Survival of propofol infusion syndrome in a head-injured patient

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol

Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.

Propofol infusion syndrome in adults: a clinical update

Propofol infusion syndrome is a rare but extremely dangerous complication of propofol administration. Certain risk factors for the development of propofol infusion syndrome are described, such as appropriate propofol doses and durations of administration, carbohydrate depletion, severe illness, and concomitant administration of catecholamines and glucocorticosteroids. The pathophysiology of this condition includes impairment of mitochondrial beta-oxidation of fatty acids, disruption of the electron transport chain, and blockage of beta-adrenoreceptors and cardiac calcium channels. The disease commonly presents as an otherwise unexplained high anion gap metabolic acidosis, rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and cardiac dysfunction. Management of overt propofol infusion syndrome requires immediate discontinuation of propofol infusion and supportive management, including hemodialysis, hemodynamic support, and extracorporeal membrane oxygenation in refractory cases. However, we must emphasize that given the high mortality of propofol infusion syndrome, the best management is prevention. Clinicians should consider alternative sedative regimes to prolonged propofol infusions and remain within recommended maximal dose limits.

Propofol infusion syndrome associated with large-dose infusion for treatment of seizure activity

This article presents a case study of a young man with a history of epilepsy and the use of a propofol infusion to control his symptoms. Propofol-related infusion syndrome is presented.

Propofol infusion syndrome: a lethal condition in critically injured patients eliminated by a simple screening protocol

Propofol infusion syndrome (PIS) is defined by arrhythmia, rhabdomyolysis, lactic acidosis, and unrecognized leads to death. We sought to determine the incidence of PIS in trauma patients and evaluate the efficacy of a prospective screening protocol in this patient population.

MATERIALS AND METHODS

In Phase I of the before-and-after study (1st January, 2005-31st December, 2005), trauma patients who received propofol were evaluated. Records were reviewed for demographics, injury severity, propofol time, dose, and rates, laboratory values, and adverse events. Patients were identified with PIS based on two of the following criteria: (1) cardiac arrhythmia/collapse, (2) metabolic acidosis, (3) rhabdomyolysis, and (4) acute kidney injury. Phase II (1st January, 2006-31st December, 2011) consisted of a prospective screening protocol (elevated lactate or creatine phosphokinase (CPK)) to identify patients at risk for PIS.

RESULTS

207 patients were identified in Phase I. 6 (2.9%) developed PIS with a 50% mortality. No differences were seen in age, gender, or mechanism. PIS patients were more injured (median ISS 44 vs 26, p=0.04; median head AIS 5 vs 4, p=0.003) and received more propofol (median 50,350 vs 9770 mg, p=0.001) with longer infusion times (413 vs 65 h, p=0.001). Sodium, creatinine, and CPK levels were higher in those that developed PIS (160 vs 145 mmol/L, p=0.001; 4.3 vs 1.1mg/dL, p=0.005; 59,871 vs 520 U/L; p=0.002). Pre-screening PIS incidence was 2.9% (6/207), but after screening (January 2006) the incidence dropped to 0.19% (2/1038, p<0.001).

CONCLUSIONS

PIS is a morbid and lethal entity associated with sedation of critically injured patients. A simple screening procedure utilizing serum CPK (<5000 U/L) can essentially eliminate the development of PIS.

Sedation, analgesia, and delirium in the critically ill patient

Most critically ill patients receive a myriad of psychoactive medications during their hospital stay. An understanding of the pharmacology of the more commonly used sedative and analgesic therapies enables the clinician to aptly utilize these medications and limit toxicity. A key to the appropriate provision of sedative and analgesic pharmacotherapy is a thorough patient assessment, use of validated monitoring tools, and defined therapeutic goals. Limiting these therapies while optimizing patient comfort has been shown to reduce the duration of mechanical ventilation and reduce intensive care unit (ICU) and hospital length of stay and should be the aim of the multidisciplinary medical team. This review is intended to provide the reader with a fundamental understanding of how to facilitate comfort of the mechanically ventilated critically ill adult patients and how to minimize medication-related toxicities.

Acute management of acquired brain injury part II: an evidence-based review of pharmacological interventions

PRIMARY OBJECTIVE

To review the research literature on pharmacological interventions used in the acute phase of acquired brain injury (ABI) to manage ICP and improve neural recovery.

MAIN OUTCOMES

A literature search of multiple databases (CINAHL, EMBASE, MEDLINE and PSYCHINFO) and hand searched articles covering the years 1980-2008 was performed. Peer reviewed articles were assessed for methodological quality using the PEDro scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Levels of evidence were assigned and recommendations were made.

RESULTS

In total, 11 pharmacological interventions used in the acute management of ABI were evaluated. These included propofol, barbiturates, opioids, midazolam, mannitol, hypertonic saline, corticosteroids, progesterone, bradykinin antagonists, dimethyl sulphoxide and cannabinoids. Of these interventions, corticosteroids were found to be contraindicated and cannabinoids were reported as ineffective. The other nine interventions demonstrated some benefit for treatment of acute ABI. However, rarely did these benefits result in improved long-term patient outcomes.

CONCLUSIONS

Substantial research has been devoted to evaluating the use of pharmacological interventions in the acute management of ABI. However, much of this research has focused on the application of individual interventions in small single-site trials. Future research will need to establish larger patient samples to evaluate the benefits of combined interventions within specific patient populations.

Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study

Introduction

While propofol is associated with an infusion syndrome (PRIS) that may cause death, the incidence of PRIS is unknown. Determining the incidence of PRIS and the frequency of PRIS-related clinical manifestations are key steps prior to the completion of any controlled studies investigating PRIS. This prospective, multicenter study sought to determine the incidence of PRIS and PRIS-related clinical manifestations in a large cohort of critically ill adults prescribed propofol.

Methods

Critically ill adults from 11 academic medical centers administered an infusion of propofol for [>/=] 24 hours were monitored at baseline and then on a daily basis until propofol was discontinued for the presence of 11 different PRIS-associated clinical manifestations and risk factors derived from 83 published case reports of PRIS.

Results

Among 1017 patients [medical (35%), neurosurgical (25%)], PRIS (defined as metabolic acidosis plus cardiac dysfunction and [>/=] 1 of: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy) developed in 11 (1.1%) patients an average of 3 (1-6) [median (range)] days after the start of propofol. While most (91%) of the patients who developed PRIS were receiving a vasopressor (80% initiated after the start of propofol therapy), few received a propofol dose >83 mcg/kg/min (18%) or died (18%). Compared to the 1006 patients who did not develop PRIS, the APACHE II score (25 +/- 6 vs 20 +/- 7, P = 0.01) was greater in patients with PRIS but both the duration of propofol use (P = 0.43) and ICU length of stay (P = 0.82) were similar.

Conclusions

Despite using a conservative definition for PRIS, and only considering new-onset PRIS clinical manifestations, the incidence of PRIS slightly exceeds 1%. Future controlled studies focusing on evaluating whether propofol manifests the derangements of critical illness more frequently than other sedatives will need to be large. These studies should also investigate the mechanism(s) and risk factors for PRIS.

Propofol infusion syndrome: case report and literature review

PURPOSE

A case of propofol infusion syndrome in a patient with respiratory failure and sepsis is reported.

SUMMARY

A 36-year-old Hispanic woman was admitted to the medical intensive care unit for treatment of respiratory failure and sepsis, likely secondary to pneumonia. Her medical history included human immunodeficiency virus infection and chronic hepatitis C virus infection. She was intubated and placed on mechanical ventilation. Empirical i.v. antimicrobial therapy was initiated with vancomycin, moxifloxacin, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, and micafungin, along with corticosteroids and vasopressors. Propofol 1.5 mg/kg per hour i.v. and midazolam i.v. were initiated for sedation, but the dosages of both propofol and midazolam needed to be increased due to persistent agitation. On hospital day 7, the patient developed a morbilliform rash on her neck, shoulders, and chest and multiple abnormal laboratory test values, including elevated levels of alanine transaminase, aspartate transaminase, amylase, lipase, creatine kinase, and triglycerides. Serial electrocardiograms revealed sinus tachycardia. Computed tomography of the abdomen showed hepatomegaly with fatty infiltration of the liver, no gallstones, and a normal pancreas. I.V. phenobarbital was added for sedation, and propofol was tapered and discontinued on the same day. The patient responded adequately to phenobarbital maintenance therapy and was eventually weaned off all other sedatives. The patient's laboratory test values returned to normal within 72 hours after discontinuation of the propofol infusion, and the rash and tachycardia resolved.

CONCLUSION

Propofol infusion syndrome developed in a patient with respiratory failure and sepsis after a prolonged infusion of high-dose propofol.

Propofol infusion syndrome

Propofol (Diprivan) is an intravenous sedative hypnotic that is used in the induction and maintenance of anesthesia and sedation. High-dose infusions have been associated with several serious adverse effects and, when combined, they are known as propofol infusion syndrome (PRIS). Although PRIS is rare, it is frequently fatal if not identified early. The purpose of this article is to raise practitioner awareness to this syndrome, with recommendations for early identification, prevention, and treatment of PRIS.

Update on the propofol infusion syndrome in ICU management of patients with head injury

PURPOSE OF REVIEW

The propofol infusion syndrome is a rare condition characterized by the occurrence of lactic acidosis, rhabdomyolysis and cardiovascular collapse following high-dose propofol infusion over prolonged periods of time. Patients with traumatic brain injury are particularly at risk of developing this complication because large doses of propofol are commonly used to control intracranial pressure, whereas vasopressors are administered to augment cerebral perfusion pressure. In this review, we provide an update on the literature with particular emphasis on patients with traumatic brain injury.

RECENT FINDINGS

Several new case reports and reviews, as well as a number of experiments, have contributed significantly to our increased understanding of the cause of the syndrome. At the basis of the syndrome lies an imbalance between energy utilization and demand resulting in cell dysfunction, and ultimately necrosis of cardiac and peripheral muscle cells. Uncertainty remains whether a genetic susceptibility exists. Nonetheless, the growing number of case reports has made it possible to identify several risk factors.

SUMMARY

Propofol infusion syndrome is a rare but frequently lethal complication of propofol use. In patients with risk factors, such as traumatic brain injury, it is suggested that an infusion rate of 4 mg/kg per hour should not be exceeded. Early warning signs include unexplained lactic acidosis, lipemia and Brugada-like ECG changes. When these occur, propofol infusion should be discontinued immediately.

Vasopressors and propofol infusion syndrome in severe head trauma

INTRODUCTION

Propofol infusion syndrome (PRIS) is a rare, but lethal complication of high-dose propofol infusions. We undertook this study to evaluate the incidence of PRIS in a cohort of patients with severe head trauma and its relation to the use of vasopressors.

METHODS

We reviewed all patients with severe head trauma admitted to our Neuro-Intensive Care Unit over a 4-year period for use of propofol and vasopressors. Those patients who developed unexplained acidosis, creatine kinase elevation unrelated to trauma, and electrocardiographic changes were considered having PRIS. We investigated the concomitant use of vasopressors while propofol was used and calculated odds ratios for developing PRIS.

RESULTS

We report three adult patients who developed PRIS out of 50 (6%) admitted patients with severe head trauma on propofol infusions. Two of these patients survived and one expired after withdrawal of life support. Concomitant use of vasopressors was associated with development of PRIS in this cohort (odds ratio 29, 95% CI 1.5-581, P < 0.05).

CONCLUSIONS

Awareness and early recognition of PRIS in critically ill neurosurgical patients on vasopressors and daily screening for creatine kinase elevation, unexplained acidosis, or electrocardiographic changes may reduce the incidence and case-fatality.

Propofol infusion syndrome: an overview of a perplexing disease

Propofol (2, 6-diisopropylphenol) is a potent intravenous hypnotic agent that is widely used in adults and children for sedation and the induction and maintenance of anaesthesia. Propofol has gained popularity for its rapid onset and rapid recovery even after prolonged use, and for the neuroprotection conferred. However, a review of the literature reveals multiple instances in which prolonged propofol administration (>48 hours) at high doses (>4 mg/kg/h) may cause a rare, but frequently fatal complication known as propofol infusion syndrome (PRIS). PRIS is characterized by metabolic acidosis, rhabdomyolysis of both skeletal and cardiac muscle, arrhythmias (bradycardia, atrial fibrillation, ventricular and supraventricular tachycardia, bundle branch block and asystole), myocardial failure, renal failure, hepatomegaly and death. PRIS has been described as an 'all or none' syndrome with sudden onset and probable death. The literature does not provide evidence of degrees of symptoms, nor of mildness or severity of signs in the clinical course of the syndrome. Recently, a fatal case of PRIS at a low infusion rate (1.9-2.6 mg/kg/h) has been reported. Common laboratory and instrumental findings in PRIS are myoglobinuria, downsloping ST-segment elevation, an increase in plasma creatine kinase, troponin I, potassium, creatinine, azotaemia, malonylcarnitine and C5-acylcarnitine, whereas in the mitochondrial respiratory electron transport chain, the activity of complex IV and cytochrome oxidase ratio is reduced. Propofol should be used with caution for sedation in critically ill children and adults, as well as for long-term anesthesia in otherwise healthy patients, and doses exceeding 4-5 mg/kg/h for long periods (>48 h) should be avoided. If PRIS is suspected, propofol must be stopped immediately and cardiocirculatory stabilization and correction of metabolic acidosis initiated. So, PRIS must be kept in mind as a rare, but highly lethal, complication of propofol use, not necessarily confined to its prolonged use. Furthermore, the safe dosage of propofol may need re-evaluation, and new studies are needed.

Medication-related complications in the trauma patient

Trauma patients are twice as likely to have adverse reactions to medication as nontrauma patients. The need for medication in trauma patients is high. Surgery is often necessary, and immunosuppression and hypercoagulability may be present. Adverse drug events can be caused in part by altered pharmacokinetics, drug interactions, and polypharmacy. Medications may also have serious long-term adverse effects, which must be considered. It is not the purpose of this review article to discuss all adverse effects of all medications. This article will discuss the more common adverse effects of medications for trauma patients in the acute care setting, in the following categories: pain control, sedation, antibiotics, seizure prophylaxis in head trauma, atrial fibrillation, deep vein thrombosis and pulmonary embolism prophylaxis, hemodynamic support, adrenal insufficiency, factor VIIa.

Propofol-related infusion syndrome in intensive care patients

The Institute of Medicine has identified adverse drug events as factors that significantly contribute to increased patient morbidity and mortality. As critically ill patients receive numerous drugs to treat a multitude of complicated health problems, they are at high risk for adverse drug events. Sedation is often a key requirement for the optimal management of critical illness, and propofol, a common sedative, has many desirable characteristics that make it the ideal agent in numerous circumstances. However, over the last decade, increasing numbers of reports have described a potentially fatal adverse effect called propofol-related infusion syndrome. Whether this adverse drug event is preventable is unclear, but recommendations have been proposed to minimize the potential for development of this syndrome. Research is under way to collect data on the use of propofol in intensive care units and on its prevalence.

[Lactic acidosis associated with propofol during general anaesthesia for neurosurgery]

Propofol infusion syndrome (PRIS) is a new clinical entity reported in critically ill patients. Lactic acidosis, cardiac failure and rhabdomyolysis are the features. Lactic acidosis related to short-term propofol administration has been described during general anaesthesia. Lactic acidosis could be an early marker of PRIS. We report here a case of very early lactic acidosis in a 66-year-old-man receiving propofol during a neurosurgery. The outcome was good after discontinuation of propofol.

The effects of sedation on gastric emptying and intra-gastric meal distribution in critical illness

OBJECTIVE

To evaluate the effects of sedation with morphine and midazolam (M&M) versus propofol on gastric emptying in critically ill patients.

DESIGN

Descriptive study.

SETTING

Mixed medical and surgical intensive care unit.

PATIENTS

Thirty-six unselected, mechanically ventilated, critically ill patients.

INTERVENTIONS

Gastric scintigraphic data were analysed retrospectively according to whether patients were receiving M&M (n=20; 14M, 6F) or propofol (n=16; 7M, 9F). Measurements were performed over 4 h after administration of 100 ml of Ensure, labelled with 20 MBq Tc99m.

MEASUREMENTS AND RESULTS

Gastric half-emptying time (t1/2) and total and regional (proximal and distal stomach) meal retention (%) were assessed. The median t1/2 of patients receiving M&M (153 (IQR: 72-434) min) was significantly longer than that of patients receiving propofol (58 (34-166) min, p=0.02). Total gastric retention was greater in patients receiving M&M compared to those receiving propofol (p<0.01). Proximal (p=0.02) but not distal (p=0.80) gastric retention was greater in patients who received M&M. Patients who received M&M were more likely to have >or=5% meal retention at 240 min than those treated with propofol (95% (19/20) vs. 56% (9/16); p=0.01). Changes in blood glucose concentrations during the study were similar in the two groups.

CONCLUSIONS

In critical illness, patients receiving M&M for sedation are more likely to have slow gastric emptying, and proximal meal retention than those receiving propofol. The apparent beneficial effects of propofol-based sedation need confirmation by a prospective randomised controlled study.

Propofol infusion syndrome

The 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.