Published online February 1, 2008
PEDIATRICS Vol. 121 No. 2 February 2008, pp. 448-449 (doi:10.1542/peds.2007-3403)

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LETTER TO THE EDITOR

Effectiveness and Safety of Propofol in Newborn Infants: In Reply

Mohamed E. Abdel-Latif, MBBS, MRCPCH, MPH, MScEpi
Julee Oei, MBBS, FRACP
Department of Newborn Care
Royal Hospital for Women
Randwick, New South Wales 2031, Australia
School of Women's and Children's Health
University of New South Wales
Kensington, New South Wales 2032, Australia

John Awad, MBBS, FANZCA, FJFICM
Department of Pediatric Intensive Care
Sydney Children's Hospital
Randwick, New South Wales 2031, Australia

Kei Lui, MBBS, FRACP, MD
Department of Newborn Care
Royal Hospital for Women
Randwick, New South Wales 2031, Australia
School of Women's and Children's Health
University of New South Wales
Kensington, New South Wales 2032, Australia

In Reply.—

We are extremely grateful for the comments by Papoff et al concerning our report¹ on the propofol regimen, compared with the morphine, atropine, and suxamethonium regimens, as induction for neonatal endotracheal intubation. We are equally interested in the findings of their pilot trial, which are encouraging.

Propofol, a general anesthetic agent, serves as a deep sedative and is amnestic at optimal dose. At hypnotic doses, propofol causes slowing of brain activity shown with electroencephalography.² We indeed had considered, but eventually decided against, the use of a narcotic in combination with propofol in our randomized trial, because one of our goals was to search for a single premedicating agent that would ease clinical practice. Furthermore, concurrent administration of analgesics with propofol has been shown to increase the likelihood of adverse outcomes,³ and there is evidence from pediatric and adult literature that propofol offers good sedation with no need for additional analgesia.⁴

It is important that the depth of sedation be controlled to achieve safe and effective intubation with as little discomfort as possible without causing hemodynamic or other instability. In our trial we used doses of 2.5 mg/kg, and by no means are we suggesting that this dose is optimal. Allegaert et al⁵ demonstrated reduced clearance and marked interindividual variability in pharmacokinetic estimates of propofol in neonates, which makes recommendation of an optimal dose particularly difficult, especially in combination with other narcotics. Most of the medications used for analgesia in the NICU, including fentanyl, have significantly longer half-lives than the 2- to 4-minute initial redistribution half-life of propofol. If concurrent narcotic analgesics were to be used, we feel it may be worth titrating from a lower initial propofol bolus dose of 1.0 to 1.5 mg/kg, similar to the approach of Gottschling et al.⁶ Additional clinical, pharmacokinetic, and pharmacodynamic studies are required before using propofol routinely in neonates, and the study from Papoff et al no doubt adds to this knowledge.

REFERENCES

1. Ghanta S, Abdel-Latif ME, Lui K, Ravindranathan H, Awad J, Oei J. Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized, controlled trial. Pediatrics. 2007;119 (6). Available at: www.pediatrics.org/cgi/content/full/119/6/e1248

2. Schwilden H, Stoeckel H, Schüttler J. Closed-loop feedback control of propofol anaesthesia by quantitative EEG analysis in humans. Br J Anaesth. 1989;62 (3):290 –296[Abstract/Free Full Text]

3. American College of Emergency Physicians. Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 1998;31 (5):663 –677[CrossRef][Web of Science][Medline]

4. Dunn T, Mossop D, Newton A, Gammon A. Propofol for procedural sedation in the emergency department. Emerg Med J. 2007;24 (7):459 –461[Abstract/Free Full Text]

5. Allegaert K, Peeters MY, Verbesselt R, et al. Inter-individual variability in propofol pharmacokinetics in preterm and term neonates. Br J Anaesth. 2007;99 (6):864 –870[Abstract/Free Full Text]

6. Gottschling S, Meyer S, Reinhard H, Furtwängler R, Klotz D, Graf N. Intraindividual propofol dosage variability in children undergoing repetitive procedural sedations. Pediatr Hematol Oncol. 2006;23 (7):571 –578[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Abdel-Latif, M. E. Articles by Lui, K. Search for Related Content PubMed Articles by Abdel-Latif, M. E. Articles by Lui, K. Related Collections Respiratory Tract Social Bookmarking                         What's this?