Archives of Medicine and Health Sciences

LETTERS TO THE EDITOR
Year
: 2019  |  Volume : 7  |  Issue : 2  |  Page : 321--322

Propofol-compatible plastics or plastic-compatible propofol?


Varun Suresh 
 Department of Anaesthesiology, Government T D Medical College, Alappuzha, Kerala, India

Correspondence Address:
Varun Suresh
Department of Anaesthesiology, Government T D Medical College, Alappuzha, Kerala
India




How to cite this article:
Suresh V. Propofol-compatible plastics or plastic-compatible propofol?.Arch Med Health Sci 2019;7:321-322


How to cite this URL:
Suresh V. Propofol-compatible plastics or plastic-compatible propofol?. Arch Med Health Sci [serial online] 2019 [cited 2020 May 25 ];7:321-322
Available from: http://www.amhsjournal.org/text.asp?2019/7/2/321/273042


Full Text



Sir,

Propofol is a widely used intravenous agent in anesthesia and critical care practice. Apart from anesthetic utility, propofol provides considerable cerebral protection and antiepileptic activity by reducing cerebral metabolism and intracranial pressure.

Several cases of iatrogenic infections have been reported with contaminated propofol in both the outpatient and inpatient settings, as well as in both surgical and nonsurgical patients.[1],[2] The preservative-lipid emulsion of propofol supports microbial growth, which raises the risk of infection. Intrinsic and extrinsic microbiological contamination of propofol-lipid emulsions occurs – the former occurs due to environmental exposure at the point of manufacture and the latter occurs after opening the vial. Extrinsic contamination is the most frequent. Since its introduction, multiple antimicrobial agents have been added to propofol such as ethylenediaminetetraacetic acid (EDTA), sodium metabisulfite, lidocaine, and benzyl alcohol; however, the risk of extrinsic contamination remains the same. Water-soluble preparation of fospropofol disodium reduces the risk of infection, but due to the prolonged onset of action compared to propofol, this drug though Food and Drug Administration approved has not gained much appreciation and widespread use. The horizontal transmission of pathogens in anesthesia begins with the breach of handling precautions by anesthesia providers of devices or drugs. Frequently neglected precautions during the induction and maintenance of anesthesia include hand hygiene and protection against incidental propofol contact with the environment.

Zorrilla-Vaca et al.,[3] in their epidemiologic analysis of propofol-related infections reported worldwide from 1989 to 2014, found infective microorganisms to be Staphylococcus aureus, Serratia marcescens, Candida albicans, and hepatitis C and hepatitis B viruses in the descending order. All the reports of propofol-related infections were from North America, Western Europe, and Australia, likely as a consequence of deficiencies of surveillance programs and poor data acquisition regarding the frequency of contaminated propofol in other regions.

Propofol dissolves and weakens some plastic components by nature of its design. It is stated that polycarbonate in medical-grade plastic interacts with propofol, resulting in leaks of components. Most of the medical-grade plastics used in three-way stopcocks, intravenous infusion sets, and syringes in use now are incompatible with propofol infusions. Some manufacturers of three-way stopcocks and syringes add a note of caution against the use of lipid solutions [Figure 1]. There are multiple reports of damage to plastic components of three-way stopcocks and infusion sets with the use of propofol.[4] Leaks along infusion line of propofol have been a frequent but often ignored occurrence in anesthesia practice. Such damage to plastic components is attributed to lipid vehicle of propofol; however, clear formulation of propofol has also been reported to produce cracks in three-way stopcocks.[5] Such leaks in infusion system components are a definite contributor to extrinsic contamination of propofol. Cracks in lipid infusion systems are reported as early as 20 min and up to 6 h of exposure to propofol. Apart from infection risk, concerns regarding human toxicity resulting from interactions between plastics and drugs or the solvents cannot be ignored.{Figure 1}

The various advantages propofol offers in anesthesia and critical care practice cannot be ignored. Safe and infection-free drug delivery, especially for drugs with lipid vehicle, needs to be ensured. A vast majority of extrinsic propofol contamination and thereby postoperative sepsis in some cases, from intraoperative use of lipid incompatible stopcocks, syringes, and extension tubings, remain unaccounted and unattributed in our setting due to lack of adequate surveillance systems. Hence, apart from aseptic precautions in drug preparation and drug administration, compatibility of medical-grade plastics to drugs in lipid vehicles and vice versa needs to be assured.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Bennett SN, McNeil MM, Bland LA, Arduino MJ, Villarino ME, Perrotta DM, et al. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med 1995;333:147-54.
2Chen SH, Kung CC, Fung ST. Endotoxemia due to propofol contamination in four consecutive patients. J Formos Med Assoc 2014;113:328-9.
3Zorrilla-Vaca A, Arevalo JJ, Escandón-Vargas K, Soltanifar D, Mirski MA. Infectious disease risk associated with contaminated propofol anesthesia, 1989-2014(1). Emerg Infect Dis 2016;22:981-92.
4Nakao M, Yamanaka S, Iwata M, Nakashima M, Onji I. The cracks of polycarbonate three-way stopcocks are enhanced by the lubricating action of fat emulsion of propofol. Masui 2003;52:1243-7.
5Puri GD, Singh KP. Damages to the three-way valves by a clear propofol formulation. Anesth Analg 2004;98:1193-4.