–5 years, 41% in children 5–10 years and 46% in the over 10 s. The two most common surgical specialties with which propofol TIVA was used were ENT (n = 66), and orthopaedics (n = 53), the most common operations stated being middle ear surgery, muscle biopsy and scoliosis surgery. The reasons for using propofol in these patients were broad and included both anaesthetic and surgical considerations. 60 consultants questioned used propofol infusions in children at least monthly, 98 rarely and 72 never. Over 50% of replies believed that propofol infusions reduced the rate of postoperative nausea and vomiting in respect to inhalational techniques, less agreed that there was faster recovery time or time to discharge. Remifentanil was commonly used with propofol infusions but target controlled infusion devices were uncommonly used. The longest time anyone considered using propofol for was 72 h, although the mode of all positive responses was 6 h. The majority of people failed to give a maximum infusion rate.

Conclusions:  Propofol infusions are used widely throughout the UK for their perceived anaesthetic and surgical benefits. Given that there are well documented catastrophic, albeit rare side effects, it is surprising that there are no guidelines for infusions in theatre. Further work is required to elucidate the exact mechanism of propofol infusion syndrome to guide future anaesthetic practice.

References  1 Parke TJ, Stevens JE, Rice AS et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. Br Med J 1992; 305: 613–616.

2 Bray RJ. Propofol infusion syndrome in children. Paediatr Anaes 1998; 8: 491–499.

3 Wolf AR, Weir P, Segar P, et al. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001; 357: 606–607.

4 Wolf AR, Potter F. Propofol infusion in children: when does an anesthetic tool become an intensive care liability? Paediatr Anaesth 2004; 14: 435–438.

5 Mehta N, DeMunter C, Habibi P et al. Short‐term propofol infusions in children. Lancet 1999; 354: 866–867.

6 Kill C, Leonhardt A, Wulf H. Lacticacidosis after short‐term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paediatr Anaesth 2003; 13: 823–826.