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Burnett GW, Taree A, Martin L, Bryson EO. Propofol misuse in medical professions: a scoping review. Can J Anaesth 2023; 70:395-405. [PMID: 36577890 DOI: 10.1007/s12630-022-02382-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 10/10/2022] [Accepted: 10/14/2022] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We aimed to describe the current literature concerning propofol misuse in medical professionals, specifically relating to the individual demographics of those misusing propofol and the outcomes of propofol misuse. METHODS We conducted a retrospective scoping review of the literature using a modified PRISMA approach. We used MEDLINE, EMBASE, and PsycINFO databases to identify relevant studies based on search terms. Studies describing individual medical professionals misusing propofol were included. RESULTS Twenty-four articles describing 88 individual cases of propofol misuse were included for data charting and analysis. Anesthesiologists and certified registered nurse anesthetists were most commonly identified. Death was a common method of identification of misuse, while rehabilitation and death were common final outcomes associated with propofol misuse. CONCLUSIONS Despite knowledge of the pharmacokinetic and pharmacodynamic properties of propofol by those misusing this medication, death was a common outcome reported in the literature. Data related to long-term outcomes including re-entry to clinical practice or success of rehabilitation were limited.
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Affiliation(s)
- Garrett W Burnett
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, 1450 Madison Avenue, KCC 8th Floor Box 411, New York, NY, 10029, USA.
| | - Amir Taree
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, 1450 Madison Avenue, KCC 8th Floor Box 411, New York, NY, 10029, USA
| | - Lily Martin
- Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ethan O Bryson
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, 1450 Madison Avenue, KCC 8th Floor Box 411, New York, NY, 10029, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Obuseh M, Yu D, DeLaurentis P. Detecting Unusual Intravenous Infusion Alerting Patterns with Machine Learning Algorithms. Biomed Instrum Technol 2022. [PMID: 35749264 DOI: 10.2345/1943-5967-56.2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To detect unusual infusion alerting patterns using machine learning (ML) algorithms as a first step to advance safer inpatient intravenous administration of high-alert medications. MATERIALS AND METHODS We used one year of detailed propofol infusion data from a hospital. Interpretable and clinically relevant variables were feature engineered, and data points were aggregated per calendar day. A univariate (maximum times-limit) moving range (mr) control chart was used to simulate clinicians' common approach to identifying unusual infusion alerting patterns. Three different unsupervised multivariate ML-based anomaly detection algorithms (Local Outlier Factor, Isolation Forest, and k-Nearest Neighbors) were used for the same purpose. Results from the control chart and ML algorithms were compared. RESULTS The propofol data had 3,300 infusion alerts, 92% of which were generated during the day shift and seven of which had a times-limit greater than 10. The mr-chart identified 15 alert pattern anomalies. Different thresholds were set to include the top 15 anomalies from each ML algorithm. A total of 31 unique ML anomalies were grouped and ranked by agreeability. All algorithms agreed on 10% of the anomalies, and at least two algorithms agreed on 36%. Each algorithm detected one specific anomaly that the mr-chart did not detect. The anomaly represented a day with 71 propofol alerts (half of which were overridden) generated at an average rate of 1.06 per infusion, whereas the moving alert rate for the week was 0.35 per infusion. DISCUSSION These findings show that ML-based algorithms are more robust than control charts in detecting unusual alerting patterns. However, we recommend using a combination of algorithms, as multiple algorithms serve a benchmarking function and allow researchers to focus on data points with the highest algorithm agreeability. CONCLUSION Unsupervised ML algorithms can assist clinicians in identifying unusual alert patterns as a first step toward achieving safer infusion practices.
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Affiliation(s)
- Marian Obuseh
- Marian Obuseh is a PhD student in the School of Industrial Engineering at Purdue University in West Lafayette, IN.
| | - Denny Yu
- Denny Yu, PhD, is an assistant professor in the School of Industrial Engineering at Purdue University in West Lafayette, IN
| | - Poching DeLaurentis
- Poching DeLaurentis, PhD, was a research scientist in the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, IN, at the time this study was conducted
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3
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Obuseh M, Yu D, DeLaurentis P. Detecting Unusual Intravenous Infusion Alerting Patterns with Machine Learning Algorithms. Biomed Instrum Technol 2022; 56:58-70. [PMID: 35749264 PMCID: PMC9767430 DOI: 10.2345/0899-8205-56.2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To detect unusual infusion alerting patterns using machine learning (ML) algorithms as a first step to advance safer inpatient intravenous administration of high-alert medications. MATERIALS AND METHODS We used one year of detailed propofol infusion data from a hospital. Interpretable and clinically relevant variables were feature engineered, and data points were aggregated per calendar day. A univariate (maximum times-limit) moving range (mr) control chart was used to simulate clinicians' common approach to identifying unusual infusion alerting patterns. Three different unsupervised multivariate ML-based anomaly detection algorithms (Local Outlier Factor, Isolation Forest, and k-Nearest Neighbors) were used for the same purpose. Results from the control chart and ML algorithms were compared. RESULTS The propofol data had 3,300 infusion alerts, 92% of which were generated during the day shift and seven of which had a times-limit greater than 10. The mr-chart identified 15 alert pattern anomalies. Different thresholds were set to include the top 15 anomalies from each ML algorithm. A total of 31 unique ML anomalies were grouped and ranked by agreeability. All algorithms agreed on 10% of the anomalies, and at least two algorithms agreed on 36%. Each algorithm detected one specific anomaly that the mr-chart did not detect. The anomaly represented a day with 71 propofol alerts (half of which were overridden) generated at an average rate of 1.06 per infusion, whereas the moving alert rate for the week was 0.35 per infusion. DISCUSSION These findings show that ML-based algorithms are more robust than control charts in detecting unusual alerting patterns. However, we recommend using a combination of algorithms, as multiple algorithms serve a benchmarking function and allow researchers to focus on data points with the highest algorithm agreeability. CONCLUSION Unsupervised ML algorithms can assist clinicians in identifying unusual alert patterns as a first step toward achieving safer infusion practices.
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Affiliation(s)
- Marian Obuseh
- Marian Obuseh is a PhD student in the School of Industrial Engineering at Purdue University in West Lafayette, IN.
| | - Denny Yu
- Denny Yu, PhD, is an assistant professor in the School of Industrial Engineering at Purdue University in West Lafayette, IN
| | - Poching DeLaurentis
- Poching DeLaurentis, PhD, was a research scientist in the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, IN, at the time this study was conducted
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4
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Drevin G, Briet M, Ferec S, Rossi LH, Jousset N, Abbara C. Lethal self-administration of propofol and atracurium. J Forensic Sci 2021; 67:827-831. [PMID: 34586645 DOI: 10.1111/1556-4029.14903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/29/2022]
Abstract
Acute propofol intoxications appear rare and remain primarily related to the acquisition of the material from the hospital. In this study, two cases of suicide following self-administration of a propofol-atracurium combination are presented as well as other propofol-related fatalities, in order to investigate propofol postmortem blood concentrations and circumstances surrounding death. The two case studies involved a 48-years-old male and a 61-year-old female, both anesthesiologists, who were found unresponsive with drugs (propofol, atracurium for both, and cisatracurium for one of them) discovered at the scene. Toxicological analyses were performed using validated chromatographic methods and highlighted the presence of propofol (1.0 µg/ml), laudanosine (0.2 µg/ml), paroxetine (3.4 µg/ml), and ethanol (12 mg/dl) for the first case and propofol (1.9 µg/ml), laudanosine (1.2 µg/ml), and hydroxyzine (0.03 µg/ml) for the second case. In the literature, 14 publications describing 27 cases of propofol-related lethal intoxications were identified. Except for two cases, all these fatalities involved healthcare professionals. Accidental overdose was the most frequently reported manner of death and the reported propofol blood concentrations ranged from 0.026 to 223.8 µg/ml. These cases, in agreement with other reported cases, highlight the concerns related to the misuse of hospital-based medicines, especially by health-care professionals, and so, the need for a much more stringent internal control of such drugs.
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Affiliation(s)
- Guillaume Drevin
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire d'Angers, Angers, France.,Université d'Angers, Angers, France
| | - Marie Briet
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire d'Angers, Angers, France.,Université d'Angers, Angers, France.,Laboratoire MitoVasc, UMR CNRS 6215 INSERM 1083, Angers, France
| | - Séverine Ferec
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire d'Angers, Angers, France
| | - Lea-Helena Rossi
- Institut de Médecine légale, Centre Hospitalo-Universitaire d'Angers, Angers, France
| | - Nathalie Jousset
- Institut de Médecine légale, Centre Hospitalo-Universitaire d'Angers, Angers, France
| | - Chadi Abbara
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire d'Angers, Angers, France
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5
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Gwiazda S, Dixon E, Cronly M, Kavanagh Y, Cullinane M, Mulligan LM. Propofol misuse in Ireland - Two case reports and a review of the literature. Forensic Sci Int 2021; 326:110909. [PMID: 34311287 DOI: 10.1016/j.forsciint.2021.110909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Propofol is a rapidly acting sedative drug, which is usually administered intravenously. It is widely used in procedural sedation due to its rapid onset and easy reversibility. It has a good safety profile when used in combination with ventilation and monitoring. However, propofol can bring on feelings of euphoria, sexual disinhibition, tension relief and hallucinations, creating a potential for abuse. At an international level, recreational propofol use among medical staff is a growing, yet under reported problem. In order to highlight this issue in an Irish context, the case reports described are among the first recorded deaths in Ireland due to unmonitored self-administration of propofol. The difficulties facing forensic pathologists in detecting propofol and its metabolites in these cases are outlined. The potential for propofol abuse should influence healthcare facilities to make their staff aware of the risks associated with it. This in turn would promote vigilance and encourage those affected to seek treatment.
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Affiliation(s)
- Sara Gwiazda
- Office of the State Pathologist, Griffith Avenue, Whitehall, Dublin D09RDT8, Ireland
| | - Eleanor Dixon
- Human Toxicology, The State Laboratory, Backweston Campus, Co., Kildare, Ireland
| | - Mark Cronly
- Human Toxicology, The State Laboratory, Backweston Campus, Co., Kildare, Ireland
| | - Yvonne Kavanagh
- Human Toxicology, The State Laboratory, Backweston Campus, Co., Kildare, Ireland
| | - Myra Cullinane
- FRCPI, MFFLM, Barrister-at-Law, Senior Coroner for the Dublin District, Store Street, Dublin 1, Ireland
| | - Linda M Mulligan
- Office of the State Pathologist, Griffith Avenue, Whitehall, Dublin D09RDT8, Ireland.
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Plunkett E, Costello A, Yentis SM, Hawton K. Suicide in anaesthetists: a systematic review. Anaesthesia 2021; 76:1392-1403. [PMID: 34061350 DOI: 10.1111/anae.15514] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
Evidence suggests that healthcare professionals are at an increased risk of dying by suicide, with anaesthetists at particularly high risk. However, much of the data on which this is based are historical. With a focus on the epidemiology and methods used, we conducted a systematic review of evidence regarding suicide and suicidal behaviour among anaesthetists to provide a more contemporary summary. The systematic review process was adapted from a previous similar study in veterinary surgeons and was consistent with recommended guidance. We identified 54 articles published in or after 1990 that had anaesthetist-specific data and met the inclusion criteria. Seven of these reported epidemiological data, of which four were published after 2000. Although none of the more recent studies reported standardised mortality rates specific to suicide in anaesthetists, the proportion of anaesthetists dying by suicide was increased with respect to comparator groups, which is consistent with previous findings. Eleven studies that included information on suicidal behaviour reported suicidal ideation in 3.2-25% of individuals (six studies) and suicide attempts in 0.5-2% (four studies). Studies reporting methods of suicide highlighted the use of anaesthetic drugs, particularly propofol, supporting the suggestion that the increased risk of suicide in anaesthetists may be related to the availability of the means. We discuss our findings in relation to other recently published data and guidance concerning mental health problems in anaesthetists.
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Affiliation(s)
- E Plunkett
- Department of Anaesthesia, University Hospitals Birmingham, Birmingham, UK
| | - A Costello
- Department of Anaesthesia, Milton Keynes University Hospitals, Milton Keynes, UK
| | - S M Yentis
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK.,Imperial College London, London, UK
| | - K Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Current status of perioperative hypnotics, role of benzodiazepines, and the case for remimazolam: a narrative review. Br J Anaesth 2021; 127:41-55. [PMID: 33965206 DOI: 10.1016/j.bja.2021.03.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022] Open
Abstract
Anaesthesiologists and non-anaesthesiologist sedationists have a limited set of available i.v. hypnotics, further reduced by the withdrawal of thiopental in the USA and its near disappearance in Europe. Meanwhile, demand for sedation increases and new clinical groups are using what traditionally are anaesthesiologists' drugs. Improved understanding of the determinants of perioperative morbidity and mortality has spotlighted hypotension as a potent cause of patient harm, and practice must be adjusted to respect this. High-dose propofol sedation may be harmful, and a critical reappraisal of drug choices and doses is needed. The development of remimazolam, initially for procedural sedation, allows reconsideration of benzodiazepines as the hypnotic component of a general anaesthetic even if their characterisation as i.v. anaesthetics is questionable. Early data suggest that a combination of remimazolam and remifentanil can induce and maintain anaesthesia. Further work is needed to define use cases for this technique and to determine the impact on patient outcomes.
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Ferrari Júnior E, Dos Santos JBA, Caldas ED. Drugs, pesticides and metabolites in forensic post-mortem blood samples. MEDICINE, SCIENCE, AND THE LAW 2021; 61:97-104. [PMID: 33081562 DOI: 10.1177/0025802420965006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Forensic post-mortem toxicological data provide valuable information for the elucidation of cause of death. However, this is still not routine practice in Brazilian laboratories. This study investigated the presence of illicit and prescription drugs, pesticides and metabolites in 111 post-mortem blood samples from cases investigated by the Forensic Medical Institute of the Federal District, Brazil. Quantitative analysis was performed for 14 analytes using a validated programmed temperature vaporisation-large volume injection-gas chromatography-mass spectrometry method, which was also used as screening (qualitative analysis) for an additional 19 substances of forensic interest. At least one analyte was found in 61.2% of the samples, of which 34 were related to homicide, 15 to accidental death and 10 to suicide cases. The victims were 14-72 years old. The benzodiazepines diazepam, midazolam and 7-aminoflunitrazepan were detected in 46% of the positive samples (0.02-1.12 µg/mL; midazolam only qualitative). Cocaine was found in 34% (0.02-4.07 µg/mL), associated with substances commonly used as cocaine adulterants (e.g. caffeine, lidocaine and phenacetin). Three suicide cases involved the illegal rodenticide chumbinho, residues of which were found in the gastric content, and blood samples showed the presence of terbufos (0.03 and 0.04 µg/mL) and carbofuran (27.3 µg/mL). These results are discussed, along with autopsy and crime-scene information.
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Affiliation(s)
- Ettore Ferrari Júnior
- Forensic Analysis Laboratory, Criminalistics Institute, Brazil
- Laboratory of Toxicology, Department of Pharmacy, University of Brasilia, Brazil
| | | | - Eloisa Dutra Caldas
- Laboratory of Toxicology, Department of Pharmacy, University of Brasilia, Brazil
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Cuzzullin MC, Curate F, Freire AR, Costa ST, Prado FB, Daruge Junior E, Cunha E, Rossi AC. Validation of anthropological measures of the human femur for sex estimation in Brazilians. AUST J FORENSIC SCI 2020. [DOI: 10.1080/00450618.2020.1729411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Francisco Curate
- Research Centre for Anthropology and Health, Department of Life Sciences, University of Coimbra, Coimbra, Portugal
| | | | | | | | | | - Eugénia Cunha
- Centre for Functional Ecology, Laboratory of Forensic Sciences, Department of Life Sciences, University of Coimbra, Coimbra, Portugal
- Department of Life Sciences, National Institute of Legal Medicine and Forensic Sciences, Lisbon, Portugal
| | - Ana Cláudia Rossi
- Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, Brazil
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Abdi M, Pourrahimi A, Yousefi K, Nouri Khaneghah Z, Rabie Siahkali S, Torkmandi H. A Preventive Approach to the Risk of Substance Abuse in Medical Personnel with Migraine: A Case Report. PREVENTIVE CARE IN NURSING AND MIDWIFERY JOURNAL 2019. [DOI: 10.29252/pcnm.8.4.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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12
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Huang YC, Huang YF, Lin MH, Yang JY, Liao YH, Lo HY, Latkin C, Nelson KE. An outbreak of HIV infection among people who inject drugs linked to injection of propofol in Taiwan. PLoS One 2019; 14:e0210210. [PMID: 30735511 PMCID: PMC6368273 DOI: 10.1371/journal.pone.0210210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/18/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to report an HIV outbreak related to propofol-injection and the impact of regulating propofol on the HIV epidemic among people who inject drugs (PWID). METHODS A retrospective cohort study of 252 PWID who were diagnosed with an HIV infection between 2014 and 2017 in Taiwan. The propofol information was collected by routine epidemic surveillance and interviews. We linked several national databases to collect other related factors, including methadone maintenance treatment (MMT) attendance and incarceration. The serums were tested for recent infection by the LAg-avidity EIA assay and relationship of the trains by the Phylogenetic tree analysis. Analyses were conducted using the R Surveillance package for retrospective modeling for outbreak detection. A multiple logistic regression was used to evaluate the association between propofol-injection and other related factors. RESULTS There were 28 cases reported with propofol-injection, all of which were reported in Central Taiwan. A total of 11 (50%) cases among 22 propofol-injectors with serums were recent infections, which were higher than that 33 (23.4%) of non-propofol group. The phylogenetic tree indicated that 6 propofol-injectors were grouped together with the same cluster in circular. The HIV epidemic curve among PWID revealed an outbreak of 82 in 2015, which then decreased to 43 in 2016 after propofol began to be regulated as a Schedule 4 controlled drug in August 2015. In a multiple logistic regression, attendance at methadone clinics was associated with a significantly higher risk for propofol-injection (adjusted OR = 2.43, 95% CI = 0.98-5.98), and HIV reported in the year 2015 was associated with an increased risk of propofol-injection (adjusted OR = 4, 95% CI = 1.08-14.86). CONCLUSIONS Our data indicate that the government regulation of propofol as a controlled drug strategy was associated with significant reduction in the spread of HIV among PWID.
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Affiliation(s)
- Yu-Ching Huang
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Yen-Fang Huang
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
- * E-mail:
| | - Min-Hau Lin
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Jyh-Yuan Yang
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Yu-Hsin Liao
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Hsiu-Yun Lo
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
| | - Carl Latkin
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Kenrad E. Nelson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
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Metabolic Profiles of Propofol and Fospropofol: Clinical and Forensic Interpretative Aspects. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6852857. [PMID: 29992157 PMCID: PMC5994321 DOI: 10.1155/2018/6852857] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 04/15/2018] [Indexed: 02/08/2023]
Abstract
Propofol is an intravenous short-acting anesthetic widely used to induce and maintain general anesthesia and to provide procedural sedation. The potential for propofol dependency and abuse has been recognized, and several cases of accidental overdose and suicide have emerged, mostly among the health professionals. Different studies have demonstrated an unpredictable interindividual variability of propofol pharmacokinetics and pharmacodynamics with forensic and clinical adverse relevant outcomes (e.g., pronounced respiratory and cardiac depression), namely, due to polymorphisms in the UDP-glucuronosyltransferase and cytochrome P450 isoforms and drugs administered concurrently. In this work the pharmacokinetics of propofol and fospropofol with particular focus on metabolic pathways is fully reviewed. It is concluded that knowing the metabolism of propofol may lead to the development of new clues to help further toxicological and clinical interpretations and to reduce serious adverse reactions such as respiratory failure, metabolic acidosis, rhabdomyolysis, cardiac bradyarrhythmias, hypotension and myocardial failure, anaphylaxis, hypertriglyceridemia, renal failure, hepatomegaly, hepatic steatosis, acute pancreatitis, abuse, and death. Particularly, further studies aiming to characterize polymorphic enzymes involved in the metabolic pathway, the development of additional routine forensic toxicological analysis, and the relatively new field of ‘‘omics” technology, namely, metabolomics, can offer more in explaining the unpredictable interindividual variability.
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Roda G, Arnoldi S, Dei Cas M, Ottaviano V, Casagni E, Tregambe F, Visconti GL, Farè F, Froldi R, Gambaro V. Determination of Cyanide by Microdiffusion Technique Coupled to Spectrophotometry and GC/NPD and Propofol by Fast GC/MS-TOF in a Case of Poisoning. J Anal Toxicol 2018; 42:e51-e57. [DOI: 10.1093/jat/bky015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/07/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gabriella Roda
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Sebastiano Arnoldi
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Michele Dei Cas
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Valeria Ottaviano
- Dipartimento di Sanità Pubblica, Laboratorio di Tossicologia Forense, Università degli Studi “Tor Vergata”, Via Montpellier 1, Roma, Italy
| | - Eleonora Casagni
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Fausto Tregambe
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Giacomo Luca Visconti
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Fiorenza Farè
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
| | - Rino Froldi
- Istituto di Medicina Legale e delle Assicurazioni, Università degli Studi di Macerata, Via Don Minzoni 9, Macerata, Italy
| | - Veniero Gambaro
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Via Mangiagalli 25, Milano, Italy
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Maas A, Maier C, Iwersen-Bergmann S, Pilgrim JL, Di Rago M, Madea B, Hess C. Propofol and propofol glucuronide concentrations in hair following medical propofol administration and in forensic death cases. Forensic Toxicol 2018. [DOI: 10.1007/s11419-017-0399-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Maas A, Maier C, Michel-Lauter B, Broecker S, Madea B, Hess C. Verification of propofol sulfate as a further human propofol metabolite using LC-ESI-QQQ-MS and LC-ESI-QTOF-MS analysis. Drug Metab Pers Ther 2017; 32:67-72. [PMID: 28259866 DOI: 10.1515/dmpt-2017-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/27/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Propofol (2,6-diisopropylphenol) is a water-insoluble, intravenous anesthetic that is widely used for the induction and maintenance of anesthesia as well as for endoscopic and pediatric sedation. After admission, propofol undergoes extensive hepatic and extrahepatic metabolism, including direct conjugation to propofol glucuronide and hydroxylation to 2,6-diisopropyl-1,4-quinol. The latter substance subsequently undergoes phase II metabolism, resulting in the formation of further metabolites (1quinolglucuronide, 4quinolglucuronide and 4quinol-sulfate). Further minor phase I propofol metabolites (2-(ω-propanol)-6-isopropylphenol and 2-(ω-propanol)-6-isopropyl-1,4-quinol)) are also described. Due to its chemical structure with the phenolic hydroxyl group, propofol is also an appropriate substrate for sulfation by sulfotransferases. METHODS The existence of propofol sulfate was investigated by liquid chromatography electrospray ionization triple quadrupole mass spectrometry (LCESIQQQ-MS) and liquid chromatography electrospray ionization quadrupole time-of-flight mass spectrometry (LCESI-QTOF-MS). A propofol sulfate reference standard was used for identification and method development, yielding a precursor at m/z 257 (deprotonated propofol sulfate) and product ions at m/z 177 (deprotonated propofol) and m/z 80 ([SO3]-). RESULTS Propofol sulfate - a further phase II metabolite of propofol - was verified in urine samples by LC-ESI-QQQ-MS and LC-ESI-QTOF-MS. Analyses of urine samples from five volunteers collected before and after propofol-induced sedation verified the presence of propofol sulfate in urine following propofol administration, whereas ascertained concentrations of this metabolite were significantly lower compared with detected propofol glucuronide concentrations. CONCLUSIONS The existence of propofol sulfate as a further phase II propofol metabolite in humans could be verified by two different detection techniques (LCESIQQQ-MS and LC-ESI-QTOFMS) on the basis of a propofol sulfate reference standard. Evaluation of the quantitative analyses of propofol sulfate imply that propofol sulfate represents a minor metabolite of propofol and is only slightly involved in human propofol clearance.
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Brechmann T, Maier C, Kaisler M, Vollert J, Schmiegel W, Pak S, Scherbaum N, Rist F, Riphaus A. Propofol sedation during gastrointestinal endoscopy arouses euphoria in a large subset of patients. United European Gastroenterol J 2017; 6:536-546. [PMID: 29881609 DOI: 10.1177/2050640617736231] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Background Propofol is recommended for sedation in gastrointestinal endoscopy (GE), but preliminary data suggest addictive potentials. Objective The objective of this article is to evaluate the frequency of predominantly euphoric reaction after GE and patients' subsequent reminiscences. Methods Eighty-two patients undergoing elective GE under propofol sedation were enrolled in a prospective observational study. The grade of anxiety, expectation or relief about the examination's result and affective state in terms of cheerfulness, relaxation, activation, sedation and anxiety were surveyed using a numeric rating scale (1 to 10) immediately before (t1), after GE (t2) and seven days (t3) later. Statistics: hierarchical cluster analysis, heat map, χ2 test and paired t test. Results Mean propofol dosage was 264 ± 120 mg. Two clusters of mood changes emerged (t1 vs. t2). One (n = 46, 56.1%) was characterized by an unease reaction pattern with equal values regarding cheerfulness, relaxation and anxiety, while relaxation decreased; the other cluster showed a euphoric reaction pattern (n = 36, 43.9%) with markedly increased cheerfulness, relaxation and decreased anxiety. These effects intensified at recall (t3). Despite similar endoscopy results, euphoric cluster patients rated these more positively. Conclusion Propofol induces euphoria in nearly half of the patients undergoing elective GE with persisting, even enhanced reminiscence (germanctr.de, trial number DRKS00011202).
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Affiliation(s)
- Thorsten Brechmann
- 1Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Department of Gastroenterology and Hepatology, Germany
| | - Christoph Maier
- 2Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Department of Pain Medicine, Germany
| | - Miriam Kaisler
- 2Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Department of Pain Medicine, Germany
| | - Jan Vollert
- 2Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Department of Pain Medicine, Germany
| | - Wolff Schmiegel
- 1Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Department of Gastroenterology and Hepatology, Germany
| | - Svetlana Pak
- 3KRH Klinikum Agnes Karll Laatzen, Department of Internal Medicine and Gastroenterology, Laatzen, Germany
| | - Norbert Scherbaum
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Fred Rist
- University of Münster, Department of Psychology, Münster, Germany
| | - Andrea Riphaus
- 3KRH Klinikum Agnes Karll Laatzen, Department of Internal Medicine and Gastroenterology, Laatzen, Germany
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Procaccianti P, Farè F, Argo A, Casagni E, Arnoldi S, Facheris S, Visconti GL, Roda G, Gambaro V. Determination of Propofol by GC/MS and Fast GC/MS-TOF in Two Cases of Poisoning. J Anal Toxicol 2017; 41:771-776. [DOI: 10.1093/jat/bkx056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/27/2017] [Indexed: 11/14/2022] Open
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Vaiano F, Busardò FP, Pascali J, Fioravanti A, Mortali C, Mari F, Bertol E. Hair testing of propofol by liquid chromatography-tandem mass spectrometry and azo-coupling derivatization. Drug Test Anal 2017; 9:1080-1084. [DOI: 10.1002/dta.2190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Fabio Vaiano
- Forensic Toxicology Division, Department of Health Sciences; University of Florence; L.go Brambilla 3 50134 Florence Italy
| | - Francesco P. Busardò
- Unit of Forensic Toxicology (UoFT), Department of Anatomical Histological, Forensic and Orthopaedic Sciences; Sapienza University of Rome; V.le Regina Elena 336 00161 Rome Italy
| | - Jennifer Pascali
- Forensic Toxicology Division, Department of Health Sciences; University of Florence; L.go Brambilla 3 50134 Florence Italy
| | - Alessia Fioravanti
- Forensic Toxicology Division, Department of Health Sciences; University of Florence; L.go Brambilla 3 50134 Florence Italy
| | - Claudia Mortali
- National Centre on Addiction and Doping, ISS; V.le Regina Elena 229 00161 Rome Italy
| | - Francesco Mari
- Forensic Toxicology Division, Department of Health Sciences; University of Florence; L.go Brambilla 3 50134 Florence Italy
| | - Elisabetta Bertol
- Forensic Toxicology Division, Department of Health Sciences; University of Florence; L.go Brambilla 3 50134 Florence Italy
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Hantson P, Bonbled F. Le propofol comme agent de suicide ou d’abus. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2015.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vaiano F, Serpelloni G, Focardi M, Fioravanti A, Mari F, Bertol E. LC–MS/MS and GC–MS methods in propofol detection: Evaluation of the two analytical procedures. Forensic Sci Int 2015; 256:1-6. [DOI: 10.1016/j.forsciint.2015.07.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/28/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
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Sørensen LK, Hasselstrøm JB. Simultaneous determination of propofol and its glucuronide in whole blood by liquid chromatography–electrospray tandem mass spectrometry and the influence of sample storage conditions on the reliability of the test results. J Pharm Biomed Anal 2015; 109:158-63. [DOI: 10.1016/j.jpba.2015.02.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/17/2015] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
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Tezcan AH, Ornek DH, Ozlu O, Baydar M, Yavuz N, Ozaslan NG, Dilek K, Keske A. Abuse potential assessment of propofol by its subjective effects after sedation. Pak J Med Sci 2015; 30:1247-52. [PMID: 25674117 PMCID: PMC4320709 DOI: 10.12669/pjms.306.5811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 11/21/2022] Open
Abstract
Objective: In this study, we examined the euphoric effect of propofol and its high satisfaction ratio regarding its liability to be abused, particularly in painless procedures, such as colonoscopy. Methods: Fifty subjects aged between 18 and 65 years who fulfilled the criteria for ASA 1-2 and were prepared for colonoscopy were enrolled into this study. For intravenous sedation induction, 2 mg/kg propofol was used, and additional injections were administered according to BIS values. After colonoscopy, the subjects were taken to a recovery room and observed for 30 minutes. Patients were interviewed with the modified Brice questionnare regarding the incidence and the content of dreams. A 5-point Likert scale was used to classify their dreams, and the content of the dreams was also recorded. To assess the subjective effects of propofol, the patients were asked to use the Hall and Van der Castle emotion scale; their biological states were also assessed. The patients’ feelings regarding propofol were each rated as absent or present. We used the Morphine-Benzedrine Group scale to measure the euphoric effects of propofol. At the end of the study, subjects scored their satisfaction on a five-point scale. Results: There were no statistically significant differences in sex age, weight, propofol dose, or satisfaction ratio (p>0.05) in the groups, although male patients received a higher dose of propofol and had higher satisfaction ratio. Patients reported no residual after-effects. The incidence of dreaming was 42%. There was no statistically significant difference in dreaming between the sexes, but male patients had a higher dreaming ratio. Dreamers received higher propofol doses and had a higher satisfaction ratio (p>0.05). All dreamers reported happy dreams regarding daily life, and their mean MBG score was 10.5. There was no correlation between MBG scores and propofol doses (r= -0.044, p= 0.761). Conclusions: We conclude that propofol functions as a reward; that patients enjoy its acute effects; and that no residual after-effects should arise. We suggest that propofol may carry potential for abuse, and further abuse liability testing is indicated.
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Affiliation(s)
- Aysu Hayriye Tezcan
- Dr. Aysu Hayriye Tezcan, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Dilsen Hatice Ornek
- Dr. Dilsen Hatice Ornek, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Onur Ozlu
- Prof. Dr. Onur Ozlu, Department of Anesthesia and Reanimation, Duzce University Faculty of Medicine, Duzce, Turkey
| | - Mustafa Baydar
- Dr. Mustafa Baydar, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Nurcan Yavuz
- Dr. Nurcan Yavuz, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Nihal Gokbulut Ozaslan
- Dr. Nihal Gokbulut Ozaslan, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Kevser Dilek
- Dr. Kevser Dilek, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Aylin Keske
- Dr. Aylin Keske, Department of Anesthesia and Reanimation, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Bryson EO. The Abuse of Agents Used to Induce or Maintain General Anesthesia: Intravenous Hypnotics and the Halogenated Hydrocarbons. Subst Abus 2015. [DOI: 10.1007/978-1-4939-1951-2_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ruffle JK. Molecular neurobiology of addiction: what's all the (Δ)FosB about? THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2014; 40:428-37. [PMID: 25083822 DOI: 10.3109/00952990.2014.933840] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The transcription factor ΔFosB is upregulated in numerous brain regions following repeated drug exposure. This induction is likely to, at least in part, be responsible for the mechanisms underlying addiction, a disorder in which the regulation of gene expression is thought to be essential. In this review, we describe and discuss the proposed role of ΔFosB as well as the implications of recent findings. The expression of ΔFosB displays variability dependent on the administered substance, showing region-specificity for different drug stimuli. This transcription factor is understood to act via interaction with Jun family proteins and the formation of activator protein-1 (AP-1) complexes. Once AP-1 complexes are formed, a multitude of molecular pathways are initiated, causing genetic, molecular and structural alterations. Many of these molecular changes identified are now directly linked to the physiological and behavioral changes observed following chronic drug exposure. In addition, ΔFosB induction is being considered as a biomarker for the evaluation of potential therapeutic interventions for addiction.
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Affiliation(s)
- James K Ruffle
- Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London , London , UK
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Maier C, Leclerc-Springer J. [Life-threatening fentanyl and propofol addiction: interview with a survivor]. Anaesthesist 2014; 61:601-7. [PMID: 22714402 DOI: 10.1007/s00101-012-2036-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anesthesiologists have a well-known increased risk of substance abuse including the intravenous administration of opioids and propofol. However, katamnestic reports from the point of view of propofol-addicted anesthesiologists themselves are missing which would aid a better understanding of the dynamics and progress of addiction. This article presents an interview with a formerly addicted female anesthesiologist who after long-term abuse with oral tilidine combined with naloxone switched to intravenous administration of fentanyl and later on propofol. Several life-threatening incidents occurred but after some severe setbacks occupational rehabilitation outside the field of anesthesiology was successful following inpatient treatment. This case shows exemplarily in accordance with the current literature that warning signs in addicted physicians are often ignored by colleagues and supervisors and rehabilitation is possible under professional therapy and continuous surveillance. Additionally, this case emphasizes the necessity of controlling the distribution of propofol to reduce the life-threatening professional risk to anesthesiologists.
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Affiliation(s)
- C Maier
- Abteilung für Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland.
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Vaiano F, Mari F, Busardò FP, Bertol E. Enhancing the sensitivity of the LC-MS/MS detection of propofol in urine and blood by azo-coupling derivatization. Anal Bioanal Chem 2014; 406:3579-87. [DOI: 10.1007/s00216-013-7573-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/03/2013] [Accepted: 12/10/2013] [Indexed: 11/30/2022]
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Suh SJ, Yim HJ, Yoon EL, Lee BJ, Hyun JJ, Jung SW, Koo JS, Kim JH, Kim KJ, Choung RS, Seo YS, Yeon JE, Um SH, Byun KS, Lee SW, Choi JH, Ryu HS. Is propofol safe when administered to cirrhotic patients during sedative endoscopy? Korean J Intern Med 2014; 29:57-65. [PMID: 24574834 PMCID: PMC3932396 DOI: 10.3904/kjim.2014.29.1.57] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/18/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS In patients with liver cirrhosis, drugs acting on the central nervous system can lead to hepatic encephalopathy and the effects may be prolonged. Recently, misuse of propofol has been reported and the associated risk of death have become an issue. Propofol is commonly used during sedative endoscopy; therefore, its safety in high-risk groups must be further investigated. We performed a pilot study of the safety and efficacy of propofol during endoscopy in Korean patients with cirrhosis. METHODS Upper gastrointestinal endoscopy was performed under sedation with propofol along with careful monitoring in 20 patients with liver cirrhosis and 20 control subjects. The presence or development of hepatic encephalopathy was assessed using the number connection test and neurologic examination. RESULTS Neither respiratory depression nor clinically significant hypotension were observed. Immediate postanesthetic recovery at 5 and 10 minutes after the procedure was delayed in the cirrhotic patients compared with the control group; however, at 30 minutes, the postanesthetic recovery was similar in both groups. Baseline psychomotor performance was more impaired in cirrhotic patients, but propofol was not associated with deteriorated psychomotor function even in cirrhotic patients with a minimal hepatic encephalopathy. CONCLUSIONS Sedation with propofol was well tolerated in cirrhotic patients. No newly developed hepatic encephalopathy was observed.
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Affiliation(s)
- Sang Jun Suh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung Joon Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Eileen L. Yoon
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Beom Jae Lee
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Woo Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ja Seol Koo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hoon Kim
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Kyung Jin Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Rok Son Choung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jong Eun Yeon
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Soon Ho Um
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Kwan Soo Byun
- Division of Hepatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Sang Woo Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jai Hyun Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ho Sang Ryu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
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Pramanik C, Kotharkar S, Patil P, Gotrane D, More Y, Borhade A, Chaugule B, Khaladkar T, Neelakandan K, Chaudhari A, Kulkarni MG, Tripathy NK, Gurjar MK. Commercial Manufacturing of Propofol: Simplifying the Isolation Process and Control on Related Substances. Org Process Res Dev 2013. [DOI: 10.1021/op400300t] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Chinmoy Pramanik
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Sandeep Kotharkar
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Pradip Patil
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Dinkar Gotrane
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Yogesh More
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Ajit Borhade
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Balaji Chaugule
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Tushar Khaladkar
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - K. Neelakandan
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Ashok Chaudhari
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Mukund G. Kulkarni
- Department
of Chemistry, University of Pune, Ganeshkhind, Pune-411 007, Maharashtra, India
| | - Narendra K. Tripathy
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
| | - Mukund K. Gurjar
- API R&D Centre, Emcure Pharmaceuticals Ltd., ITBT Park, Phase-II, MIDC, Hinjewadi, Pune-411057, India
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Hikiji W, Fukunaga T. Suicide of physicians in the special wards of Tokyo Metropolitan area. J Forensic Leg Med 2013; 22:37-40. [PMID: 24485419 DOI: 10.1016/j.jflm.2013.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 12/01/2013] [Accepted: 12/07/2013] [Indexed: 09/30/2022]
Abstract
Numerous studies on physician suicide in various countries have been reported but no data from Japan on the issue can be found to date. In this study, physician suicides in the special wards of Tokyo Metropolitan area in 1996-2010 were investigated retrospectively. A total of 87 cases were enrolled. The results suggested that physician suicide has been linked to pre-existing psychiatric illnesses and occupational problems, and that psychiatrists have a relatively higher suicide risk compared to those majoring in other specialities of medicine. A distinctive feature was that 19 cases had used either drugs or devices which were accessible due to their profession some time during the process of committing suicide. Another notable feature was that 4 out of 5 anaesthesiologists enrolled in the study had chosen poisoning for their suicide method, with the drugs frequently used in their speciality. The findings advocate strongly for efficient suicide prevention measures for physicians including an early detection and treatment of psychiatric illnesses, as well as an urgent need for a more effective pharmacy management in applicable institutions together with the implementation of self discipline on each physician. This is the first broad academic study on physician suicide in Japan.
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Affiliation(s)
- Wakako Hikiji
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, 4-21-18 Otsuka, Bunkyo-ku, Tokyo 112-0012, Japan.
| | - Tatsushige Fukunaga
- Tokyo Medical Examiner's Office, Tokyo Metropolitan Government, 4-21-18 Otsuka, Bunkyo-ku, Tokyo 112-0012, Japan.
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Han E, Jung S, Baeck S, Lee S, Chung H. Deaths from recreational use of propofol in Korea. Forensic Sci Int 2013; 233:333-7. [DOI: 10.1016/j.forsciint.2013.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 09/17/2013] [Accepted: 10/05/2013] [Indexed: 11/15/2022]
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Han E. A study of analytical methods for the determination of propofol in blood. Arch Pharm Res 2013; 37:157-67. [DOI: 10.1007/s12272-013-0265-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 10/13/2013] [Indexed: 11/28/2022]
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Šrámková I, Amorim CG, Sklenářová H, Montenegro MCBM, Horstkotte B, Araújo AN, Solich P. Fully automated analytical procedure for propofol determination by sequential injection technique with spectrophotometric and fluorimetric detections. Talanta 2013; 118:104-10. [PMID: 24274276 DOI: 10.1016/j.talanta.2013.09.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
In this work, an application of an enzymatic reaction for the determination of the highly hydrophobic drug propofol in emulsion dosage form is presented. Emulsions represent a complex and therefore challenging matrix for analysis. Ethanol was used for breakage of a lipid emulsion, which enabled optical detection. A fully automated method based on Sequential Injection Analysis was developed, allowing propofol determination without the requirement of tedious sample pre-treatment. The method was based on spectrophotometric detection after the enzymatic oxidation catalysed by horseradish peroxidase and subsequent coupling with 4-aminoantipyrine leading to a coloured product with an absorbance maximum at 485 nm. This procedure was compared with a simple fluorimetric method, which was based on the direct selective fluorescence emission of propofol in ethanol at 347 nm. Both methods provide comparable validation parameters with linear working ranges of 0.005-0.100 mg mL(-1) and 0.004-0.243 mg mL(-1) for the spectrophotometric and fluorimetric methods, respectively. The detection and quantitation limits achieved with the spectrophotometric method were 0.0016 and 0.0053 mg mL(-1), respectively. The fluorimetric method provided the detection limit of 0.0013 mg mL(-1) and limit of quantitation of 0.0043 mg mL(-1). The RSD did not exceed 5% and 2% (n=10), correspondingly. A sample throughput of approx. 14 h(-1) for the spectrophotometric and 68 h(-1) for the fluorimetric detection was achieved. Both methods proved to be suitable for the determination of propofol in pharmaceutical formulation with average recovery values of 98.1 and 98.5%.
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Affiliation(s)
- Ivana Šrámková
- Department of Analytical Chemistry, Faculty of Pharmacy, Charles University in Prague, Heyrovského 1203, 500 05 Hradec Králové, Czech Republic
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ALSUntangled No. 22: Propofol. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:640-2. [DOI: 10.3109/21678421.2013.826469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Colucci AP, Gagliano-Candela R, Aventaggiato L, De Donno A, Leonardi S, Strisciullo G, Introna F. Suicide by self-administration of a drug mixture (propofol, midazolam, and zolpidem) in an anesthesiologist: the first case report in Italy. J Forensic Sci 2013; 58:837-41. [PMID: 23406307 DOI: 10.1111/1556-4029.12053] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 11/18/2011] [Accepted: 02/25/2012] [Indexed: 11/26/2022]
Abstract
The authors report an unusual case of suicide of an anesthesiologist, in which the suicide manner and means depend upon the victim's occupation. This is the first case report published in Italy of a death involving propofol and other drugs. The anesthesiologist was found dead with an empty drip still inserted in the hand and another one near his body. Forensic and toxicological findings suggested that the cause of death was a respiratory depression due to a self-administration of a rapidly infused lethal drug mixture. Analytical drug quantification was performed by gas chromatography-mass spectrometry. Blood analysis revealed: zolpidem (0.86 μg/mL), propofol (0.30 μg/mL), midazolam (0.08 μg/mL), thiopental (0.03 μg/mL), and amitriptyline (0.07 μg/mL). Adipose tissue and hair analysis suggested a previous and repeated use of these drugs verifying the fact that in Italy recreational abuse of anesthetic and sedative agents in health care practitioners is becoming an increasing problem.
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Affiliation(s)
- Anna Pia Colucci
- Laboratory of Forensic Toxicology of Department of Internal Medicine and Public Health, University of Bari, Bari, Italy
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Salerno J, Jones J, Jones M, Plate C, Lewis D. Long-Term Detection of Propofol Glucuronide in Urine Following Anesthetic Induction and Maintenance with Propofol. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/pp.2013.47076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Circumstantial and toxicological features of deaths from self-administered intravenous anesthetic/narcotic agents. Forensic Sci Med Pathol 2012; 9:138-44. [DOI: 10.1007/s12024-012-9374-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2012] [Indexed: 11/27/2022]
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Han E, Kim E, Hong H, Jeong S, Kim J, In S, Chung H, Lee S. Evaluation of postmortem redistribution phenomena for commonly encountered drugs. Forensic Sci Int 2012; 219:265-71. [DOI: 10.1016/j.forsciint.2012.01.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 01/02/2012] [Accepted: 01/05/2012] [Indexed: 10/14/2022]
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Park JH, Kim HJ, Seo JS. Medicolegal Review of Deaths Related to Propofol Administration: Analysis of 36 Autopsied Cases. ACTA ACUST UNITED AC 2012. [DOI: 10.7580/koreanjlegmed.2012.36.1.56] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jong Hyeok Park
- Department of Forensic Medicine, Division of Forensic Medicine, National Forensic Service, Seoul, Korea
| | - Hyoung-Joong Kim
- Department of Forensic Medicine, Division of Forensic Medicine, National Forensic Service, Seoul, Korea
| | - Joong-Seok Seo
- Department of Forensic Medicine, Division of Forensic Medicine, National Forensic Service, Seoul, Korea
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Kim DK. Propofol use for sedation or sedation for propofol use? J Anesth 2011; 26:289-91. [PMID: 22120100 DOI: 10.1007/s00540-011-1275-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/20/2011] [Indexed: 11/28/2022]
Abstract
A large amount of pharmacological and clinical evidence supports the abuse potential of propofol. Although previous case reports have indicated that recreational use of propofol is primarily by medical professionals, its spread among the general public has recently been highlighted. This is the first case report to show that cravings for propofol can be quite intense in some people, and thus propofol can be wrongfully used by clinicians who are enticed by the promise of monetary gain. Illicit diversion of propofol in hospitals has been confirmed; thus, propofol has been designated as a controlled substance in South Korea as of February 2011.
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Affiliation(s)
- Duk-Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, 50 Irwon-Dong, Gangnam-Gu, Seoul 135-710, Republic of Korea.
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Xiong M, Li J, Ye JH, Zhang C. Upregulation of DeltaFosB by propofol in rat nucleus accumbens. Anesth Analg 2011; 113:259-64. [PMID: 21642609 DOI: 10.1213/ane.0b013e318222af17] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is well established that all drugs of abuse converge onto common circuitry and induce chronic addiction by modulating the addictive signaling molecules such as DeltaFosB in the mesocorticolimbic system. Recent case reports suggest that propofol may have abuse potential. However, there is no direct evidence showing that propofol has an effect on the key addictive signaling molecules in the mesocorticolimbic system. In this study, we determined the effect of propofol on the expression of DeltaFosB in rat nucleus accumbens (NAc) and the potential mechanism involved. METHODS To determine the effect of propofol on the expression of DeltaFosB in rat NAc, 2 well-known addictive agents, ethanol and nicotine, were used as positive controls. Experiments were conducted on 36 male Sprague-Dawley rats (150 to 200 g). These animals were divided into 4 treatment groups: vehicle (saline), propofol (10 mg/kg), ethanol (1 g/kg), and nicotine (0.5 mg/kg). All drugs were administered by intraperitoneal injection twice per day for 7 days. The animals were then killed and their NAc were isolated for DeltaFosB measurements. RESULTS As expected, both ethanol and nicotine significantly increased DeltaFosB expression. Intriguingly, propofol elicited a robust increase in DeltaFosB expression similar to that of ethanol and nicotine. Moreover, the dopamine receptor D1, an upstream molecule of DeltaFosB, was also significantly upregulated by propofol. CONCLUSIONS In the current study, we have identified, for the first time, that propofol is able to induce the addictive signaling molecule DeltaFosB in NAc via dopamine receptor D1. This new evidence at the molecular level suggests that propofol may have abuse potential.
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Affiliation(s)
- Ming Xiong
- Department of Anesthesiology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 185 South Orange Avenue, Newark, NJ 07101, USA
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Stocks G. Abuse of Propofol by Anesthesia Providers: The Case for Re-Classification as a Controlled Substance. J Addict Nurs 2011. [DOI: 10.3109/10884602.2010.545091] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Media attention on the misuse of propofol increased significantly when the drug was implicated in the death of pop music superstar Michael Jackson in 2010. The misuse and abuse of propofol among healthcare providers has been reported worldwide, with some misuse resulting in death. Propofol policies guiding healthcare worker re-entry into the workplace after misusing propofol have received rare attention in the research literature. The paucity of information regarding propofol-specific re-entry policies suggests that little research has addressed this problem and the lack of research and policy guidance can contribute to unsafe re-entry and even death. This paper focuses on healthcare providers because they have an easy access to propofol and therefore are vulnerable to misusing or abusing the drug. To accomplish this, the pharmacology and misuse/abuse potential of propofol and the influence of the 12-step recovery paradigm in the re-entry literature are reviewed. In conclusion, existing research and policy are drawn upon to suggest employment re-entry guidelines for healthcare workers.
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Affiliation(s)
- Todd Monroe
- School of Nursing, Vanderbilt University, Nashville, Tennessee 37240, USA.
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Abstract
Propofol is a potent intravenous anesthetic agent that rapidly induces sedation and unconsciousness. The potential for propofol dependency, recreational use, and abuse has only recently been recognized, and several cases of accidental overdose and suicide have emerged. In addition, the first documented case of murder using propofol was reported a few months ago, and a high profile case of suspected homicide with propofol is currently under investigation. A number of analytical methods have been employed to detect and quantify propofol concentrations in biological specimens. The reported propofol-related deaths and postmortem blood and tissue levels are reviewed. Importantly, limitations of propofol detection are discussed, and future considerations are presented. Because propofol has the potential for diversion with lethal consequences, the forensic scientist must have a basic understanding of its clinical indications and uses, pharmacologic properties, and detection methods. In addition, medical institutions should develop systems to prevent and detect diversion of this potential drug of abuse.
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Affiliation(s)
- Richard J Levy
- Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010.
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Gilboy N. Decrease the Risk of Diversion: Increase the Control. J Emerg Nurs 2010; 36:274-6. [DOI: 10.1016/j.jen.2010.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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