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Zhong T, Lin Y, Zhuge R, Lin Y, Huang B, Zeng R. Reviewing the mechanism of propofol addiction. ALL LIFE 2023. [DOI: 10.1080/26895293.2023.2174708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Tianhao Zhong
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yuyan Lin
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Ruohuai Zhuge
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yujie Lin
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Bingwu Huang
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
- Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Ruifeng Zeng
- The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, People’s Republic of China
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
- Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, People’s Republic of China
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Dai Y, Li Y, Zhao K, Wang Y, Gu J, Bai H, Wurita A, Hasegawa K. Simple quantification of propofol and its metabolites in blood and urine using gas chromatography-tandem mass spectrometry (GC-MS/MS). Leg Med (Tokyo) 2023; 65:102333. [PMID: 37820542 DOI: 10.1016/j.legalmed.2023.102333] [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: 07/15/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
An analytical method which was used for the simultaneous detection and quantification of propofol and its metabolites in human blood and urine by gas chromatography-tandem mass spectrometry (GC-MS/MS) was newly established and applied to authentic human samples obtained from the deceased. The QuEChERS method was employed, and then analyzed by GC-MS/MS. We separately used sulfatase and β-glucuronidase to hydrolyze the urine sample and calculated the increase of propofol and 4-hydroxypropofol before and after the hydrolysis. The results of urinary concentrations in urine from the subject were: 4.88 μg/mL for propofol, 0.53 μg/mL for 4-hydroxypropofol, 3.35 μg/mL for propofol-glucuronide, 0.31 μg/mL for the total concentration of 1-(2,6-diisopropyl-1,4-quinol)-glucuronide plus 4-(2,6-diisopropyl-1,4-quinol)-glucuronide, and 0.39 μg/mL for 4-(2,6- diisopropyl-1,4-quinol)-sulfate. The lower limit of quantification was 10 ng/mL for all determined compounds; the extraction recoveries were not less than 57.2 %. Intraday and interday precisions and accuracies were all less than 10 %. The calibration curves for propofol and 4-hydroxypropofol in human urine showed the correlation values of not less than 0.999; propofol and 4-hydroxypropofol in blood also presented good linearities in the concentration ranges of 0.1-10 μg/mL. The two compounds had good stability within 7 days at 25, 4, and -20 ℃. To our knowledge, this is the first trial to establish a simple and reliable method to simultaneously detect and quantify of propofol and its phase I and II metabolites in human blood and urine samples by GC-MS/MS.
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Affiliation(s)
- Yinyin Dai
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Yaqing Li
- Guangdong Nantian Institute of Forensic Science, Shenzhen 518026, Guangdong, China
| | - Kundi Zhao
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Yue Wang
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Jie Gu
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Huiru Bai
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Amin Wurita
- Department of Legal Medicine, College of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China.
| | - Koutaro Hasegawa
- Department of Legal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Japan.
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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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Zhao K, Yang N, Yue J, Han Y, Wang X, Kang N, Zhang T, Guo X, Xu M. Factors associated with euphoria in a large subset of cases using propofol sedation during gastrointestinal endoscopy. Front Psychiatry 2023; 14:1001626. [PMID: 37181900 PMCID: PMC10174461 DOI: 10.3389/fpsyt.2023.1001626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
Background The utilization of Propofol, a widely used intravenous sedative or anesthetic, is characterized by its quick onset, predictable control, and fleeting half-life during both general anesthesia and intensive care unit sedation. Recent evidence, however, has highlighted propofol's propensity to induce euphoria, particularly in patients undergoing painless procedures such as gastrointestinal or gastric endoscopy. Given its widespread use in patients undergoing such procedures, this study aims to investigate the clinical evidence and factors that may influence propofol-induced euphoria in these settings. Methods The Addiction Research Center Inventory-Chinese Version (ARCI-CV) scale was administered to 360 patients undergoing gastric or gastrointestinal endoscopy using propofol as a sedative. Patient characteristics including past medical history, depression, anxiety, alcohol abuse, and sleep disturbance were recorded through history taking and assessment using various questionnaires prior to the examination. The euphoric and sedative statuses were assessed at 30 min and 1 week post-examination. Results The experimental results of a survey of 360 patients who underwent gastric or gastrointestinal endoscopy using propofol showed that the mean Morphine-Benzedrine Group (MBG) score before the procedure and after 30 min of the procedure was 4.23 and 8.67, respectively. The mean Pentobarbital-Chlorpromazine-Alcohol Group (PCAG) score before the procedure and after 30 min of the procedure was 3.24 and 6.22, respectively. These results showed that both MBG and PCAG scores increased significantly after the procedure. Certain factors, such as dreaming, propofol dose, duration of anesthesia, and etomidate dose, were all correlated with MBG both at 30 min and 1 week after the examination. In addition, etomidate had an effect of decreasing MBG scores and increasing PCAG scores both at 30 min and 1 week after the examination. Conclusion Taken together, propofol may elicit euphoria and potentially contribute to propofol addiction. There are several risk factors for the development of propofol addiction, including dreaming, propofol dose, duration of anesthesia, and etomidate dose. These findings suggest that propofol may have a euphoric effect and may have the potential for drug addiction and abuse.
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Affiliation(s)
- Kaixuan Zhao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Ning Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Jingli Yue
- Department of Psychiatry and Clinical Psychology, Peking University Sixth Hospital, Beijing, China
| | - Ying Han
- National Institute of Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
| | - Xiaoxiao Wang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Ning Kang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Tianhao Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- *Correspondence: Xiangyang Guo,
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Mao Xu,
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Involvement of the ERK signaling pathways in the NAc in propofol-seeking behavior induced by cues in rats. Pharmacol Biochem Behav 2022; 219:173447. [PMID: 35970339 DOI: 10.1016/j.pbb.2022.173447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 07/08/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022]
Abstract
Propofol, an intravenous short-acting anesthetic, has the potential to induce craving and relapse. Accumulated evidence demonstrates that extracellular signal-regulated kinase (ERK) plays an essential role in drug reward and relapse. In the previous study, we demonstrated that the ERK signaling pathways in the Nucleus accumbens (NAc) were involved in propofol reward. However, the role of the ERK signaling pathways in propofol relapse is still unknown. We first trained rats to self-administer propofol for 14 days, then evaluated propofol-seeking behavior of relapse induced by a contextual cues and conditioned cues after 14-day withdrawal. Meanwhile, MEK inhibitor U0126 was used to investigate the role of the ERK signal pathways in propofol-seeking behavior induced by contextual cues and conditioned cues. Results showed that the number of active nose-poke responses in propofol-seeking behavior induced by conditioned cues was much higher compared to contextual cues. U0126 (5.0 μg/side, Lateral Ventricle (LV)) pretreatment significantly decreased the active responses induced by conditioned cues, which was associated with a large decline in the expression of p-ERK in the NAc. Moreover, microinjectionofU0126 (2.0 μg/side) in the NAc also attenuated the active responses of propofol-seeking behavior. Additionally, microinjections with U0126 in the LV (5.0 μg/side) or NAc (2.0 μg/side) both failed to alter sucrose self-administration or locomotor activity of rats. Therefore, we conclude that ERK phosphorylation in the NAc maybe involved in propofol relapse.
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Chernova AP, Shormanov VK, Davydkina AE. [Propofol: use, toxicology and assay features]. Sud Med Ekspert 2022; 65:46-51. [PMID: 36196840 DOI: 10.17116/sudmed20226505146] [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] [Indexed: 06/16/2023]
Abstract
The study objective is to review the literature on the use, pharmacological properties, toxicology, and assay methods for intravenous anesthetic propofol. The scope and forms of propofol use, its pharmacokinetics, biotransformation features, which occurs more than 90% in the liver, and side effects associated with propofol use for anesthesia, are addressed. Propofol infusion syndrome (also known as PrIS) and deaths from propofol overdose due to medical errors, abuse, suicide attempts, and homicide are reported. Propofol identification and assay methods based on high-performance liquid chromatography (HPLC), gas chromatography with mass spectrometry (GC-MS), and liquid chromatography (LC) are described. The features of the methods performance are outlined; biological materials (the study objects) are listed: mainly blood and plasma, as well as urine, bile, hair, etc. The relevance of a comprehensive forensic chemical study of propofol is indicated, though there are few forensic studies of propofol.
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Chen BP, Huang XX, Dong DM, Wu H, Zhu TQ, Wang BF. The role of NMDA receptors in rat propofol self-administration. BMC Anesthesiol 2020; 20:149. [PMID: 32539742 PMCID: PMC7294660 DOI: 10.1186/s12871-020-01056-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Propofol is among the most frequently used anesthetic agents, and it has the potential for abuse. The N-methyl-D-aspartate (NMDA) receptors are key mediators neural plasticity, neuronal development, addiction, and neurodegeneration. In the present study, we explored the role of these receptors in the context of rat propofol self-administration. METHODS Sprague-Dawley Rats were trained to self-administer propofol (1.7 mg/kg/infusion) using a fixed-ratio (FR) schedule over the course of 14 sessions (3 h/day). After training, rats were intraperitoneally administered the non-competitive NDMA receptor antagonist MK-801, followed 10 min later by a propofol self-administration session. RESULTS After training, rats successfully underwent acquisition of propofol self-administration, as evidenced by a significant and stable rise in the number of active nose-pokes resulting in propofol administration relative to the number of control inactive nose-pokes (P < 0.01). As compared to control rats, rats that had been injected with 0.2 mg/kg MK-801 exhibited a significantly greater number of propofol infusions (F (3, 28) = 4.372, P < 0.01), whereas infusions were comparable in the groups administered 0.1 mg/kg and 0.4 mg/kg of this compound. In addition, MK-801 failed to alter the numbers of active (F (3, 28) = 1.353, P > 0.05) or inactive (F (3, 28) = 0.047, P > 0.05) responses in these study groups. Animals administered 0.4 mg/kg MK-801 exhibited significantly fewer infusions than animals administered 0.2 mg/kg MK-801 (P = 0.006, P < 0.01). In contrast, however, animals in the 0.4 mg/kg MK-801 group displayed a significant reduction in the number of active nose-poke responses (F (3, 20) = 20.8673, P < 0.01) and the number of sucrose pellets (F (3, 20) = 23.77, P < 0.01), while their locomotor activity was increased (F (3, 20) = 22.812, P < 0.01). CONCLUSION These findings indicate that NMDA receptors may play a role in regulating rat self-administration of propofol.
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Affiliation(s)
- Bei-Ping Chen
- Department of Anesthesiology, Second Affiliated Hospital and Institute of Neuroendocrinology, Wenzhou Medical University, 109 Xueyuan Western Road, Wenzhou City, 325000, Zhejiang Province, China
- Department of Anesthesiology, First Affiliated Hospital of Wenzhou Medical University, Shangcai village, Nanbaixiang town, Ouhai District, Wenzhou City, 325000, Zhejiang Province, China
| | - Xi-Xi Huang
- Department of Anesthesiology, Second Affiliated Hospital and Institute of Neuroendocrinology, Wenzhou Medical University, 109 Xueyuan Western Road, Wenzhou City, 325000, Zhejiang Province, China
| | - Dong-Mei Dong
- Department of Anesthesiology, First Affiliated Hospital of Wenzhou Medical University, Shangcai village, Nanbaixiang town, Ouhai District, Wenzhou City, 325000, Zhejiang Province, China
| | - Hui Wu
- Department of Anesthesiology, First Affiliated Hospital of Wenzhou Medical University, Shangcai village, Nanbaixiang town, Ouhai District, Wenzhou City, 325000, Zhejiang Province, China
| | - Tian-Qi Zhu
- Department of Anesthesiology, First Affiliated Hospital of Wenzhou Medical University, Shangcai village, Nanbaixiang town, Ouhai District, Wenzhou City, 325000, Zhejiang Province, China
| | - Ben-Fu Wang
- Department of Anesthesiology, Second Affiliated Hospital and Institute of Neuroendocrinology, Wenzhou Medical University, 109 Xueyuan Western Road, Wenzhou City, 325000, Zhejiang Province, China.
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Habchi KM, Li MT, Mallard CA, Baker M, Ortega R. The Anesthesiologist's Armamentarium: From Recreation to Medication and Back. J Anesth Hist 2020; 6:17-26. [PMID: 32473762 DOI: 10.1016/j.janh.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/25/2019] [Indexed: 01/20/2023]
Abstract
For millennia, mankind has sought a means of altering consciousness, often aided by naturally occurring elements. Psychotropic substances have been an integral part of spiritual, medicinal, and recreational aspects of life. The origin of anesthesiology stems directly from the use of recreational drugs; early inhaled anesthetics were first used as a means of entertainment. Hence, it is no surprise that many medications in the anesthesiologist's armamentarium are diverted for recreational use. In the 172 years following the first successful public demonstration of ether anesthesia, many drugs with abuse potential have been introduced to the practice of anesthesia. Although anesthesiologists are aware of the abuse potential of these drugs, how these drugs are obtained and used for recreational purposes is worthy of discussion. There are articles describing the historical and recreational use of specific drug classes. However, to the best of our knowledge, this is the first comprehensive review focusing on the breadth of drugs used by anesthesiologists.
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Affiliation(s)
- Karam M Habchi
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118.
| | - Michael T Li
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118.
| | | | | | - Rafael Ortega
- Boston Medical Center, Department of Anesthesiology, 1 Boston Medical Center Place, Boston, MA 02118.
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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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Wang S, Wang X, Lin W, Bao S, Wang B, Wu B, Su Y, Lian Q. Dopamine D 1 Receptor Within Basolateral Amygdala Is Involved in Propofol Relapse Behavior Induced by Cues. Neurochem Res 2018; 43:2393-2403. [PMID: 30357654 DOI: 10.1007/s11064-018-2667-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/12/2018] [Accepted: 10/19/2018] [Indexed: 12/16/2022]
Abstract
Propofol has been proven to be potentially abused by humans and laboratory animals; however, studies that have examined propofol relapse behavior are limited, and its underlying mechanism remains unclear. In this study, we examined whether basolateral amygdala-specific or systematic administration of the dopamine receptor antagonist alters cue-induced propofol-seeking behaviors in a rat model. Male Sprague-Dawley rats first received 14 days of propofol self-administration training, where active nose poke resulted in the delivery of propofol infusion paired with a tone and light cues. After 1-30 days of forced abstinence, the cue-induced propofol-seeking behaviors were tested in the operant chamber. We demonstrated, for the first time, after a few days of withdrawal from intravenous bolus administration of propofol, propofol-related cues could induce robust reinstatement of drug-seeking behavior. Systematic administration of dopamine D1 receptor antagonist (SCH-23390) or dopamine D2 receptor antagonist (spiperone) inhibited propofol relapse behavior induced by drug-related cues. Furthermore, we show that microinfusion of SCH-23390 into basolateral amygdala dose-dependently attenuated cue-induced propofol drug-seeking behavior, whereas infusion of spiperone had no effect on the propofol relapse behavior. Our results reveal the involvement of dopamine receptors within the basolateral amygdala in the cue-induced propofol relapse behavior in rats.
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Affiliation(s)
- Sicong Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China
| | - Xin Wang
- Department of Anesthesiology, Suzhou Municipal Hospital, Suzhou, 234000, China
| | - Wenxuan Lin
- Department of Anesthesiology, Sir Run Run Shaw Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Suhao Bao
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China
| | - Benfu Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China
| | - Binbin Wu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China
| | - Ying Su
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China
| | - Qingquan Lian
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, No.109, Xue-yuan Road(West), Lu-cheng District, Wenzhou, 325027, China.
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Abstract
RATIONALE Anesthesiologists have a well-known increased risk of substance abuse. High-concentration of inhalation anesthetics in exhaled air of operating room personnel is detected. such secondhand exposure produces neurobiological sensitization to the reinforcing effects of inhalation anesthetics. PATIENT CONCERNS An addictive young male anesthesiologist who was long-term abuse with sevoflurane after 4 years occupational exposure. A 28-year-old anesthesiologist on duty was found deeply sleep in the locker room and coved his nose with Gauze with high-concentration of sevoflurane. He was found addiction to sevoflurane second time. Several life-threatening incidents occurred including severe aspiration pneumonia. No other addiction was found in his history before he became severely dependent on sevoflurane. DIAGNOSES A visual analog scale was employed to assess the severity of craving for sevoflurane and the Benzodiazepine Withdrawal Symptom Scale (BWSQ2)-scale was used to assess sevoflurane withdrawal syndrome(WS). INTERVENTIONS First time an opened original sevoflurane container filled with water instead of sevoflurane was handed out for a minute in order to elicit craving and withdrawal symptom in five therapeutic single-sessions. Second time an opened original sevoflurane container filled with sevoflurane instead of water was used as his powerful cur-stimulus and also was handed out for a minute. OUTCOMES After professional therapy and continuous surveillance he was rehabilitation and back to work. However, after three weeks he became addiction to sevoflurane again. He showed very sensitive to sevoflurane and switched to other career. LESSONS This case emphasizes that secondhand exposure to inhalation anesthetics may be dangerous and increase the life-threatening professional risk to anesthesiologists, although identification of the responsible factor remains difficult. However, the safety of operating room staff should be aroused wide-spread social concern.
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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: 48] [Impact Index Per Article: 8.0] [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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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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Wu B, Lin W, Wang H, Abdullah T, Wang B, Su Y, Ge RS, Lian Q. Glucocorticoid receptor in rat nucleus accumbens: Its roles in propofol addictions. Neurosci Lett 2017; 662:115-121. [PMID: 29037790 DOI: 10.1016/j.neulet.2017.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/27/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022]
Abstract
Propofol has been demonstrated as a drug of abuse in humans. Our previous study indicated that dexamethasone, a potent agonist of glucocorticoid receptor (GR), inhibited propofol-maintained rat self-administration behaviors by systematic injection. However, the direct effect of GR in the nucleus accumbens (NAc) on propofol self-administration behavior has not been explored. The propofol-maintained self-administration was established in rats after a successive 3-h daily self-administration of propofol for 14days. On day 15, 30min prior to the last training, rats received one of three doses (0.3, 1.0, or 3.0μg/site) of dexamethasone or vehicle via intra-NAc injection. The number of active nose-poke responses, propofol injections, and inactive nose-poke responses was recorded. Dopamine D1 receptor and c-Fos expressions were detected. Plasma corticosterone level was measured by enzyme-linked immunosorbent assay. Intra-NAc administration of dexamethasone (1.0 and 3.0μg/site) facilitated the active nose-poke responses, which was accompanied by the upregulation of D1 receptor and c-Fos in the NAc. Plasma corticosterone level was not changed in dexamethasone-treated groups. This study provides crucial evidence that GR in the NAc plays an important role in regulating propofol self-administration behaviors in rats, which may be mediated by changes in D1 receptor and c-Fos expressions, and this also needs further examination with GR antagonist in the future.
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Affiliation(s)
- Binbin Wu
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Wenxuan Lin
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Hong Wang
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Taha Abdullah
- Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA
| | - Benfu Wang
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Ying Su
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Ren-Shan Ge
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
| | - Qingquan Lian
- Department of Anesthesiology and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
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Shahzadi A, Uskur T, Akkan AG, Çevreli B, Uzbay T. Effects of propofol on conditioned place preference in male rats: Involvement of nitrergic system. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:167-174. [PMID: 28750179 DOI: 10.1080/00952990.2017.1344681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Drug-induced conditioned place preference (CPP) is linked to the addictive properties of the drug used. The number of studies that have investigated the effects of propofol on CPP is limited. Research findings suggest that nitric oxide (NO) might play an important role in substance use disorders. OBJECTIVES The present study sought to investigate the role of the nitrergic system on the rewarding effects of propofol by using the CPP protocol in rats. METHODS The experiment followed habituation, pre-conditioning, conditioning, and post conditioning sessions. Male Wistar albino rats weighing 240-290 g were divided into eight groups: control (saline), propofol (10, 20, and 40 mg/kg), the NO synthase (NOS) inhibitor NG-nitro-L-arginine methyl ester (L-NAME) alone (30 and 60 mg/kg), and in combination with propofol (30 and 60 mg/kg L-NAME plus 40 mg/kg propofol) (n = 8 for each group). The CPP effects of propofol, L-NAME, saline, and their combinations were evaluated. All the drug and saline administrations were performed by intraperitoneal (ip) injections. RESULTS Propofol (10-40 mg/kg) produced CPP that was statistically significant relative to saline. Propofol-induced CPP was significantly reversed by pretreatment with L-NAME. When administered alone, L-NAME did not produce CPP and also did not produce any significant change on locomotor activity of naïve rats. CONCLUSION Our results suggest that propofol produces CPP effects in rats and that NO-related mechanisms may be responsible for propofol-induced CPP. Thus, propofol might have the potential to be addictive, and this possibility should be considered during clinical applications of this drug.
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Affiliation(s)
- Andleeb Shahzadi
- a Institute of Health Science, Department of Medical Pharmacology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Tuğçe Uskur
- a Institute of Health Science, Department of Medical Pharmacology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - A Gökhan Akkan
- a Institute of Health Science, Department of Medical Pharmacology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Burcu Çevreli
- b Neuropsychopharmacology Application and Research Center (NPARC) , Üsküdar University , Istanbul , Turkey
| | - Tayfun Uzbay
- b Neuropsychopharmacology Application and Research Center (NPARC) , Üsküdar University , Istanbul , Turkey
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Kang H, Kim DK, Choi YS, Yoo YC, Chung HS. Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation. Korean J Anesthesiol 2016; 69:545-554. [PMID: 27924193 PMCID: PMC5133224 DOI: 10.4097/kjae.2016.69.6.545] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 12/18/2022] Open
Abstract
In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.
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Affiliation(s)
- Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Seon Choi
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Chul Yoo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Sik Chung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Non-opioid anesthetic drug abuse among anesthesia care providers: a narrative review. Can J Anaesth 2016; 64:169-184. [PMID: 27470230 DOI: 10.1007/s12630-016-0698-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/19/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The objective of this narrative review is to provide an overview of the problem of non-opioid anesthetic drug abuse among anesthesia care providers (ACPs) and to describe current approaches to screening, therapy, and rehabilitation of ACPs suffering from non-opioid anesthetic drug abuse. SOURCE We first performed a search of all literature available on PubMed prior to April 11, 2016. The search was limited to articles published in Spanish and English, and the following key words were used: anesthesiology, anesthesia personnel, AND substance-related disorders. We also searched Ovid MEDLINE® databases from 1946-April 11, 2016 using the following search terms: anesthesiology OR anesthesia, OR nurse anesthetist OR anesthesia care provider OR perioperative nursing AND substance-related disorders. PRINCIPAL FINDINGS Despite an increased awareness of drug abuse among ACPs and improvements in preventive measures, the problem of non-opioid anesthetic drug abuse remains significant. While opioids are the most commonly abused anesthesia medications among ACPs, the abuse of non-opioid anesthetics is a significant cause of morbidity, mortality, and professional demise. CONCLUSION Early detection, effective therapy, and long-term follow-up help ACPs cope more effectively with the problem and, when possible, resume their professional activities. There is insufficient evidence to determine the ability of ACPs to return safely to anesthesia practice after rehabilitation, though awareness of the issue and ongoing treatment are necessary to minimize patient risk from potentially related clinical errors.
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Köroğlu G, Tezcan AH. A Case Report of the First Propofol Addiction in Turkey. Turk J Anaesthesiol Reanim 2016; 43:434-6. [PMID: 27366543 DOI: 10.5152/tjar.2015.54872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/25/2015] [Indexed: 11/22/2022] Open
Abstract
Propofol is a potent anaesthetic drug and also an effective sedative agent. Also, propofol may be used for non-anaesthetic purposes such as the treatment of seizures, migraine and tension headache in clinical practice. It has been abused, particularly among healthcare providers with high mortality rate. This report presents the case of a propofol-dependent patient who was an emergency medicine doctor with no difficulties in obtaining the drug. He himself visited our clinic for the treatment of propofol dependence. We started the patient's treatment with pharmacotherapeutic medicines and individual psychotherapy. Fourteen days after starting the therapy, the patient was discharged from hospital on his own will and he did not attend the follow-up visits in the outpatient clinic. Then, we were informed of his death, which was suspected to have occurred owing to drug intoxication in the hospital in which he worked. Nevertheless, the reason of death was important; the importance of this case report is to provide information regarding the drug's dependence profile. This is the first case report indicating propofol dependence in Turkey. Because of its easy access, rapid onset time and short duration of action, propofol dependence is increasing. We think that adding propofol to the controlled drug list and improving the knowledge of the clinicians regarding its abuse potential may limit the dependence cases.
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Affiliation(s)
- Gültürk Köroğlu
- Department of Pschiatry, Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatry, Neurology and Neurosurgery, İstanbul, Turkey
| | - Aysu Hayriye Tezcan
- Clinic of Anaesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
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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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Kwak JH, Kim HK, Choe S, In S, Pyo JS. Determination of propofol glucuronide from hair sample by using mixed mode anion exchange cartridge and liquid chromatography tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1015-1016:209-213. [DOI: 10.1016/j.jchromb.2016.01.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/26/2016] [Accepted: 01/30/2016] [Indexed: 11/25/2022]
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Kim EJ, Kim SH, Hyun YJ, Noh YK, Jung HS, Han SY, Park CH, Choi BM, Noh GJ. Clinical and psychological characteristics of propofol abusers in Korea: a survey of propofol abuse in 38, non-healthcare professionals. Korean J Anesthesiol 2015; 68:586-93. [PMID: 26634083 PMCID: PMC4667145 DOI: 10.4097/kjae.2015.68.6.586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 07/22/2015] [Accepted: 08/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to investigate the characteristics of propofol abuse based on the results of a survey analysis of abusers among non-healthcare professionals in Korea. METHODS Thirty-eight propofol abusers were questioned between October and December 2010, and were enrolled and voluntarily participated in a structured survey consisting of an interview and completing a previously prepared questionnaire. The questionnaire was divided into three distinct parts: part 1 dealt with the history of propofol abuse; part 2 highlighted the problems caused by propofol abuse; and part 3 enquired regarding demographics of abusers. RESULTS Thirty-one (81.6%) of the 38 interviewees abused propofol for more than one year. During the last 12 months, 34 (89.0%) received propofol at two or three times a week. The minimum and maximum amounts of propofol (median, range) administered each time were 500 (100, 1000) and 2000 (500, 4000) mg, respectively. Stress relief and the maintenance of a sense of well-being were quoted the most important reasons for the first-time administration of propofol and its subsequent abuse, respectively. The majority of abusers (36.0, 97.3%) reported a sense of pleasure or euphoria at the time of their propofol injection. Withdrawal symptoms occurred in five abusers (13.2%). Thirteen (36.1%) reported disruptions in their work life. None of the respondents had previously admitted to and or reported abuse of any other controlled substances. CONCLUSIONS These results provided reference data for the regulation of propofol in Korea as a controlled substance and may also be of interest to international agencies in other countries.
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Affiliation(s)
- Eun-Jung Kim
- Korea Ministry of Food and Drug Safety, Cheongju, Korea
| | - Seon-Hwa Kim
- Korea Ministry of Food and Drug Safety, Cheongju, Korea
| | - Yang-Jin Hyun
- Korea Ministry of Food and Drug Safety, Cheongju, Korea
| | | | - Ho-Sang Jung
- Korea Ministry of Food and Drug Safety, Cheongju, Korea
| | | | - Chan-Hye Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Locomotor stimulation by acute propofol administration in rats: Role of the nitrergic system. Pharmacol Rep 2015; 67:980-5. [PMID: 26398394 DOI: 10.1016/j.pharep.2015.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 02/21/2015] [Accepted: 03/05/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The addictive potential of propofol has been scientifically discussed. Drugs' psychostimulant properties that can be assessed via measurements of locomotor activity are linked to their addictive properties. No studies that have investigated the effects of propofol on locomotor activity have been reported to date. The present study sought to investigate the effects and possible mechanisms of action of propofol on locomotor activity in rats. METHODS Adult male albino Wistar rats (250-330g) were used as subjects. The locomotor activities of the rats were recorded for 30min immediately following intraperitoneal administration of propofol (20 and 40mg/kg), saline or vehicle (n=8 for each group). NG-nitro arginine methyl ester (l-NAME, 15-60mg/kg), a nitric oxide (NO) synthase inhibitor, and haloperidol (0.125-5mg/kg), a non-specific dopamine receptor antagonist, were also administered to other groups of rats 30min prior to the propofol (40mg/kg) injections, and locomotor activity was recorded for 30min immediately after propofol administration (n=8 for each group). RESULTS Propofol produced significant increases in the locomotor activities of the rats in the first 5min of the observation period [F(2,21)=9.052; p<0.001]. l-NAME [F(4,35)=3.112; p=0.02] but not haloperidol [F(4,35)=2.440; p=0.067] pretreatment blocked the propofol-induced locomotor hyperactivity. l-NAME did not cause any significant change in locomotor activity in naïve rats [F(2,21)=0.569; p=0.57]. CONCLUSIONS Our results suggest that propofol might cause a short-term induction of locomotor activity in rats and that this effect might be related to nitrergic but not dopaminergic mechanisms.
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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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Shin JY, Lee SH, Shin SM, Kim MH, Park SG, Park BJ. Prescribing patterns of the four most commonly used sedatives in endoscopic examination in Korea: propofol, midazolam, diazepam, and lorazepam. Regul Toxicol Pharmacol 2015; 71:565-70. [PMID: 25659208 DOI: 10.1016/j.yrtph.2015.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 12/20/2022]
Abstract
As the sedative use increases due to the effectiveness and relatively safe profile, the abuse potential is also increasing. This study was conducted to examine the usage of four sedative agents in endoscopic examination and to compare the propofol use with the other three sedatives. Using National Health Insurance claims data from 2008 to 2012, we identified the number of cases of conscious sedation during endoscopy using one or more of the following agents: propofol, midazolam, diazepam, and lorazepam. The general characteristics of patients and medical service providers were analyzed, and the regional and annual distributions of frequency of use were compared. We also identified patient cases with excessive number of endoscopic examinations. Among the total of 3,156,231 sedatives users, midazolam was the most commonly used agent (n=2,845,250, 90.1%). However, the largest increase in patient number, which increased from 11,410 in 2008 to 28,170 in 2012, was observed with propofol. While the majority of patients received an annual endoscopy, we identified several suspected abuse cases of patients receiving endoscopies repetitively as many as 114 times in five years. The rise of sedative use in endoscopic examinations and several patient cases of repeated sedative administration suggest a potential risk for abuse. Medical service providers should be cautious when using sedatives and carefully review each patient's medical history prior to the procedure.
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Affiliation(s)
- Ju-Young Shin
- Korea Institute of Drug Safety and Risk Management (KIDS), 136 Changgyeonggung-ro, Jongno-gu, Seoul 110-750, Republic of Korea
| | - Shin Haeng Lee
- Korea Institute of Drug Safety and Risk Management (KIDS), 136 Changgyeonggung-ro, Jongno-gu, Seoul 110-750, Republic of Korea
| | - Sun Mi Shin
- Korea Institute of Drug Safety and Risk Management (KIDS), 136 Changgyeonggung-ro, Jongno-gu, Seoul 110-750, Republic of Korea
| | - Mi Hee Kim
- Korea Institute of Drug Safety and Risk Management (KIDS), 136 Changgyeonggung-ro, Jongno-gu, Seoul 110-750, Republic of Korea
| | - Sung Geon Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyeong-dong, Jongno-gu, Seoul 110-746, Republic of Korea
| | - Byung-Joo Park
- Korea Institute of Drug Safety and Risk Management (KIDS), 136 Changgyeonggung-ro, Jongno-gu, Seoul 110-750, Republic of Korea; Department of Preventive Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Republic of Korea.
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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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Affiliation(s)
- Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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30
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Affiliation(s)
- Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Affiliation(s)
- Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Abstract
As a widely used intravenous short-acting anesthetic, propofol is recently indicated by clinical and animal studies for its abuse potential, but the mechanism underlying propofol abuse is largely unknown. This study examined the contribution of dopamine receptor subtype (D1 and D2 receptors) and neuroanatomical locus (i.e. nuclear accumbens) in the maintenance of propofol self-administration in rats. After the acquisition and maintenance of self-administration of propofol (1.7 mg/kg/infusion) under a fixed ratio (FR1) schedule of reinforcement over 14 days, rats were treated by either intraperitoneal injection or intra-nucleus accumbens (NAc) injection of D1 receptor antagonist (SCH23390) or D2 receptor antagonists (spiperone and eticlopride) 10 min prior to the subsequent propofol self-administration. We demonstrated (i) systemic administration of SCH23390 (10, 30, 100 μg/kg, i.p.) dose-dependently decreased the rate of propofol-maintained self-administration, suggesting a critical role of the D1 receptor in mediating propofol self-administration; (ii) the blockade of the propofol self-administration by SCH23390 was specific since spiperone and eticlopride did not affect propofol self-administration and SCH23390 at these doses did not affect food-maintained responding under an FR5 schedule; (iii) intra-accumbenal injection of SCH23390 (2.5 μg/site) but not eticopride (3.0 μg/site) attenuated the propofol self-administration, localizing nuclear accumbal D1 receptors as a critical locus in the reinforcement of propofol. Together, these findings provide the first direct evidence that D1 receptors in nuclear accumbens play an important role in the maintenance of propofol self-administration.
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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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Bonnet U, Scherbaum N. Craving Dominates Propofol Addiction of an Affected Physician. J Psychoactive Drugs 2012; 44:186-90. [DOI: 10.1080/02791072.2012.684635] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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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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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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Lee MS, Ahn W. Designation of a new drug as a controlled substance. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2011. [DOI: 10.5124/jkma.2011.54.2.189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Mi Soon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Wonsik Ahn
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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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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Merlo LJ, Goldberger BA, Kolodner D, Fitzgerald K, Gold MS. Fentanyl and Propofol Exposure in the Operating Room: Sensitization Hypotheses and Further Data. J Addict Dis 2008; 27:67-76. [DOI: 10.1080/10550880802122661] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Bruce A. Goldberger
- b Departments of Pathology, Immunology and Laboratory Medicine and Psychiatry , Gainesville, FL
| | - Dara Kolodner
- c University of Florida College of Medicine , Gainesville, FL
| | | | - Mark S. Gold
- d Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health and Family Medicine , McKnight Brain Institute, University of Florida College of Medicine , Gainesville, FL
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Merlo LJ, Gold MS. Prescription opioid abuse and dependence among physicians: hypotheses and treatment. Harv Rev Psychiatry 2008; 16:181-94. [PMID: 18569039 DOI: 10.1080/10673220802160316] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Physician impairment is a serious public health issue affecting physicians as well as their families, colleagues, and patients. Though physicians generally display healthier habits than members of the general population, overall rates of impairment are similar among both groups, and prescription drug abuse (including prescription opioids) is particularly problematic among physicians. The current review focuses mainly on prescription opioid abuse and dependence among physicians. It includes a brief history of early physician experiences with anesthetic and analgesic agents, and explores several hypotheses regarding the etiology of prescription opioid abuse and dependence among physicians. Barriers to identification and to treatment entry among physicians are discussed. In addition, methods of assessment and successful treatment in specialized impaired physician programs are described. Medical and psychosocial interventions, 12-step involvement, and extensive use of evaluations are highlighted. Attention is paid to typical follow-up contracting and monitoring strategies, as well as strategies for prevention. Given the extremely positive outcomes demonstrated by specialized programs for treating impaired professionals, it is recommended that their methods be disseminated and utilized in treatment centers for the general public.
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Affiliation(s)
- Lisa J Merlo
- Department of Psychiatry, University of Florida, Gainesville, FL 32610-0183, USA.
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Bonnet U, Harkener J, Scherbaum N. A Case Report of Propofol Dependence in a Physician. J Psychoactive Drugs 2008; 40:215-7. [DOI: 10.1080/02791072.2008.10400634] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Roussin A, Montastruc JL, Lapeyre-Mestre M. Pharmacological and clinical evidences on the potential for abuse and dependence of propofol: a review of the literature. Fundam Clin Pharmacol 2007; 21:459-66. [PMID: 17868199 DOI: 10.1111/j.1472-8206.2007.00497.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Propofol (2,6-diisopropylphenol) is an intravenous short-acting anaesthetic widely used for inducing and maintaining anaesthesia. Propofol is also being increasingly used for sedation. Beside medical use, propofol is abused for recreational purpose, mostly in medical professionals who are not informed of the risk of dependence to this compound. The aim of this review was to provide an overview of molecular, animal and clinical pharmacological data of the literature evidencing the potential for abuse and dependence of propofol.
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Affiliation(s)
- Anne Roussin
- Service de Pharmacologie Clinique, Centre d'Evaluation et d'Information sur la Pharmacodépendance de Toulouse, EA 3696, Université Paul Sabatier, Faculté de Médecine, 31000 Toulouse, France.
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Wischmeyer PE, Johnson BR, Wilson JE, Dingmann C, Bachman HM, Roller E, Tran ZV, Henthorn TK. A Survey of Propofol Abuse in Academic Anesthesia Programs. Anesth Analg 2007; 105:1066-71, table of contents. [PMID: 17898389 DOI: 10.1213/01.ane.0000270215.86253.30] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although propofol has not traditionally been considered a drug of abuse, subanesthetic doses may have an abuse potential. We used this survey to assess prevalence and outcome of propofol abuse in academic anesthesiology programs. METHODS E-mail surveys were sent to the 126 academic anesthesiology training programs in the United States. RESULTS The survey response rate was 100%. One or more incidents of propofol abuse or diversion in the past 10 yr were reported by 18% of departments. The observed incidence of propofol abuse was 10 per 10,000 anesthesia providers per decade, a fivefold increase from previous surveys of propofol abuse (P = 0.005). Of the 25 reported individuals abusing propofol, 7 died as a result of the propofol abuse (28%), 6 of whom were residents. There was no established system to control or monitor propofol as is done with opioids at 71% of programs. There was an association between lack of control of propofol (e.g., pharmacy accounting) at the time of abuse and incidence of abuse at the program (P = 0.048). CONCLUSIONS Propofol abuse in academic anesthesiology likely has increased over the last 10 yr. Much of the mortality is in residents. Most programs have no pharmacy accounting or control of propofol stocks. This may be of concern, given that all programs reporting deaths from propofol abuse were centers in which there was no pharmacy accounting for the drug.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology, University of Colorado, Denver, Colorado, USA.
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Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis M. Lethal self administration of propofol (Diprivan). A case report and review of the literature. Forensic Sci Int 2007; 167:56-8. [PMID: 16431058 DOI: 10.1016/j.forsciint.2005.12.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Revised: 12/21/2005] [Accepted: 12/22/2005] [Indexed: 11/22/2022]
Abstract
The death of a female anaesthesiologist is reported. Although the situation at the scene indicated propofol overdose-related death, self-administration of such high doses of propofol was unlikely, given the pharmacological properties of this drug. The analysis of the situation at the scene and the toxicological analysis in which the blood and liver propofol concentrations were 2.40microg/ml and 0.56microg/g, respectively, supported the conclusion that the death was a consequence of propofol self-administration at therapeutic doses from a person who used the drug on chronic basis seeking to its euphoric effects. However, because the toxic concentrations of propofol in non-intubated patients may be different from those intubated and fully supported in the operating room or in the intensive care unit, a mere interpretation of the blood and tissue concentrations of propofol in the toxicological analysis can confirm the drug intake but it may be of limited diagnostic significance without taking into account this difference.
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Affiliation(s)
- Elena F Kranioti
- Department of Forensic Sciences, Medical School, University of Crete 71110, Heraklion, Greece
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