Goldilocks and Propofol Dosage in Older Adults: Too Much, Too Little, or Just Right?

Michael J. Devinney MD, PhD; Miles Berger MD, PhD


J Am Geriatr Soc. 2021;69(8):2106-2109. 

In This Article

Should FDA Dosing Ranges for Anesthetics be Considered Mandates?

FDA package inserts provide general guidance for drug administration: the FDA package insert for propofol simply states that most elderly patients will "require approximately 1 mg/kg to 1.5 mg/kg (approximately 20 mg every 10 seconds) of DIPRIVAN (i.e., propofol) for induction of anesthesia according to their condition and responses. A rapid bolus should not be used, as this will increase the likelihood of undesirable cardiorespiratory depression including hypotension, apnea, airway obstruction, and/or oxygen desaturation."

These FDA recommendations are just that—recommendations, not legally binding limits on drug dosage—and they explicitly recognize that the appropriate propofol induction dosage will vary across patients "according to their condition and response." In this statement, the FDA guidance recognizes a point well known to geriatricians—the heterogeneity in human physiology and functional capacity increases significantly with age.[12] While most 10 year olds can run a mile in a roughly similar time range, some older adults cannot walk while others run marathons. Similarly, some older adults need similar propofol doses to those given to healthy 40 year olds, while administering even a small fraction of these doses will cause PEA in other older adults.