Propofol infusion syndrome

Background

• PRIS = propofol infusion syndrome
• Refractory bradycardia and cardiovascular collapse
• Poorly understood mechanism
• Risk factors
  • High doses of (> 4 mg/kg/hr or 67 mcg/kg/min)
  • Long duration (> 48 hrs)
  • Younger age (PRIS first recognized in pediatric population)
  • Critical illness
  • Malnutrition
  • Liver disease
  • Carnitine deficiency
  • Mitochondrial disease
  • Catecholamine, vasopressor infusion
  • Corticosteroid infusion

Clinical Features

• Elevated AG metabolic acidosis
• Hypotension
• Bradycardia
• Rhabdomyolysis
• Hyperkalemia
• AKI
• Hyperlipidemia
• Transaminitis, fatty liver

Diagnosis

• Serum lipids (TGs, cholesterol)
• BMP, Cr
• CK, potassium, urinary myoglobin
• Lactate, ABG
• Propofol levels if available
• ECG
  • Brugada like pattern, coved-type
  • RBBB
  • Heart block

Management

• Immediate d/c of propofol infusion
• Treatment of rhabdomyolysis, to include renal replacement therapy
• Hemodynamic support, cardiac pacing
• L-carnitine supplementation
• Carbohydrate administration at 6-8 mg/kg/min
• Hemodialysis
• ECMO in refractory cases

Sources

• Fudickar A, Bein B. Propofol infusion syndrome: update of clinical manifestation and pathophysiology. Minerva Anestesiol. 2009 May;75(5):339-44
• Mirrakhimov AE et al. Propofol Infusion Syndrome in Adults: A Clinical Update. Critical Care Research and Practice. Volume 2015 (2015), Article ID 260385, 10 pages.