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Anesth Analg 2009; 108:1182-1184
© 2009 International Anesthesia Research Society
doi: 10.1213/ane.0b013e318198d45e
ANESTHETIC PHARMACOLOGY
Death from Propofol: Accident, Suicide, or Murder?
Robert R. Kirby, MD*, James M. Colaw, JD, and Sgt Michael M. Douglas, BA Criminal Justice
From the *Department of Anesthesiology, The University of Florida College of Medicine, Gainesville, Florida; Eighth Judicial Circuit of Florida, Gainesville, Florida; and SGT Tactical Impact Unit, Gainesville Police Department, Gainesville, Florida.
Abstract
A 24-yr-old woman was found dead in her home from apparent propofol "toxicity." Her blood level of propofol was 4.3 µg/mL. She had no history of drug abuse and no evidence of such behavior at autopsy. The medical examiner and police investigators felt that she died from probable homicide. Attention was focused on a male registered nurse acquaintance, who had acquired propofol and other drugs in the course of his regular duties in a surgical intensive care unit. This is the first reported case of murder with propofol.
Introduction
Propofol has been used in anesthesiology since 1986. Although its clinical properties are well known to anesthesia providers, knowledge concerning its abuse potential and more complex issues, such as its use in suicide, are less commonly appreciated. Before 1992, clinicians and the manufacturer were convinced that such abuse was rare to nonexistent. Since 1992, however, reports have been published (largely in forensic medical journals) concerning abuse, accidental overdose and suicide. Presented herein is the first report involving murder with propofol, and a review of the literature about propofol diversion.
CASE DESCRIPTION
A 24-yr-old, 5'5 in., 138 pound female was found dead in her house near Gainesville, Florida by police detectives and fire rescue personnel on November 10, 2005. Numerous items, including syringes, needles, and two empty 20 mL vials of 1% propofol (10 mg/mL), were found in grocery store bags lying on the ground adjacent to garbage cans outside the house. After the initial crime scene investigation, an autopsy was performed. The left antecubital fossa had a pinpoint puncture wound with underlying subcutaneous hemorrhage. The puncture wound directly overlaid a subcutaneous vein. No other premortem physical abnormalities were noted.
Laboratory analysis revealed a blood propofol concentration of 4.3 µg/mL. This value is within the range of blood propofol concentrations (1.3–6.8 µg/mL) after a bolus induction dose of 2.5 mg/kg of body weight. The medical examiner ruled that the manner of death was homicide. She noted that the fatal dose of propofol was administered by someone with skill in IV injections.
Follow-up investigation of the propofol national drug code lot numbers on the bottles at the crime scene revealed the drug had been obtained from an automated Omnicell® dispenser (Omnicell Headquarters, 1201 Charleston Road, Mountain View, CA) by a male registered nurse who worked in the surgical intensive care of Shands Hospital at the University of Florida. The most recent propofol had been dispensed to him on November 3, 2005. On or about the day of her death (between November 8 and 9, 2005), he left the area, subsequently went briefly to Georgia on approximately November 24, 2005, and ultimately flew to Ireland on November 29, 2005.
After further investigation, a second degree murder warrant was issued for the suspect on January 24, 2006. In June 2006, he was apprehended in the West African Republic of Senegal. On October 16, 2006, he was transported to the Alachua County Department of the Jail by the United States Marshall’s Service, and on November 29, 2007, the prior indictment for second degree murder was upgraded to first degree murder. Trial commenced on May 19, 2008. On May 23, he was found guilty of first degree murder and was sentenced to life in prison without the possibility of parole.
DISCUSSION
In cases such as this one, investigation involves the determination of the following: was drug abuse or drug dependence involved, and was death accidental, by suicide or caused by a third party? Drug abuse is "the use of a psychoactive substance in a manner detrimental to the individual or society but not meeting criteria for substance or drug dependence."1 Drug dependence is characterized by several typical findings including "1) compulsion or craving; 2) loss of control over the amount or frequency of the drug used, and 3) continued use of the drug despite adverse consequences."2
The abuse potential of propofol was not recognized initially. As late as 1992, Stuart Pharmaceuticals reported no propofol abuse or "Diprivan-seeking" behavior. However, propofol is increasingly popular as a drug of abuse for several reasons, including rapid onset (
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