Goldilocks and Propofol Dosage in Older Adults: Too much, Too Little, or Just Right?

BACKGROUND/OBJECTIVES: Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia prior to endotracheal intubation in a nationwide sample of older adults presenting for surgery. DESIGN: Retrospective observational study using the Multicenter Perioperative Outcomes Group dataset. SETTING: 36 institutions across the United States. PARTICIPANTS: 350,766 patients over age 65 who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018. INTERVENTION: None MEASUREMENTS: Total induction bolus dose of propofol administered. RESULTS: The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients age 65-69 to 45.8% among patients age 80 or over. CONCLUSION. The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients age ≥ 65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice, or alternatively, whether what is published as the typical propofol induction dose range should be revisited.