Co-induction with a vasopressor "chaser" to mitigate propofol-induced hypotension when intubating critically ill/frail patients-A questionable practice

Prophylactic administration of a vasopressor to mitigate the hypotensive effect of propofol (and/or other co-induction agents) during sedation/anesthesia immediately prior to tracheal intubation in frail patients in the intensive care unit and emergency and operating rooms appears to be not an uncommon practice. Wesubmit that this practice is unnecessary and potentially harmful. Despite restoring the blood pressure, phenylephrine, for instance, may have an additive or synergistic effectwith propofol in reducing the cardiac output and, ultimately, organ perfusion. Airway instrumentation often leads to sympathetic activation and hypertension (thereby increasing myocardial oxygen consumption) which may be exacerbated by an arbitrary prophylactic dose of phenylephrine. Finally, in spite of the well-recognized need to reduce dosages of propofol in frail patients, excessive doses are commonly given, leading to hypotension. We herein discuss each of these points and suggest alternative techniques to promote a stable induction in frail patients. (C) 2019 Elsevier Inc. All rights reserved.