1
|
Calvano J, Paluska MR, Armijo AJ, Petersen TR, Soneru C, Broman A, Lopez-Hernandez G. Propofol-Related Infusion Syndrome in a Child With Refractory Status Epilepticus: Successful Resuscitation With Veno-Arterial Extracorporeal Membrane Oxygenation, Continuous Renal Replacement Therapy, and Therapeutic Plasma Exchange. Cureus 2023; 15:e47866. [PMID: 37908691 PMCID: PMC10613782 DOI: 10.7759/cureus.47866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Propofol is used for sedation, anxiolysis, anesthesia induction, and as an anticonvulsant. In cases of refractory status epilepticus (RSE), propofol is more efficient than barbiturates. We present a case of a 3-year-old female with RSE who developed propofol-related infusion syndrome (PRIS) despite low dosage after failed attempts with multiple anti-epileptic drips and bolus therapies. Careful consideration must be made before initiating propofol administration for RSE. We discuss our PRIS treatment approach with extracorporeal membrane oxygenation, therapeutic plasma exchange, and continuous renal replacement therapy leading to our patient recovering to baseline and being discharged home from the hospital.
Collapse
Affiliation(s)
- Joshua Calvano
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Matthew R Paluska
- Department of Anesthesiology, Rocky Vista University College of Osteopathic Medicine, Englewood, USA
| | - Arthur J Armijo
- Department of Graduate Medical Education, Healthcare Corporation of America/HealthOne, Lone Tree, USA
| | - Timothy R Petersen
- Department of Graduate Medical Education, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Codruta Soneru
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Alia Broman
- Department of Pediatrics, University of Colorado School of Medicine, Denver Health Medical Center, Denver, USA
| | | |
Collapse
|
2
|
Paramsothy J, Gutlapalli SD, Ganipineni VDP, Mulango I, Okorie IJ, Arrey Agbor DB, Delp C, Apple H, Kheyson B, Nfonoyim J, Isber N, Yalamanchili M. Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome. Cureus 2023; 15:e40456. [PMID: 37456460 PMCID: PMC10349530 DOI: 10.7759/cureus.40456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/18/2023] Open
Abstract
Propofol has revolutionized anesthesia and intensive care medicine owing to its favorable pharmacokinetic characteristics, fast onset, and short duration of action. This drug has been shown to be remarkably effective in numerous clinical scenarios. In addition, propofol has maintained an overwhelmingly favorable safety profile; however, it has been associated with both antiarrhythmic and proarrhythmic effects. This review concisely summarizes the dual arrhythmic cardiovascular effects of propofol and a rare but serious complication, propofol infusion syndrome (PRIS). We also discuss the need for careful patient evaluation, compliance with recommended infusion rates, and vigilant monitoring.
Collapse
Affiliation(s)
- Jananthan Paramsothy
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
- Internal Medicine Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vijay Durga Pradeep Ganipineni
- Internal Medicine, Thomas Hospital Infirmary Health, Fairhope, USA
- General Medicine, Sri Ramaswamy Memorial (SRM) Medical College Hospital and Research Center, Chennai, IND
- General Medicine, Andhra Medical College/King George Hospital, Visakhapatnam, IND
| | - Isabelle Mulango
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Ikpechukwu J Okorie
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Divine Besong Arrey Agbor
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Crystal Delp
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Hanim Apple
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Borislav Kheyson
- Internal Medicine, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Nidal Isber
- Electrophysiology, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| | - Mallikarjuna Yalamanchili
- Anesthesiology, Richmond University Medical Center Affiliated with Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, Staten Island, USA
| |
Collapse
|
3
|
Singh A, Anjankar AP. Propofol-Related Infusion Syndrome: A Clinical Review. Cureus 2022; 14:e30383. [PMID: 36407194 PMCID: PMC9671386 DOI: 10.7759/cureus.30383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023] Open
Abstract
Propofol-related infusion syndrome (PRIS) is a lethal condition characterized by multiple organ system failures. It can occur due to prolonged administration of propofol (an anesthetic) in mechanically intubated patients. The main presenting features of this condition include cardiovascular dysfunction with particular emphasis on impairment of cardiovascular contractility, metabolic acidosis, lactic acidosis, rhabdomyolysis, hyperkalaemia, lipidaemia, hepatomegaly, acute renal failure, and eventually mortality in most cases. The significant risk factors that predispose one to PRIS are: critical illnesses, increased serum catecholamines, steroid therapy, obesity, young age (significantly below three years), depleted carbohydrate stores in the body, increased serum lipids, and most importantly, heavy or extended dosage of propofol. The primary pathophysiology behind PRIS is the disruption of the mitochondrial respiratory chain that causes inhibition of adenosine triphosphate (ATP) synthesis and cellular hypoxia. Further, excess lipolysis of adipose tissue occurs, especially in critically ill patients where the energy source is lipid breakdown instead of carbohydrates. This process generates excess free fatty acids (FFAs) that cannot undergo adequate beta-oxidation. These FFAs contribute to the clinical pathology of PRIS. It requires prompt management as it is a fatal condition. The clinicians must observe the patient's electrocardiogram (ECG), serum creatine kinase, lipase, amylase, lactate, liver enzymes, and myoglobin levels in urine, under propofol sedation. Doctors should immediately stop propofol infusion upon noticing any abnormality in these parameters. The other essentials of management of various manifestations of PRIS will be discussed in this article, along with a detailed explanation of the condition, its risk factors, diagnosis, pathophysiology, and presenting features. This article aims to make clinicians more aware of the occurrence of this syndrome so that better ways to manage and treat this condition can be formulated in the future.
Collapse
Affiliation(s)
- Aayushi Singh
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Ashish P Anjankar
- Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| |
Collapse
|
4
|
Barajas MB, Wang A, Griffiths KK, Sun L, Yang G, Levy RJ. Modeling propofol-induced cardiotoxicity in the isolated-perfused newborn mouse heart. Physiol Rep 2022; 10:e15402. [PMID: 35923108 PMCID: PMC9350423 DOI: 10.14814/phy2.15402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 06/15/2023] Open
Abstract
Infants and children are vulnerable to developing propofol infusion syndrome (PRIS) and young age is a risk factor. Cardiac involvement is often prominent and associated with death. However, the mechanisms of pediatric PRIS are poorly understood because of the paucity of investigation and lack of a gold standard animal model. Unfortunately, in vivo modeling of PRIS in a newborn mouse is not feasible and would be complicated by confounders. Thus, we focused on propofol-induced cardiotoxicity and aimed to develop an ex-vivo model in the isolated-perfused newborn mouse heart. We hypothesized that the model would recapitulate the key cardiac features of PRIS seen in infants and children and would corroborate prior in vitro observations. Isolated perfused newborn mouse hearts were exposed to a toxic dose of propofol or intralipid for 30-min. Surface electrocardiogram, ventricular contractile force, and oxygen extraction were measured over time. Real-time multiphoton laser imaging was utilized to quantify calcein and tetramethylrhodamine ethyl ester fluorescence. Propidium iodide uptake was assessed following drug exposure. A toxic dose of propofol rapidly induced dysrhythmias, depressed ventricular contractile function, impaired the mitochondrial membrane potential, and increased open probability of the permeability transition pore in propofol-exposed hearts without causing cell death. These features mimicked the hallmarks of pediatric PRIS and corroborated prior observations made in isolated newborn cardiomyocyte mitochondria. Thus, acute propofol-induced cardiotoxicity in the isolated-perfused developing mouse heart may serve as a relevant ex-vivo model for pediatric PRIS.
Collapse
Affiliation(s)
- Matthew B. Barajas
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Aili Wang
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Keren K. Griffiths
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Linlin Sun
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Guang Yang
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Richard J. Levy
- Department of AnesthesiologyColumbia University Medical CenterNew YorkNew YorkUSA
| |
Collapse
|
5
|
Propofol infusion syndrome: a structured literature review and analysis of published case reports. Br J Anaesth 2019; 122:448-459. [PMID: 30857601 DOI: 10.1016/j.bja.2018.12.025] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/26/2018] [Accepted: 12/20/2018] [Indexed: 12/31/2022] Open
Abstract
Propofol infusion syndrome is a rare, potentially fatal condition first described in children in the 1990s and later reported in adults. We provide a narrative review of what is currently known about propofol infusion syndrome, including a structured analysis of all published case reports; child and adult cases were analysed separately as propofol is no longer used for long-term sedation in children. The review contains an update on current knowledge of the pathophysiology of this condition along with recommendations for its diagnosis, prevention, and management. We reviewed 108 publications documenting 168 cases of propofol infusion syndrome. We evaluated clinical features and analysed factors influencing mortality in child and adult cases using separate multivariate analysis models. We used separate multiple linear regression models to analyse relationships between cumulative dose of propofol and the number of features seen and organ systems involved. Lipidaemia, fever, and hepatomegaly occurred more frequently in children than in adults, whilst rhabdomyolysis and hyperkalaemia were more frequent in adults. Mortality from propofol infusion syndrome is independently associated with fever and hepatomegaly in children, and electrocardiogram changes, hypotension, hyperkalaemia, traumatic brain injury, and a mean propofol infusion rate >5 mg kg-1 h-1 in adults. The cumulative dose of propofol was associated with an increased number of clinical features and the number of organ systems involved in adult cases only. Clinicians should consider propofol infusion syndrome in cases of unexplained metabolic acidosis, ECG changes, and rhabdomyolysis. We recommend early consideration of continuous haemofiltration in the management of propofol infusion syndrome.
Collapse
|
6
|
Abstract
INTRODUCTION Propofol infusion syndrome (PRIS) is a rare but potentially fatal complication of propofol infusion. It is clinically characterized by metabolic acidosis, refractory bradycardia, rhabdomyolysis, renal failure, hyperlipidemia, and hepatomegaly. Brain lesion was only reported once in a pediatric patient. We present the 1st adult case with colon polyp and cancer who was diagnosed with PRIS. Her brain magnetic resonance imaging (MRI) and computed tomography (CT) scans reveal prominent bilateral brain lesions, matching with the proposed pathophysiologic mechanism of the syndrome. The patient received prompt acidosis correction and cardiorespiratory support. At last, she died from refractory circulatory failure. CONCLUSION It may be necessary to order a prompt neuroimaging examination in patients suspected with PRIS to judge whether brain lesions exist or not.
Collapse
Affiliation(s)
| | - Zhangning Zhao
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaomin Liu
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, Jinan, Shandong, China
| | - Gaoting Ma
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, Jinan, Shandong, China
| | - Mei-Jia Zhu
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, Jinan, Shandong, China
| |
Collapse
|
7
|
Lemm H, Janusch M, Buerke M. [Special aspects of analgosedation in cardiogenic shock patients]. Med Klin Intensivmed Notfmed 2016; 111:22-8. [PMID: 26809564 DOI: 10.1007/s00063-015-0131-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/19/2022]
Abstract
Patients with cardiogenic shock pose a challenge to physicians due to cardiorespiratory instability in addition to the underlying medical condition. If analgosedation and ventilation are indicated, commonly administered drugs themselves often influence hemodynamics and oxygenation. The present article provides an overview of the available substances with consideration of the patients' condition, then monitoring and optimization of analgosedation.
Collapse
Affiliation(s)
- H Lemm
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland.
| | - M Janusch
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland
| | - M Buerke
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen GmbH, Kampenstraße 51, 57072, Siegen, Deutschland
| |
Collapse
|
8
|
Şahin T. PRIS may be diagnosed before ICU period for patients undergoing cardiopulmonary bypass. Perfusion 2015; 31:281-7. [PMID: 26354738 DOI: 10.1177/0267659115604708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There are many published articles on the clinical manifestations of propofol-related infusion syndrome (PRIS), but they are not the same in each case.(1)Moreover, PRIS is only encountered infrequently and, therefore, it may create a diagnostic challenge. Nearly all of the published articles on PRIS are related to the use of long-term (> 48 hour) propofol infusion with a dose range of at least 4-5 mg/kg/h. In this case, not only a short duration, but also a low-dose propofol administration seems to induce PRIS. A 73-year-old male patient under cardiopulmonary bypass (CPB) suffered from some clinical symptoms of PRIS, such as hyperlactatemia and persistent low metabolic acidosis which promptly resolved on the discontinuation of propofol. Therefore, we suggest that any propofol administration (bolus or infusion) may result in such clinical symptoms, which may be the earliest indicators of PRIS. When those symptoms are observed on propofol administration during cardiopulmonary bypass (CPB), the perfusionist must alert both the anaesthesiologist and the surgeon to stop the propofol in order to prevent the patient from further adverse effects of PRIS.
Collapse
Affiliation(s)
- Türker Şahin
- Near East University Hospital, Perfusion Services, Nicosia, Northern Cyprus, Turkey
| |
Collapse
|
9
|
Alford EL, Wheless JW, Phelps SJ. Treatment of Generalized Convulsive Status Epilepticus in Pediatric Patients. J Pediatr Pharmacol Ther 2015; 20:260-89. [PMID: 26380568 PMCID: PMC4557718 DOI: 10.5863/1551-6776-20.4.260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Generalized convulsive status epilepticus (GCSE) is one of the most common neurologic emergencies and can be associated with significant morbidity and mortality if not treated promptly and aggressively. Management of GCSE is staged and generally involves the use of life support measures, identification and management of underlying causes, and rapid initiation of anticonvulsants. The purpose of this article is to review and evaluate published reports regarding the treatment of impending, established, refractory, and super-refractory GCSE in pediatric patients.
Collapse
Affiliation(s)
- Elizabeth L. Alford
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| | - James W. Wheless
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Pediatric Neurology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Neuroscience Center and Comprehensive Epilepsy Program, Memphis, Tennessee
| | - Stephanie J. Phelps
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|
10
|
Abstract
Propofol is an intravenous agent used commonly for the induction and maintenance of anesthesia, procedural, and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially the gamma-aminobutyric acid A receptor. Approved for use in the USA by the Food and Drug Administration in 1989, its use for induction of anesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not "little adults", in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exists despite the Food and Drug Administration mandating addition of antimicrobial preservative, calling for manufacturers' directions to discard open vials after 6 h. While propofol has advantages over inhalation anesthesia such as less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol-induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research.
Collapse
Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH, 45229, USA,
| | | | | |
Collapse
|
11
|
|
12
|
Mayette M, Gonda J, Hsu JL, Mihm FG. Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature. Ann Intensive Care 2013; 3:32. [PMID: 24059786 PMCID: PMC3850887 DOI: 10.1186/2110-5820-3-32] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/03/2013] [Indexed: 02/03/2023] Open
Abstract
We report a case of propofol infusion syndrome (PRIS) in a young female treated for status epilepticus. In this case, PRIS rapidly evolved to full cardiovascular collapse despite aggressive supportive care in the intensive care unit, as well as prompt discontinuation of the offending agent. She progressed to refractory cardiac arrest requiring emergent initiation of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR). She regained a perfusing rhythm after prolonged (>8 hours) asystole, was weaned off ECMO and eventually all life support, and was discharged to home. We also present a review of the available literature on the use of ECMO for PRIS.
Collapse
Affiliation(s)
- Michael Mayette
- Divisions of Pulmonary and Critical Care Medicine, Critical Care Medicine and Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | | | | | | |
Collapse
|
13
|
Olson N, Lim MJ, Ferreira SW, Mehdirad AA. Potential for Infra-Nodal Heart Block and Cardiogenic Shock With Propofol Administration. Cardiol Res 2013; 4:35-40. [PMID: 28348701 PMCID: PMC5358186 DOI: 10.4021/cr252w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2013] [Indexed: 11/29/2022] Open
Abstract
We report a case of infra-nodal complete heart block and cardiogenic shock in a previously healthy 64-year-old man after administration of 180 mg of intravenous Propofol. Although bradycardia, hypotension, and heart block are commonly seen with propofol administration, such findings are transient and respond quickly to administration of vagolytic or sympathomimetic agents suggesting an AV nodal mechanism of heart block. Sustained left ventricular systolic dysfunction and cardiogenic shock by an alternative, non-autonomic mechanism has also been described in the setting of Propofol administration. Our case is the first to note sustained complete infra-nodal heart block in this setting. Early recognition of such a complication, restoration of atrio-ventricular (A-V) synchrony with dual chamber pacing, and aggressive circulatory support is essential in bridging such patients to recovery.
Collapse
Affiliation(s)
- Nicholas Olson
- Saint Louis University, Department of Cardiology, 3635 Vista Avenue, Saint Louis, MO, 63110-0250, 13th floor Desloge Tower, 63110-0250, USA
| | - Michael J Lim
- Saint Louis University, Department of Cardiology, 3635 Vista Avenue, Saint Louis, MO, 63110-0250, 13th floor Desloge Tower, 63110-0250, USA
| | - Scott W Ferreira
- Saint Louis University, Department of Cardiology, 3635 Vista Avenue, Saint Louis, MO, 63110-0250, 13th floor Desloge Tower, 63110-0250, USA
| | - Ali A Mehdirad
- Saint Louis University, Department of Cardiology, 3635 Vista Avenue, Saint Louis, MO, 63110-0250, 13th floor Desloge Tower, 63110-0250, USA
| |
Collapse
|
14
|
Diedrich DA, Brown DR. Analytic Reviews: Propofol Infusion Syndrome in the ICU. J Intensive Care Med 2011; 26:59-72. [DOI: 10.1177/0885066610384195] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Propofol is an alkylphenol derivative named 2, 6, diisopropylphenol and is a potent intravenous short-acting hypnotic agent. It is commonly used as sedation, as well as an anesthetic agent in both pediatric and adult patient populations. There have been numerous case reports describing a constellation of findings including metabolic derangements and organ system failures known collectively as propofol infusion syndrome (PRIS). Although there is a high mortality associated with PRIS, the precise mechanism of action has yet to be determined. The best preventive measure for this syndrome is awareness and avoidance of clinical scenarios associated with development of PRIS. There is no established treatment for PRIS; care is primarily supportive in nature and may include the full array of advanced cardiopulmonary support, including extracorporeal membrane oxygenation (ECMO). This article reviews the reported cases of PRIS and describes the current understanding of the underlying pathophysiology and treatment options.
Collapse
Affiliation(s)
- Daniel A. Diedrich
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Daniel R. Brown
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA,
| |
Collapse
|
15
|
Guitton C, Gabillet L, Latour P, Rigal JC, Boutoille D, Al Habash O, Derkinderen P, Bretonniere C, Villers D. Propofol Infusion Syndrome During Refractory Status Epilepticus in a Young Adult: Successful ECMO Resuscitation. Neurocrit Care 2010; 15:139-45. [DOI: 10.1007/s12028-010-9385-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
16
|
Le syndrome de perfusion du propofol. ACTA ACUST UNITED AC 2010; 29:377-86. [PMID: 20399595 DOI: 10.1016/j.annfar.2010.02.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Accepted: 02/17/2010] [Indexed: 01/08/2023]
|
17
|
Roberts RJ, Barletta JF, Fong JJ, Schumaker G, Kuper PJ, Papadopoulos S, Yogaratnam D, Kendall E, Xamplas R, Gerlach AT, Szumita PM, Anger KE, Arpino PA, Voils SA, Grgurich P, Ruthazer R, Devlin JW. Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R169. [PMID: 19874582 PMCID: PMC2784401 DOI: 10.1186/cc8145] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 10/14/2009] [Accepted: 10/29/2009] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Russel J Roberts
- Department of Pharmacy, Tufts Medical Center, Boston, MA 02111, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
There are numerous sedatives and analgesics used in critical care medicine today; these medications are used on critically ill patients, many of whom have heart disease, including coronary artery disease or congestive heart failure. The purpose of this review is to recognize the effects of these medications on the heart. Studies that evaluated the effects of sedatives and analgesics on normal individuals or on those with heart disease were reviewed. Current choices for sustained sedation in the critically ill include the benzodiazepines, morphine, propofol, and etomidate. Each of these medications has their particular advantages and disadvantages. Benzodiazepines provide the greatest amnesia and cardiovascular safety but they can cause significant hypotension in the hemodynamically unstable patient. Morphine provides analgesia and cardioprotective activity after ischemia, although the large observational study CRUSADE showed increased mortality rate in those patients with non-ST segment elevation myocardial infarction who received morphine. Propofol is the most easily titratable drug with cardioprotective features, but its use must be accompanied with great attention to possible development of propofol infusion syndrome, which is a deadly disease, especially in patients with head injury and those with septic shock receiving vasopressors. Etomidate has a rapid onset effect and short period of action with great hemodynamic stability even in patients with shock and hypovolemia, but the incidence of adrenal insufficiency during infusion, not bolus doses, may cause deterioration in the circulatory stability. In conclusion, the sedatives and analgesics mentioned here have characteristics that give them a cardiovascular safety profile useful in critically ill patients. However, use of these drugs on an individual basis is dependent on each agent's safety and efficacy.
Collapse
|
19
|
Orsini J, Nadkarni A, Chen J, Cohen N. Propofol infusion syndrome: case report and literature review. Am J Health Syst Pharm 2009; 66:908-15. [PMID: 19420309 DOI: 10.2146/ajhp070605] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jose Orsini
- Division of Critical Care Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467-2490, USA.
| | | | | | | |
Collapse
|
20
|
Update on the propofol infusion syndrome in ICU management of patients with head injury. Curr Opin Anaesthesiol 2009; 21:544-51. [PMID: 18784477 DOI: 10.1097/aco.0b013e32830f44fb] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
|
21
|
Abstract
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.
Collapse
Affiliation(s)
- Vincenzo Fodale
- Department of Neurosciences, Psychiatric and Anaesthesiological Sciences, University of Messina, Messina, Italy.
| | | |
Collapse
|
22
|
|
23
|
Sztark F, Lagneau F. [Agents for sedation and analgesia in the intensive care unit]. ACTA ACUST UNITED AC 2008; 27:560-6. [PMID: 18595650 DOI: 10.1016/j.annfar.2008.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sedation-analgesia for critically ill patients is usually performed with the combination of a sedative agent and an opioid. Midazolam and propofol are the agents most commonly used for sedation in ICU. The quality of the sedation is quite comparable with both agents, but pharmacokinetic properties of propofol allow a more rapid weaning process from mechanical ventilation. However, implementation of algorithms to adjust drug dosages reduces ventilator days and limits the kinetic differences between propofol and midazolam. Among the adverse events associated with propofol, propofol infusion syndrome is a rare but lethal aspect of propofol therapy. Opioids are the mainstay of analgesic therapy. They interact synergistically with hypnotics. Sufentanil, fentanyl and morphine are the most frequently used opioids. Remifentanil is an ultrashort acting opiate that does not appear to accumulate with prolonged use. The advent of remifentanil has allowed the use of analgesia-based sedation.
Collapse
Affiliation(s)
- F Sztark
- Service d'anesthésie-réanimation 1, université Victor-Segalen Bordeaux-2, groupe hospitalier Pellegrin, CHU de Bordeaux, 33076 Bordeaux cedex, France.
| | | |
Collapse
|
24
|
Corbett SM, Rebuck JA. Medication-related complications in the trauma patient. J Intensive Care Med 2008; 23:91-108. [PMID: 18372349 DOI: 10.1177/0885066607312966] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
|
25
|
Corbett SM, Montoya ID, Moore FA. Propofol-related infusion syndrome in intensive care patients. Pharmacotherapy 2008; 28:250-8. [PMID: 18225970 DOI: 10.1592/phco.28.2.250] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Stephanie Mallow Corbett
- University of Houston College of Pharmacy, Department of Pharmacy, Methodist Hospital, Houston, TX, USA.
| | | | | |
Collapse
|
26
|
[Lactic acidosis associated with propofol during general anaesthesia for neurosurgery]. ACTA ACUST UNITED AC 2008; 27:261-4. [PMID: 18313882 DOI: 10.1016/j.annfar.2008.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 01/17/2008] [Indexed: 11/23/2022]
Abstract
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.
Collapse
|
27
|
Abstract
The propofol infusion syndrome is a rare but potentially lethal complication resulting from a prolonged continuous administration of propofol. It was first described in the beginning of the 1990's and in recent years there have been frequent reports of problems in association with the use of propofol sedation. The cardinal signs and symptoms of the propofol infusion syndrome are metabolic acidosis, rhabdomyolysis, renal failure, cardiac arrhythmias and a progressive, often therapy-resistant cardiac failure. The pathophysiology of this syndrome appears to involve a disturbance of mitochondrial metabolism induced by propofol. Our report involves a case of propofol infusion syndrome in a patient having undergone cardiac surgery.
Collapse
Affiliation(s)
- E Trampitsch
- Abt. für Anästhesie und Allgemeine Intensivmedizin, Landeskrankenhaus, St. Veiter Strasse 47, 9020 Klagenfurt, Austria.
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
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.
Collapse
Affiliation(s)
- P C A Kam
- Department of Anaesthetics, University of Sydney, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | | |
Collapse
|
29
|
Zarovnaya EL, Jobst BC, Harris BT. Propofol-associated fatal myocardial failure and rhabdomyolysis in an adult with status epilepticus. Epilepsia 2007; 48:1002-6. [PMID: 17381434 DOI: 10.1111/j.1528-1167.2007.01042.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Propofol is increasingly used for the treatment of status epilepticus due to the ease of use and tolerability, even if safety data from randomized clinical trials are lacking. An association of high infusion rates of propofol (>5 mg/kg/h) for more than 48 h and constellation of acidosis, rhabdomyolysis, and cardiovascular collapse has been reported in children, but has only been described in a few adult cases. We report a case and autopsy findings of an adult who developed rhabdomyolysis and cardiac failure after receiving propofol for status epilepticus. The patient became symptomatic within 55 h after initiation of propofol infusion. The maximal infusion rate did not exceed 7.2 mg/kg/h, and propofol in excess of 5mg/kg/h was infused for less than 20 h. Preexisting antiepileptic medication may have exacerbated acidosis. Propofol infusion for the treatment of status epilepticus should be carefully weighted against its real risk to develop propofol infusion syndrome, and alternative agents such as benzodiazepines or barbiturates should be considered for first line therapy. If necessary, prolonged propofol infusion at high doses for the treatment of status epilepticus should be used with caution, and in all cases careful monitoring for rhabdomyolysis and acidosis must be performed.
Collapse
Affiliation(s)
- Elena L Zarovnaya
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
| | | | | |
Collapse
|
30
|
Nouette-Gaulain K, Quinart A, Letellier T, Sztark F. [Mitochondria in anaesthesia and intensive care]. ACTA ACUST UNITED AC 2007; 26:319-33. [PMID: 17349772 DOI: 10.1016/j.annfar.2007.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Accepted: 01/17/2007] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Mitochondria play a key role in energy metabolism within the cell through the oxidative phosphorylation. They are also involved in many cellular processes like apoptosis, calcium signaling or reactive oxygen species production. The objectives of this review are to understand the interactions between mitochondrial metabolism and anaesthetics or different stress situations observed in ICU and to know the clinical implications. DATA SOURCES References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: mitochondria, anaesthesia, anaesthetics, sepsis, preconditioning, ischaemia, hypoxia. DATA SYNTHESIS Mitochondria act as a pharmacological target for the anaesthetic agents. The effects can be toxic like in the case of the local anaesthetics-induced myotoxicity. On the other hand, beneficial effects are observed in the anaesthetic-induced myocardial preconditioning. Mitochondrial metabolism could be disturbed in many critical situations (sepsis, chronic hypoxia, ischaemia-reperfusion injury). The study of the underlying mechanisms should allow to propose in the future new specific therapeutics.
Collapse
Affiliation(s)
- K Nouette-Gaulain
- Département d'anesthésie-réanimation I, CHU Pellegrin, 33076 Bordeaux cedex, France
| | | | | | | |
Collapse
|
31
|
Fudickar A, Bein B, Tonner PH. Propofol infusion syndrome in anaesthesia and intensive care medicine. Curr Opin Anaesthesiol 2006; 19:404-10. [PMID: 16829722 DOI: 10.1097/01.aco.0000236140.08228.f1] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Propofol infusion syndrome is a rare but often fatal syndrome, characterized by lactacidosis, lipaemic plasma and cardiac failure, associated with propofol infusion over prolonged periods of time. As propofol is used worldwide, knowledge of propofol infusion syndrome is essential for all anaesthesiologists and intensive care physicians. This review will provide an update on reported cases, and describe recent findings relevant to the pathophysiology and clinical presentation of propofol infusion syndrome. RECENT FINDINGS Case reports of propofol infusion syndrome have contributed new pathophysiological evidence. Reported cases of similar syndromes may represent initial propofol infusion syndrome, and may help to identify further risk factors such as low carbohydrate supply and early warning signs such as lactacidosis. Newly identified gene defects mimicking propofol infusion syndrome may elicit the underlying genetic susceptibility. Recommendations for the limitation of propofol use have been devised by various institutions. SUMMARY Propofol infusion syndrome must be kept in mind as a rare but highly lethal complication of propofol use, not necessarily confined to the prolonged use of propofol. Dose limitations must be adhered to, and early warning signs such as lactacidosis should lead to the immediate cessation of propofol infusion.
Collapse
Affiliation(s)
- Axel Fudickar
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.
| | | | | |
Collapse
|
32
|
Corbett SM, Moore J, Rebuck JA, Rogers FB, Greene CM. Survival of propofol infusion syndrome in a head-injured patient. Crit Care Med 2006; 34:2479-83. [PMID: 16791112 DOI: 10.1097/01.ccm.0000230238.72846.b3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the clinical progression of an adult patient with traumatic brain injury who survived propofol infusion syndrome. DESIGN Case report. SETTING Tertiary care surgical intensive care unit. PATIENT A 21-yr-old male with traumatic brain injury was administered high doses of propofol for sedation and intracranial pressure control combined with vasopressor therapy to maintain cerebral perfusion pressure >60 mmHg. He developed a significant metabolic acidosis with a lactic acid level of 10.9 mmol/L. INTERVENTIONS Exploratory laparotomy, discontinuation of propofol infusion. MEASUREMENTS AND MAIN RESULTS An exploratory abdominal laparotomy was negative for traumatic injury. During the procedure, the propofol infusion was considered a possible cause and was discontinued. On review, it became apparent that a combination of high-dose propofol and catecholamines were responsible for the lactic acidosis. An echocardiogram revealed severe left ventricular dysfunction and cardiomyopathy, which resolved within 19 days. CONCLUSIONS High-dose propofol should be avoided and alternative agents should be instituted for sedation and intracranial pressure management. The use of catecholamine infusions to maintain cerebral perfusion pressure in the setting of a high-dose propofol infusion may be pharmacologically unsound and may be a triggering factor for propofol infusion syndrome. Identification of the syndrome and discontinuation of propofol resulted in complete reversal of symptoms in the case described.
Collapse
Affiliation(s)
- Stephanie Mallow Corbett
- Department of Surgery, Division of Trauma/Critical Care, University of Vermont College of Medicine Burlington, USA
| | | | | | | | | |
Collapse
|
33
|
Abstract
Ongoing refinements in pharmacology continue to provide new medications for the treatment of seizure disorders and other neurologic conditions. The authors present the cases of two children who developed relatively uncommon adverse effects to new anticonvulsant medications, including metabolic acidosis with topiramate and hyponatremia with oxcarbazepine. In one of our two patients, intraoperative acidosis related to topiramate was noted. Appropriate investigation with documentation of normal serum lactate resulted in the exclusion of other potentially serious causes of acidosis and in the identification of topiramate as the causative agent. In our second patient, hyponatremia and status epilepticus resulted from therapy with oxcarbazepine. Prompt recognition of hyponatremia, fluid restriction, and cessation of oxcarbazepine therapy resulted in prompt correction of the hyponatremia. We review previous reports of these adverse effects with topiramate and oxcarbazepine, describe the pathophysiology of these metabolic alterations, provide treatment strategies, and make suggestions for monitoring patients during therapy with these anticonvulsant medications.
Collapse
Affiliation(s)
- Zachary Tebb
- University of Missouri School of Medicine, and the Department of Anesthesiology, University of Missouri, Columbia, MO 65212, USA
| | | |
Collapse
|
34
|
Kumar MA, Urrutia VC, Thomas CE, Abou-Khaled KJ, Schwartzman RJ. The syndrome of irreversible acidosis after prolonged propofol infusion. Neurocrit Care 2006; 3:257-9. [PMID: 16377841 DOI: 10.1385/ncc:3:3:257] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Propofol infusion syndrome is described in the pediatric literature as metabolic acidosis, rhabdomyolysis, and bradycardia that results in death. The pathogenesis of this syndrome is thought to be activation of the systemic inflammatory response, which culminates in acidosis and muscle necrosis. MATERIALS AND METHODS Retrospective chart review of three patients in the Neurological Critical Care Units at Hahnemann and Massachusetts General Hospitals between October 2001 and September 2004. RESULTS Patient 1: A 27-year-old woman had seizures secondary to hemorrhage from an arteriovenous malformation. Propofol coma was induced for sedation. After initiation of propofol, she developed a metabolic acidosis, hypotension, and bradycardia and expired. Patient 2: A 64-year-old man presented in status epilepticus. After prolonged propofol administration, he developed metabolic acidosis, hypotension, and rhabdomyolysis and expired. Patient 3: A 24-year-old woman presented in status epilepticus secondary to encephalitis. Propofol was added for seizure control. She developed hypotension, metabolic acidosis, and bradyarrhythmias. Despite transvenous pacing, she expired. CONCLUSION These data show an association between extended propofol use and metabolic acidosis, rhabdomyolysis, and death in adults, as well as children. Risk factors for propofol infusion syndrome in adults include lean body mass index, high dose, and administration of more than 24-hour duration. Creatine phosphokinase, lactic acid levels, electrolytes, and arterial blood gases should be monitored frequently. Both bacterial and fungal cultures should be obtained. If this syndrome is suspected, hemodialysis should be considered. In fatal cases, autopsy should include electron microscopy of cardiac and skeletal muscle to look for mitochondrial dysfunction. Further study is warranted.
Collapse
Affiliation(s)
- Monisha A Kumar
- Vascular and Critical Care Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | | | | | | | | |
Collapse
|
35
|
Errando CL, Tatay J, Serrano-Romero A, Gudín-Uriel M, Revert M, Peiró CM. Splenic rupture and haemoperitoneum in a patient with non-compaction of the left ventricular myocardium. Br J Anaesth 2005; 95:358-61. [PMID: 16040634 DOI: 10.1093/bja/aei207] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The anaesthetic and critical care management of blunt abdominal trauma in a patient previously diagnosed with non-compaction of the left ventricular myocardium (a rare autosomal dominant inherited disease) is reported. The management was influenced by the presence of an implanted automated internal defibrillator and treatment with anticoagulants because of the high frequency of severe arrhythmias and systemic embolism. The pathophysiology of ventricular non-compaction is reviewed briefly.
Collapse
Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Avenida Tres Cruces s/n, 46014-Valencia, Spain.
| | | | | | | | | | | |
Collapse
|
36
|
Liolios A, Guérit JM, Scholtes JL, Raftopoulos C, Hantson P. Propofol Infusion Syndrome Associated with Short-Term Large-Dose Infusion During Surgical Anesthesia in an Adult. Anesth Analg 2005; 100:1804-1806. [PMID: 15920217 DOI: 10.1213/01.ane.0000153017.93666.bf] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this case report we describe a case of propofol infusion syndrome in an adult after a short-term infusion of large-dose propofol during a neurosurgical procedure. Large-dose propofol (9 mg.kg(-1).h(-1)) was given for only 3 h during surgery and was followed by a small-dose infusion (2.3 mg.kg(-1).h(-1)) for 20 h postoperatively. The patient had also received large doses of methylprednisolone. He developed a marked lactic acidosis with mild biological signs of renal impairment and rhabdomyolysis but no cardiocirculatory failure. There were no other evident causes of lactic acidosis as documented by laboratory data. We believe this is the first report of reversible lactic acidosis associated with a short duration of large-dose propofol anesthesia.
Collapse
Affiliation(s)
- Antonios Liolios
- Department of Intensive Care, Laboratory of Neurophysiology, Department of Anesthesiology, Department of Neurosurgery, Cliniques Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | | | | | | | | |
Collapse
|
37
|
Augoustides JG, Culp KE, Ochroch AE, Milas BL. Total Suppression of Cerebral Activity by Thiopental Mimicking Propofol Infusion Syndrome: A Fatal Common Pathway? Anesth Analg 2005; 100:1865. [PMID: 15920242 DOI: 10.1213/01.ane.0000156682.59859.f3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- John G Augoustides
- Department of Anesthesia (Cardiothoracic Section), Hospital of the University of Pennsylvania, Philadelphia, PA,
| | | | | | | |
Collapse
|
38
|
Riker RR, Fraser GL. Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care Unit. Pharmacotherapy 2005; 25:8S-18S. [PMID: 15899744 DOI: 10.1592/phco.2005.25.5_part_2.8s] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the 2002 publication of multidisciplinary clinical practice guidelines for intensive care unit (ICU) sedation and analgesia, additional information regarding adverse drug events has been reported. Our understanding of the risks associated with these sedative and analgesic agents promises to improve outcomes by helping clinicians identify and respond to therapeutic misadventures sooner. This review focuses on many issues, including the potentially fatal consequences associated with the propofol infusion syndrome, the evolving understanding of propylene glycol intoxication associated with parenteral lorazepam, new data involving high-dose and long-term dexmedetomidine therapy, haloperidol- and methadone-related prolongation of QTc intervals on the electrocardiogram, adverse events associated with atypical antipsychotics, and the potential for nonsteroidal antiinflammatory drugs to interfere with bone healing.
Collapse
Affiliation(s)
- Richard R Riker
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Maine Medical Center, Portland, Maine 04102, USA
| | | |
Collapse
|