Propofol infusion syndrome

Abstract

SummaryThe clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following: metabolic acidosis (base deficit > 10 mmol.l−1), rhabdomyolysis, hyperlipidaemia, and enlarged or fatty liver. There is an association between PRIS and propofol infusions at doses higher than 4 mg.kg−1.h−1 for greater than 48 h duration. Sixty‐one patients with PRIS have been recorded in the literature, with deaths in 20 paediatric and 18 adult patients. Seven of these patients (four paediatric and three adult patients) developed PRIS during anaesthesia. It is proposed that the syndrome may be caused by either a direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. An early sign of cardiac instability associated with the syndrome is the development of right bundle branch block with convex‐curved (‘coved type’) ST elevation in the right praecordial leads (V1 to V3) of the electrocardiogram. Predisposing factors include young age, severe critical illness of central nervous system or respiratory origin, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake and subclinical mitochondrial disease. Treatment options are limited. Haemodialysis or haemoperfusion with cardiorespiratory support has been the most successful treatment.

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

“…Although there are no data supporting any particular drugs or regimens, propofol should not be used for long-term sedation in children younger than 3 years because of the reported association with fatal metabolic acidosis. The use of etomidate and/or dexmedetomidine during septic shock should be discouraged, or at least considered carefully, because these drugs inhibit the adrenal axis and the sympathetic nervous system, respectively, both of which are needed for hemodynamic stability [617][618][619][620].…”

Drug-induced acid-base disorders

“…Patients should be monitored closely for the presence of elevated triglycerides and lactic acidosis [43]. PRIS leads to characteristic symptoms and clinical signs, including hepatomegaly, severe metabolic acidosis, rhabdomyolysis, hyperkalemia, acute kidney injury, dyslipidemia, and progressive myocardial failure with dysrhythmias [44]. Most patients with PRIS present with severe metabolic acidosis with elevated lactate levels and metabolic alkalosis.…”

Propofol-Related Infusion Syndrome: Role of Propofol in Medical Complications of Sedated Critical Care Patients

“…Despite this, the American College of Critical Care Medicine 6 recommends checking triglyceride levels after 2 days, and European regulatory authorities suggest monitoring for metabolic acidosis, rhabdomyolysis, hyperkalemia, and heart failure. 8 Case studies 2 have shown that stopping propofol administration can reverse impending PRIS at an early stage. Once in full swing, the hemodynamic instability is refractory to fluids and inotropes.…”

“…4 Various mechanisms have been proposed for the pathophysiology of PRIS. 2,5 To summarize, propofol impairs function of the mitochondrial respiratory chain. The impaired production of mitochondrial adenosine triphosphate and presence of soya bean (added to enhance solubility of propofol) increase triglyceride load.…”