Propofol: A Medication That Changed Pediatric Anesthesia Practice

The introduction of propofol changed our understanding of pediatric anesthesia pharmacology, research approaches for intravenous drug study, and led to infusion pump development for the maintenance phase of anesthesia. The story of propofol development provides a blueprint for other intravenous drug development. The introduction of the target concentration strategy based on pharmacokinetic-pharmacodynamic and covariate understanding is central to total intravenous anesthesia techniques and is best exemplified by propofol. While use of the EEG to gauge depth of anesthesia preceded the propofol era, processed EEG signals enabled description of the relationship between propofol plasma concentration and effect, advancing propofol use and safety. Clinical need drove the characterization of propofol pharmacokinetics and concentration effect relationships in children. Subsequently, study in populations such as neonates, the critically ill, and children with obesity explored covariate influences. Target-controlled infusions also required an appreciation of effect site concentrations and time delays, and drug interactions such as those between propofol and opioids. Supraglottic airway use in children paralleled propofol use because greater depression of pharyngeal and laryngeal reactivity was noted with propofol than seen than with thiopental. Environmental concerns with the carbon footprint of inhalational agents may yet see infusions assume dominance for maintenance anesthesia.