Propofol-induced hyperamylasaemia in a general intensive care unit

The Effect of Concomitant Sirolimus and Propofol Therapy on Triglyceride Concentrations in Critically Ill Patients

BACKGROUND

Sirolimus and propofol are both independently associated with the development of hypertriglyceridemia (HTG) during therapy. To date, there are no published reports describing synergistic or additive drug interaction resulting in HTG with concomitant use of these medications.

STUDY QUESTION

To identify the occurrence of HTG in patients receiving concomitant sirolimus and propofol infusion therapy.

METHODS

Adult patients receiving sirolimus and a continuous propofol infusion for at least 12 hours from January 2005 to August 2009 were retrospectively evaluated. Data included Acute Physiology and Chronic Health Evaluation II score, weight, length of propofol therapy, and baseline triglyceride (TG) concentrations. The major outcome was incidence of HTG (TGs ≥500 mg/dL). Minor outcomes included the change in TG concentration from therapy initiation and manifestations of propofol-related infusion syndrome (PRIS).

RESULTS

Sixteen patients were included in the analysis, with 8 (50%) of the patients developing HTG. The patients in this case series had the following mean values: Acute Physiology and Chronic Health Evaluation II score of 20.2 ± 5.3, weight of 76.3 ± 21.2 kg, and baseline TG concentrations of 181.3 ± 89.7 mg/dL. Indications for sirolimus therapy included hematopoietic stem-cell transplantation (n = 15) and heart transplantation (n = 1). Mean length of propofol infusion was 99.8 ± 88.5 hours. The mean TG concentration during infusion was 515.6 ± 468.1 mg/dL. Fourteen (87.5%) patients had an increase of ≥100 mg/dL, 12 (75%) patients had an increase of ≥200 mg/dL, and 6 (37.5%) patients had an increase of ≥300 mg/dL in TG concentrations during therapy. Eleven patients developed one manifestation of PRIS, excluding HTG, and one patient had more than 2 new onset PRIS manifestations during propofol therapy.

CONCLUSIONS

Coadministration of propofol and sirolimus can potentially result in HTG, which may warrant more frequent monitoring. Further analysis is needed to examine the mechanism and clinical impact of this interaction.

A pilot study of cerebral and haemodynamic physiological changes during sedation with dexmedetomidine or propofol in patients with acute brain injury

Sedation for the mechanically-ventilated, brain-injured patient remains challenging. The purpose of this pilot study was to compare the cerebral physiologic effects of sedation with propofol versus dexmedetomidine in mechanically-ventilated, brain-injured patients. Using a randomised, crossover, unblinded clinical trial, we enrolled patients with severe brain injury (Glasgow Coma Score ≤8) from traumatic injury, subarachnoid haemorrhage or intracerebral haemorrhage undergoing multimodal monitoring (intracranial pressure, brain temperature, oximetry and microdialysis). Patients received an infusion of either propofol or dexmedetomidine for six hours and then a crossover for the subsequent six hours after sufficient washout/in. Clinical and physiological measurements were recorded hourly. In eight patients, (four traumatic injury, three subarachnoid haemorrhage and one intracerebral haemorrhage), the mean dose of propofol used was 25.5 µg/kg/minute while the mean dose of dexmedetomidine was 0.54 µg/kg/hour. All subjects were effectively sedated to a goal of Richmond Agitation Sedation Scale -2 and Bispectral Index of 50-70 throughout the study period. We did not observe any statistically significant differences between the groups in systemic or cerebral physiologic metrics. Though differences were noted in cerebral metabolic substrates (lactate/pyruvate ratio), none were statistically significant. In our pilot cohort, dexmedetomidine and propofol appear equally effective in sedating severely brain-injured patients and neither is associated with adverse physiological effects as measured by multimodal monitoring. Larger long-term studies are required to determine whether clinically favourable benefits demonstrated in the medical critical care setting also apply to this patient population.

Exocrine pancreatic involvement in critically ill patients

PURPOSE OF REVIEW

To learn about the prevalence, pathophysiology, and treatment of exocrine pancreatic involvement in critically ill patients.

RECENT FINDINGS

Elevations in the levels of pancreatic enzymes are observed in up to 80% of intensive care patients. Most of these patients do not develop clinically relevant pancreatitis. However, elevations in enzyme levels do represent pancreatic damage with a risk of complications. Different factors have been discussed, which may contribute to pancreatic damage in critically ill patients. These include splanchnic hypoperfusion during shock or major surgery, bacterial translocation, elevated triglyceride levels, development of biliary sluge, and biliary pancreatitis, as well as several drugs. Imaging procedures and inflammatory markers help to identify relevant disease. Several therapeutic options have been discussed recently with a focus on early enteral nutrition.

SUMMARY

Pancreatic damage is frequently observed in critically ill patients. Although in most of these patients, this is without major clinical consequences, some patients develop relevant pancreatitis, which contributes to morbidity and mortality. Risk factors have been identified and therapeutic strategies have been changed.

The use of propofol for medium and long-term sedation in critically ill adult patients: a meta-analysis

OBJECTIVE

To investigate the effects of using propofol for medium and long-term sedation on mortality and length of intensive care unit (ICU) stay of critically ill adult patients.

DESIGN

Randomised controlled studies comparing propofol with an alternative sedative agent in critically ill adult patients were included without language restriction from the Cochrane Controlled Trial Register (2007 issue 3), EMBASE, and MEDLINE databases (1966 to 1 December 2007). Two reviewers reviewed the quality of the studies and performed data extraction independently.

MEASUREMENTS AND RESULTS

Sixteen randomised controlled studies with a total of 1,386 critically ill adult patients were considered. Nine of the pooled studies (56%) limited the doses of propofol infusion to <6 mg/kg h(-1). Mortality was not significantly different between patients sedated with propofol, or an alternative sedative agent (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.80-1.38, P = 0.74; I(2) = 0%). Using propofol for medium and long-term sedation was associated with a significant reduction in length of ICU stay (overall weighted-mean-difference [WMD] in days -0.99, 95%CI -1.51 to -0.47, P = 0.0002; I(2) = 82.26%) when compared to an alternative sedative agent; however, this benefit became insignificant (overall WMD in days -0.98, 95%CI -2.86 to 0.89, P = 0.30; I(2) = 78.8%) when the comparison was limited to between propofol and midazolam.

CONCLUSIONS

Using propofol for prolonged sedation in critically ill patients appears to be safe and may reduce duration of mechanical ventilation. It reduces the length of ICU stay when compared to long acting benzodiazepines, but not when compared to midazolam.