Diprivan (Propofol) Sequestration

During Cardiopulmonary Bypass

Gerard J Myers CCP , Cheri Voorhees BAH(ASCP)SH ,
Bob Eke BA and Ren Ren Johnston

Diprivan (Propofol)
Intravenous hypnotic agent that is estimated to be
used in 1 of every 2 operations undertaken
worldwide
(making it the world`s leading I.V general anesthetic agent)

White oil in water emulsion with a pH 6.0-8.5. Oil

made of soybean (100 mg/ml), glycerol (22.5
mg/ml) and egg phospholipid (12.0 mg/ml). Also
contains disodium edetate and sodium hydroxide.

Propofol

Induction (1.5-3.0 mg/kg)

Maintenance 2.0-6.0 mg/kg/hr)
Highly fat soluble and widely distributed
throughout body and tissues
Rapidly acting (< 60 sec.)
Metabolized by the liver/excreted in urine
97-98% protein bound
Unbound fraction is < 3-4%
Renal disease, liver dysfunction and
hypothermia can alter drug pharmacokenetics

Extraneous Propofol Concerns ??

The styrene based plastic luer lock collar was shattered by what
was believed to be the constant infusion of the Propofol
emulsion. Exact reason was not fully understood.
(Rutherford, JS et al: Effect of Propofol on plastic components Anesth 2005, 60:1046)

Plastic upper casing of two syringe pumps (used exclusively for

propofol infusions) developed multiple cracks. Pump
manufacturer stated Propofol was originally developed as
plasticizer and not an anesthetic.
(Fujise, K et al: Damage to a syringe pump by Propofol Anesth 2005, 60:1045)

Sequestration of Propofol in an Extracorporeal Circuit

Methods: First in vitro study using 4 Uncoated Cobe CML oxygenators
with uncoated tubing and arterial filters. 2000 ml Hartmanns solution/ 2
units PRBC. Hct was 21-25%. Blood flows 5 lpm at 37oC. Propofol 10
mg was added to perfusate to achieve concentration of 2-4 mcg/ml.
Samples taken 18 times over 4 hour period. Total propofol
measurements were done using HPLC method.

Conclusion: They found that the total propofol levels at the start of CPB
fell by an amount greater than 50% in 15 minutes. This was more than
the decrease predicted by hemodilution alone, and therefore surface
sequestration was an important factor. Total propofol continued to
decrease during the course of the study.

Tarr, TJ and Kent, AP : J Cardiothoracic Anes 1989 3(1):75

Propofol sequestration within the extracorporeal circuit

Methods: Study consisted of in vitro and in vivo groups. In vitro group
consisted of three uncoated membranes with uncoated silicone and PVC
tubings, with no arterial filter. Total prime volume was 2000 mls (Ringers
and 2 units whole blood). Pump flow was 4 lpm at 28oC for 120 minutes.
Propofol 4 mg was infused to achieve a level of 2 mcg/ml and Total
Propofol was measured using HPLC. In vivo group consisted of 14 patients
undergoing CPB and Propofol infusion was between 3-10 mg/kg/hr
throughout cases.

Results: After infusion, in vitro total Propofol decreased by 35% after 5

minutes and 75% after 120 minutes of circulation. Similar decreases in total
propofol levels were found with the in vivo study group. Hemodilution
contributes to decreases in total propofol, but continued decrease due to
sequestration.
Hynynen M et al: Can J Anaesth 1994; 41(7):583-8

Coating of the extracorporeal circuit with heparin does

not prevent sequestration of propofol in vitro
Measured Total Propofol in 4 in vitro oxygenator/circuit
combinations without arterial filters
(two uncoated and two Heparin coated)
4 mg/2000 ml Total Propofol remaining after 60 minutes
Uncoated 30% Heparin coated 26%

40 mg/2000 ml Total Propofol remaining after 60 minutes

Uncoated 34% Heparin coated 39.5%

356 mg/2000 ml Total Propofol remaining after 60 minutes

Uncoated 49% Heparin coated 50%
Hammaren E et al Br J Anaesth 1999; 82:38-40

Total Propofol vs Unbound Propofol

Measurement of Total drug concentrations in plasma during
CPB may fail to elucidate the true picture of changes in
drug effect unless measurement of the Unbound
concentration is also reported
The ability of a drug to produce its effect on the body
depends on the ability of the Unbound drug to reach its
receptor and bind with that receptor to transduce its
signal

The effects of cardiopulmonary bypass on total and

unbound plasma concentrations of propofol
Methods: Twelve patients undergoing cardiac surgery were given 1
mg/kg Propofol preop followed by 3 mg/kg/hr intraop. Membrane
oxygenation with a prime that consisted of Plasmalyte and Haemaccel
and temp maintained at 30oC. Total propofol measured by HPLC
method and Unbound propofol measured by ultrafiltration.

Conclusion: At the start of CPB, total propofol levels dropped by >58%

but after 6 minutes, the unbound propofol levels actually increased from
1.97 0.36 ng/ml to 2.18 0.43 ng/ml (9.7%). They concluded that total
propofol decreases were consistent with hemodilution and sequestration.
Unbound increases were believed to be due to hemodilution of protein
and displacement of bound drug by protein binding site competition
from plasma free fatty acids
Dawson PJ et al: J Cardiothorac Vasc Anesth 1997 Aug;11(5):556-61

Changes in the effect of propofol in response to

altered plasma protein binding during normothermic
cardiopulmonary bypass
Methods: Randomized study included 30 patients undergoing CPB for
cardiac surgery. Prime consisted of 1600 mls Ringers with flows 2.4
l/m2/min at temps >35oC. Total propofol measured by HPLC and unbound
propofol measured by equilibrium dialysis. Measurements done at intervals
up to 60 minutes after start of CPB.

Conclusion: Initial drop in total propofol levels at the start of CPB, but
returned to prebypass values after 30 minutes. They concluded that
variations in total propofol levels were consistent with the effects of
hemodilution of albumin/erythrocytes and volume distribution. There was
also a two fold increase in the unbound propofol concentration during CPB.
Takizawa E et al: Brit J Anaesth 2006; 96(2):179-85

Propofol adsorption has been studied on

uncoated and heparin coated circuitry
Propofol is a lipid emulsion
Is Propofol adsorption reduced by
Phosphorylcholine (phospholipid) coated
surfaces during extracorporeal circulation?

Does Propofol affect oxygenation and CO2

removal in PC coated membranes?

Phosphorylcholine
(PC, PHISIO, Mimesys)

Phospholipid based synthetic polymer

Industry only biomimetic (mimics endothelial
surfaces) coating made of both positive/negative PC
head groups (zwitterionic)
Hydrophilic head groups adsorb water molecules and
render surface nonthrombogenic or biologically inert
to native circulation
Used on extracorporeal blood surfaces, coronary
stents, urological devices and tympanostomy tubes

Study Circuit

3 hardshell PrimO2X oxygenators

without filters
3 hardshell PrimO2X oxygenators with
Dideco D732 (27 ) arterial filters
Lengths of circuits identical all
experiments
All oxygenators/circuits were coated
with Phosphorylcholine

Circuit Prime
1250 ml fresh bovine blood/750 ml
normal saline (total 2000 mls)
Mean hematocrit of 41 1.0%
Mean Total protein 3.7 0.5g/dl
Mean Lipids 81.6 19.0mg/dl
Mean Temperature 34 degrees C
Mean Glucose 217 mg/dl

Management
Mean ACT >1500 seconds
4.5 LPM Blood flow
Line pressure maintained 150 5
mmHg
Total Propofol and Unbound
Propofol

Study Protocol
Propofol 1% (10mg/ml)

1st stage - Low Dose Propofol 4 mg (2.0 mcg/ml)

21 ml sample taken 20 min, 40 min and 60 min
2nd stage High Dose Propofol 40 mg (22.7 mcg/ml)
21 ml sample taken 20 min, 40 min and 60 min

3rd stage Extreme Dose Propofol 356 mg(214 mcg/ml)

21 ml sample taken 20 min, 40 min and 60 min

Sample Preparation
Collected samples were placed in 10 ml blood
tubes containing 143 units Sodium Heparin
and centrifuged for 10 minutes at 3000 RPM
and 4oC within 5 minutes of collection.
Separated plasma was then placed in Low
Temperature Freezer Vials tubes and stored at
70 degrees C until assayed.

High Performance Liquid Chromatography

Sample Assay
Both Total and Unbound Propofol testing was done by an
independent GMP/GLP laboratory in Colorado
All samples were analyzed on an Applied Biosystems 4000
QTrap tandem mass spectrometer equipped with two
Shimadzu LC-20AD pumps and a Leap HTC PAL
autosampler. Chromatography was performed on a 50 mm x
4.6 mm Sunfire C18 column

Unbound Propofol was determined through diffusion, by adding

500 L of plasma to a Nanosep 3,000 daltons centrifugal filter.
The plasma was centrifuged for 10 minutes at 13,000 rpm

Total Propofol
No Arterial Filter
(2 mcg/ml)
2.5
2

2
1.7

mcg/ml

1.5
0.91

1.11

1
0.87

0.5

0.52

0.59

0.36
0.19

0.02

Calc

20

40

60

minutes

Oxy 4

Oxy 5

Oxy 6

Total Propofol
With Arterial Filter
(2 mcg/ml)
2.5
2

2
1.66

mcg/ml

1.5
1

1
0.44

0.41

0.5
0.36

0.33
0.28

0.4

0
Calc

20

40

60

minutes

Oxy 1

Oxy 2

Oxy 3

Total Propofol
No Arterial Filter
(22.7 mcg/ml)
25

mcg/ml

20

22.7

22.7

22.7

15

12.7
11.5

10.5

11.5

10

9.78

11.3

9.79

10.1

9.69

5
0
Calc

20

40

60

minutes

Oxy 4

Oxy 5

Oxy 6

Total Propofol
With Arterial Filter
(22.7 mcg/ml)
25
20

22.7

22.7

22.7

mcg/ml

15.1
13.5

15

11.1
11

11.9

10

11.4

11.1

11.6
9.4

5
0
Calc

20

40

60

minutes

Oxy 1

Oxy 2

Oxy 3

Total Propofol
No Arterial Filter
(214 mcg/ml)
250

mcg/ml

200

214

214

214
214

153

150

150

136

132
132

100

121

117

119

50
0
Calc

20

40

60

minutes

Oxy 4

Oxy 5

Oxy 6

Total Propofol
With Arterial Filter
(214 mcg/ml)
250
214

200

214
214

mcg/ml

155

150

150
136

150

131
132

100

122
119

108

50
0
Calc

20

40

60

minutes

Oxy 1

Oxy 2

Oxy 3

Low Dose (2 mcg/ml)

Percent of Total Propofol remaining in blood
(Bound + Unbound)

20 minutes
%

40 minutes
%

60 minutes
%

No Arterial
Filter

45.0 14.5

22 12.1

47 34

Arterial
Filter

19.9 3.2

21 27.3

16.3 64

High Dose (22.7 mcg/ml)

Percent of Total Propofol remaining in blood
(Bound + Unbound)

20 minutes
%

40 minutes
%

60 minutes
%

No Arterial
Filter

50.7 5.1

44.5 6.2

43.1 3.1

Arterial
Filter

52.4 7.1

51.1 14.1

48.5 7.3

Extreme Dose (214 mcg/ml)

Percent of Total Propofol remaining in blood
(Bound + Unbound)

20 minutes
%

40 minutes
%

60 minutes
%

No Arterial
Filter

70.1 29.1

61.7 9.8

56.5 6.9

Arterial
Filter

70.1 9.8

61.2 8.8

57.0 6.5

Unbound Propofol
Percent of Total

0.7
P
e
r
c
e
n
t

0.66

0.61

0.6
0.5

0.52

0.46
0.43
0.35

0.4

0.34

0.31

0.3
0.17

0.2
0.1
0
20

40

60

Minutes
2.0 mcg/ml

22.7 mcg/ml

214 mcg/ml

Adsorption Conclusion
Coating of extracorporeal surfaces with
Phosphorylcholine does not prevent
the adsorption of Propofol under in
vitro conditions

Does Propofol alter the gas exchange in

membrane oxygenators?
In vitro (n=10) and in vivo (n=10) studies into gas exchange and
oxygenation during clinically relevant doses of Propofol during
extracorporeal circulation.
In vivo study involved BGA 30 min after infusion of 125 mg
Propofol on bypass. In vitro study used crystalloid primed
oxygenators, with an FiO2 of 100% and a gas:blood ratio of 1:1.
In vitro BGA were collected 30 sec. after 100 mg bolus of
Propofol and 30 sec. after bolus dose of 200 mg Propofol.

In both arms, they concluded that at clinically relevant doses,

Propofol does not adversely affect gas exchange or oxygenation.
Nader-Djalal, N et al: Ann Thorac Surg 1998;66:298-99

Blood Gas Analysis

Radiometer ABL500 Blood Gas analyzer
BGs done at 20, 40 and 60 minutes after each
Propofol injection on each oxygenator studied
FiO2 was 21% and flow was 3.1 Lpm Air with
0.4 Lpm CO2 throughout experiment
Mean pH 7.38, PCO2 41.8, PO2 119,BE -0.8

Oxygen
After 180 Minutes of Circulation
120
PO2 mmHg

119.5

118.7

119
118

118.2

p=ns

117

117.3

116
Baseline
100

602 min

120 3min

180 min
4

Carbon Dioxide
After 180 Minutes of Circulation
43
PCO2 mmHg

42.5
42
41.6

41

41.7
p=ns

40.8
40
39
Baseline
1

602 min

120
3 min

180
4 min

Gas Exchange Conclusion

After 180 minutes of circulation and
exposure to 400 mg Propofol, there is
no in vitro evidence to suggest that
Propofol interferes with oxygenation
or carbon dioxide removal in the PC
coated PrimO2X oxygenator