Propofol-related Infusion Syndrome

Reviewed and revised 4 August 2015

OVERVIEW

Propofol-related Infusion Syndrome (PRIS) is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of:

  1. metabolic acidosis
  2. rhabdomyolysis
  3. hyperlipidaemia
  4. enlarged or fatty liver

MECHANISM

Poorly understood — even the central role of propofol has been questioned

  • ? direct mitochondrial respiratory chain inhibition
  • ? impaired mitochondrial fatty acid metabolism

CLINICAL FEATURES

  • high dose, long duration proprofol infusion (maximum dose should be 28mL/hr (70kg adult, 1% propofol at maximum of 4mg/kg/hr)
  • on propofol!
  • increasing inotrope support
  • green urine (some sources say no correlation with PRIS)
  • cardiovascular collapse (reflected in PICCO, PAC, ECHO)

RISK FACTORS

  • >4mg/kg/hr for 48 hours (large dose, long time); but can occur at lower doses
  • younger age
  • acute neurological injury
  • low carbohydrate intake
  • catecholamine infusion
  • corticosteroids infusion

INVESTIGATIONS

Bedside

  • ECG: Brugada like pattern (coved type = convex-curved ST elevation in V1-V3), RBBB, arrhythmia, heart block
  • blood gas: unexplained lactic acidosis; hyperkalaemia (if rhabdomyolysis or renal failure)

Laboratory

  • lipids (lipaemic serum)
  • UEC (renal failure)
  • CK (rhabdomyolysis)
  • propofol levels or chromatography (if available)

MANAGEMENT

  • high index of suspicion
  • monitor for early warning signs (lactate, CK, urinary myoglobin, ECG)
  • discontinue propofol immediately
  • supportive care and monitoring
  • consider pacing
  • adequate carbohydrate intake (6-8mg/kg/min)
  • carnitine supplementation (theoretical benefit)
  • haemodialysis and haemoperfusion (used with success in case reports)
  • ECMO (at least 2 cases reported, reasonable strategy given readily reversible pathology)

References and Links

Journal articles

  • Fudickar A, Bein B. Propofol infusion syndrome: update of clinical manifestation and pathophysiology. Minerva Anestesiol. 2009 May;75(5):339-44. PMID: 19412155

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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