Propofol infusion syndrome: case report and literature review

Drugs associated with a risk of supraventricular tachycardia: analysis using the OpenVigil database

OBJECTIVE

The OpenVigil database can be used to assess medications that may cause supraventricular tachycardia (SVT) and to produce a reference for their safe use in clinical settings.

METHODS

We analyzed first-quarter data from 2004 to 2023, obtained by searching the OpenVigil database using the keyword "supraventricular tachycardia." Trade names and generic names were obtained by querying the RxNav database, and the proportions were summarized. The proportionate reporting ratio (PRR), reporting odds ratio, and chi-square values were also summarized. We created Asahi diagrams and set the screening criteria to drug events ≥30, PRR >2, and chi-square >4. Outcomes were evaluated using the Side Effect Resource database, several scientific literature databases, and the Hangzhou Yiyao Rational Medication System.

RESULTS

A total of 2435 distinct medications were found to induce SVT between the first quarter of 2004 and 2023, leading to 22,375 documented adverse events related to SVT. Further investigation revealed that salbutamol, paroxetine, formoterol, paclitaxel, venlafaxine, and theophylline were most likely to cause SVT.

CONCLUSION

We conducted signal mining of adverse drug events using the OpenVigil database and evaluated the six drugs most likely to cause SVT. The results of this research can serve as a drug safety reference in the clinic.

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-Related Infusion Syndrome: A Clinical Review

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.

Under the Microscope: A Look Into the Role of Critical Care Pharmacists During the COVID-19 Pandemic

Among disciplines, the COVID-19 pandemic has reinforced the importance of critical care pharmacists in assuming responsibility for managing medication therapy in direct patient care settings. Historically, pharmacists have been relied upon for prospective evaluation of drug therapy for appropriate indications, dosage, drug interactions, and drug allergies; monitoring patients' pharmacotherapeutic regimens for effectiveness and adverse effects; providing drug information to providers; and educating health professionals regarding drug therapies. Specific to COVID-19, pharmacists have been an integral member of the multidisciplinary rounding team, assisting with drug shortages and strategies for drug conservation; participating in emergencies, such as advanced cardiac life support (ACLS) and rapid sequence intubations; and creating as well as integrating evidence-based guidelines and pathways during the pandemic into clinical practice. The purpose of this article is to demonstrate the various roles of critical care pharmacists among the healthcare team in caring for critically ill COVID-19 patients.

A case report of multiple anesthesia for pediatric surgery: 80 anesthesia applications in a period of 6 years

Background

The side and adverse effects of anesthesia and its neurotoxicity to children have become major concerns of anesthesiologists in recent years.

Currently, no clinical trials have provided clear evidence indicating the suitable minimum age for a patient’s first anesthetic application, importance of anesthesia duration, number of anesthetic applications or interval between two consecutive anesthesia applications.

A very rare case concerning the side, adverse and neurotoxic effects of multiple anesthesia in a child is presented.

Case presentation

A case of a 9-year-old child who received 80 applications of anesthesia in 6 years because of corrosive esophagitis is presented. The commonly used anesthetic agents were propofol, fentanyl, rocuronium and sevoflurane.

Conclusion

In our case, there were no permanent side or adverse effects due to multiple anesthesia. The minimal psychological and scholastic problems of our case were tied to frequent hospitalization by the pediatric psychiatry consultation.

Propofol promotes apoptosis and suppresses the HOTAIR-mediated mTOR/p70S6K signaling pathway in melanoma cells

Propofol is an intravenous anesthetic, which is widely used in clinical anesthesia induction and maintenance and is critical in the sedation of patients. However, the functions and mechanisms of propofol on apoptosis of melanoma cells remain unclear. The present study investigated whether propofol promotes cell apoptosis and suppresses the HOX transcript antisense RNA (HOTAIR)-mediated mechanistic target of rapamycin (mTOR) pathway in melanoma cells. B16F10 cells were cultured with different concentrations (0-10 µM) of propofol for 24 or 48 h. Proliferation and apoptosis of B16F10 cells were detected using MTT assay and flow cytometry. The pcDNA 3.1(-)-HOTAIR and pcDNA 3.1(-)-control plasmids were transfected into B16F10 cells using Lipofectamine 2000. In the present study, treatment with propofol significantly reduced viability, and induced apoptosis and caspase-3 activity in melanoma cells. Propofol treatment significantly inhibited HOTAIR expression and the expression of phosphorylated (p)-mTOR and p- p70S6K protein in melanoma cells. Overexpression of HOTAIR significantly increased viability of melanoma cells, and increased HOTAIR, p-mTOR and p-p70S6K protein expression in melanoma cells. These results indicated that propofol promotes apoptosis and suppresses the HOTAIR-mediated mTOR signaling pathway in melanoma cells.

Propofol-Related Infusion Syndrome in the Peripartum Period

Background Propofol is a widely known, commonly used drug. Complications can occur with the use of this drug, including propofol-related infusion syndrome (PRIS). PRIS, in the obstetric population, has not been documented; however, we report a case of a patient who developed PRIS after an emergent cesarean delivery of a preterm infant. Case Study A 35-year-old multigravida woman presented complaining of leakage of fluid and decreased fetal movement. Her pregnancy was complicated by methadone maintenance therapy due to a history of opioid abuse. Complications after admission for prolonged monitoring and a prolonged fetal heart tone deceleration was noted with no recovery despite intrauterine resuscitation. An emergent cesarean delivery was performed using general anesthesia and endotracheal intubation after which she developed aspiration pneumonia. She was admitted to the intensive care unit and reintubation and sedation were required secondary to respiratory distress. Sedation was achieved using propofol infusion. She subsequently developed changes in her electrocardiogram, an increase of her serum creatinine, creatinine protein kinase, lipase, amylase, and triglycerides, making the diagnosis of PRIS. Conclusion PRIS should be included in the differential diagnosis of intubated or postoperative patients in the obstetric population.

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

PRIS may be diagnosed before ICU period for patients undergoing cardiopulmonary bypass

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.

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.

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

Electrochemical quantification of 2,6-diisopropylphenol (propofol)

2,6-Diisopropylphenol (propofol) is a potent anesthetic drug with fast onset of the anesthetic effect and short recovery time for the patients. Outside of the United States, propofol is widely used in performing target controlled infusion anesthesia. With the long term vision of an electrochemical sensor for in vivo monitoring and feedback controlled dosing of propofol in blood, different alternatives for the electrochemical quantification of propofol using diverse working electrodes and experimental conditions are presented in this contribution. When the electrochemical oxidation of propofol takes place on a glassy carbon working electrode, an electrochemically active film grows on the electrode surface. The reduction current of the film is proportional to the propofol concentration and the accumulation time. Based on these findings a stripping analytical method was developed for the detection of propofol in acidic solutions between 0 and 30 μM, with a detection limit of 5.5±0.4 μM. By restricting the scanned potential window between 0.5 V and 1.0 V in cyclic voltammetric experiments, the formation of the electrochemically active polymer can be prevented. This allowed the development of a direct voltammetric method for assessing propofol in acidic solutions between 0 and 30 μM, with a 3.2±0.1 μM (n=3) detection limit. The stripping method has a better sensitivity but somewhat worse reproducibility because the electrode surface has to be renewed between each experiment. The direct method does not require the renewal of the electrode surface between measurements but has no adequate selectivity towards the common interfering compounds.

Dexmedetomidine use in pediatric airway reconstruction

OBJECTIVE

Assess the postoperative use of dexmedetomidine (Precedex) in pediatric patients following airway reconstruction.

STUDY DESIGN

Historical cohort study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

A retrospective review of 24 children undergoing laryngotracheal reconstruction (LTR) or laryngeal cleft repair (LCR) was conducted. Twelve children were treated with standard sedation protocols where dexmedetomidine was administered in lieu of propofol (Diprivan); 12 age-, gender-, and procedure-matched controls were selected. Subjects were divided into groups based on duration of postoperative intubation for cross-comparison; group 1 was intubated <24 hours, group 2 was intubated 2 to 6 days, and group 3 was intubated 7 days or longer. Baseline heart rate and blood pressure measurements were compared to hourly measurements for the first 6 hours following initiation of dexmedetomidine or mechanical ventilation in the control group. Number of supportive respiratory interventions, adverse events, self-extubations, premature termination of dexmedetomidine, amount of muscle relaxants, agents to treat withdrawal, and length of stay were evaluated.

RESULTS

Ten patients undergoing LTR and 2 patients undergoing LCR receiving dexmedetomidine were compared to 10 LTR and 2 LCR control patients. Overall, dexmedetomidine was well tolerated and without significant adverse effects, particularly in cases of short-term intubation or as a bridge to extubation.

CONCLUSION

In cases requiring short-term intubation following airway reconstruction, dexmedetomidine may offer a safe alternative to propofol by providing readily reversible sedation during the periextubation period. Further studies are needed to determine the safety, efficacy, dosing, and potential complications of longer term dexmedetomidine administration in pediatric airway reconstruction.

m-Azipropofol (AziPm) a photoactive analogue of the intravenous general anesthetic propofol

Propofol is the most commonly used sedative-hypnotic drug for noxious procedures, yet the molecular targets underlying either its beneficial or toxic effects remain uncertain. In order to determine targets and thereby mechanisms of propofol, we have synthesized a photoactivateable analogue by substituting an alkyldiazirinyl moiety for one of the isopropyl arms but in the meta position. m-Azipropofol retains the physical, biochemical, GABA_A receptor modulatory, and in vivo activity of propofol and photoadducts to amino acid residues in known propofol binding sites in natural proteins. Using either mass spectrometry or radiolabeling, this reagent may be used to reveal sites and targets that underlie the mechanism of both the desirable and undesirable actions of this important clinical compound.

Immunonutrition and critical illness: an update

Dietary supplementation with nutrients that have physiologic effects on immune function has been shown to be beneficial in subsets of patients with surgical and medical critical illness. However, several meta-analyses have suggested potential harm when immune nutrients are used inappropriately. This has led to concern among clinicians that in turn has curtailed the more widespread use of immunonutrition as a therapeutic modality. This article discusses the mechanisms by which immune nutrients can be used to modulate alterations in innate and acquired immunity associated with critical illness. In addition, recent evidence-based clinical practice guidelines for use of immunonutrition in adults is reviewed as a means to clarify some of the more controversial issues and provide a "roadmap" for the practitioner.