Megan Feeney, BCCCP, PharmD
Boston Medical Center
Boston, Massachusetts
Disclosure information not submitted.
Katrina Steiling, MD, MSc
Pulmonary/Critical Care Physician
Boston University School of Medicine, United States
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Title: Successful Management of Propofol Dependence with Phenobarbital in an Adult Patient with COVID-19
Case Report Body:
Introduction: Coronavirus Disease 2019 (COVID-19) brought unique challenges to the management of pain and agitation in mechanically ventilated patients. High sedation requirements for prolonged durations were often needed to achieve ventilator synchrony. Currently no guidelines address sedation management in this population or the withdrawal syndromes that may occur as a result of these practices.
Description: A 64 year old male with hypertension was transferred from an outside hospital for the management of acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia. He arrived intubated and was initiated on fentanyl, propofol, and cisatracurium. Paralysis was stopped after 48 hours but high doses of fentanyl and propofol were continued with periods of concomitant midazolam and dexmedetomidine over the next 12 days. Upon improvement in lung function, attempts to wean sedation all failed due to a paradoxical hemodynamic response observed with the down titration of propofol. Decreases of as little as 5 mcg/kg/min resulted in tachypnea, tachycardia, and hypertension with resolution only upon return to the previous dose. Adjunctive quetiapine, valproic acid, and clonidine were tried without success. Due to similarity in presentation to alcohol withdrawal, phenobarbital was trialed for possible propofol withdrawal. Phenobarbital 130 mg (approximately 2 mg/kg) was administered with a plan for propofol rate decreases of 2.5 mcg/kg/min as tolerated. Within 2 hours of the first dose, propofol was decreased from 45 mcg/kg/min to 35 mcg/kg/min without any corresponding hemodynamic response. Within 12 hours the rate had decreased to 25 mcg/kg/min. Over the next 36 hours, the patient received 5 more doses of phenobarbital 130 mg at 8 to 12 hour intervals until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission.
Discussion: Extended courses of deep sedation are often required in mechanically ventilated COVID-19 patients and may result in withdrawal phenomena not previously seen with standard sedation practices. There is limited information concerning a propofol withdrawal syndrome in the literature and our experience describes the successful use of phenobarbital to facilitate weaning after prolonged exposure.