Propofol Related Infusion Syndrome (PRIS)
➧ It is a rare syndrome that affects patients undergoing long-term treatment with high doses of the anesthetic and sedative drug propofol.
➧ It is associated with high doses and long-term use of propofol (>4 mg/kg/hr for more than 24 hours). It occurs more commonly in children, and critically ill patients receiving catecholamines and glucocorticoids are at high risk.
Clinical Picture:
➧ Arrhythmias
➧ Progressive Myocardial Failure
➧ Cardiovascular Collapse
➧ Lipemia
➧ Hypertriglyceridemia
➧ Acute Renal Failure
➧ Rhabdomyolysis
➧ Metabolic acidosis
➧ Hyperkalemia
➧ Hepatomegaly
➧ Green urine (phenol metabolites), (Figure 1)
➧ It is often fatal
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| Figure 1: Green Urine |
Laboratory Results:
➧ Elevated serum lactate
➧ Elevated CPK
➧ Myoglobinuria
➧ Hyperkalemia
➧ Hypertriglyceridemia
ECG changes:
➧ ST elevation in precordial leads V1 to V3
Predisposing factors for developing PRIS:
➧ Propofol dose >4 mg/kg/h
➧ Propofol infusion >48 h
➧ Presence of “triggering factor” (i.e. catecholamine infusion or corticosteroids)
➧ Inadequate delivery of carbohydrate
➧ Critical Illness
➧ Severe Cerebral Injury
➧ Sepsis
➧ Pancreatitis
➧ Trauma
Prevention:
➧ Avoid high propofol doses and minimize the duration of infusion in high-risk patients
➧ Avoid lipid overload by assessing all sources of fat calories (e.g., parenteral nutrition, enteral nutrition).
➧ Monitoring of serum triglycerides in any patient receiving propofol in doses >4 mg/kg/h or >48 is highly recommended.
➧ Assure adequate provision of carbohydrates.
➧ Depletion of carbohydrate stores can promote mobilization of fat stores and increase lipid metabolism. This, in turn, increases circulating fatty acid load and may predispose patients to PRIS.
➧ Theoretically, it is, therefore, possible that early adequate carbohydrate intake may prevent PRIS by preventing the switch to fat metabolism.
➧ There is some suggestion that providing a carbohydrate intake of 6–8 mg/kg/min. can suppress fat metabolism and thus prevent PRIS.
Treatment: (Supportive)
➧ Early recognition of the syndrome and discontinuation of the propofol infusion reduces morbidity and mortality.
➧ Once a patient presents with symptoms compatible with PRIS, propofol infusion should be discontinued promptly and an alternative sedative agent should be initiated.
➧ Cardiovascular support by the combination of vasopressors and inotropes.
➧ Cardiac pacing should be considered.
➧ Hemodialysis or hemofiltration to decrease the plasma concentrations of circulating metabolic acids and lipids.
➧ Extracorporeal membrane oxygenation (ECMO) for combined respiratory and circulatory support.
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