What are the management steps for propofol (2,6-diisopropylphenol) toxicity?

Management of Propofol Toxicity

Immediate discontinuation of propofol is the first and most critical step in managing propofol toxicity, followed by supportive measures including artificial ventilation with oxygen for respiratory depression and cardiovascular support through patient repositioning, intravenous fluid administration, and pressor agents as needed. 1

Types of Propofol Toxicity

1. Acute Overdose

• Presentation: Cardiorespiratory depression, hypotension, respiratory depression
• Management:
  • Discontinue propofol immediately
  • Provide respiratory support with artificial ventilation and oxygen
  • Address cardiovascular depression:
    • Reposition patient by raising legs
    • Increase IV fluid administration rate
    • Administer pressor agents and/or anticholinergic agents 1

2. Propofol Infusion Syndrome (PRIS)

PRIS is a rare but potentially fatal complication characterized by multiple organ system failures, typically associated with prolonged high-dose propofol administration.

• Risk Factors:

  • High-dose propofol (>4-5 mg/kg/hr)
  • Prolonged administration (>48 hours)
  • Critical illness
  • Young age
  • Concomitant catecholamine or steroid administration
  • Carbohydrate depletion 2, 3

• Clinical Manifestations:

  • Metabolic acidosis (high anion gap)
  • Rhabdomyolysis
  • Hyperkalemia
  • Hyperlipidemia
  • Cardiac dysfunction (bradycardia, arrhythmias)
  • Acute kidney injury
  • Elevated liver enzymes 2, 3

• Management of PRIS:

  1. Immediately discontinue propofol infusion
  2. Correct metabolic acidosis
  3. Provide hemodynamic support
  4. Consider hemodialysis for severe cases
  5. Extracorporeal membrane oxygenation (ECMO) for refractory cardiac dysfunction 3

Monitoring for Propofol Toxicity

For patients receiving propofol, especially at higher doses or for prolonged periods, monitor:

• ECG for arrhythmias
• Serum creatine kinase
• Serum triglycerides
• Lactate levels
• Liver enzymes
• Myoglobin in urine
• Acid-base status 2

Prevention of Propofol Toxicity

1. Limit propofol doses to <4 mg/kg/hr when possible
2. Consider alternative sedatives for prolonged sedation (>48 hours)
3. Use with caution in critically ill patients
4. Monitor for early signs of PRIS, particularly in high-risk patients
5. Consider dexmedetomidine as an alternative for ICU sedation, especially in non-intubated patients 4

Special Considerations

• Hypertriglyceridemia: Monitor triglyceride levels during extended propofol use as the lipid emulsion can cause hypertriglyceridemia and potentially acute pancreatitis 5

• Infection risk: The lipid emulsion can support microbial growth; use strict aseptic technique when handling propofol 5

• Allergic reactions: While rare, propofol contains egg phosphatide and soybean oil. However, guidelines indicate there is no published evidence that propofol should be avoided in patients with egg, soya, or nut allergies, as the manufacturing process likely removes or denatures the proteins responsible for allergic reactions 4, 5

Early recognition of propofol toxicity and prompt intervention are crucial for improving outcomes, particularly in cases of PRIS which carries a high mortality rate despite treatment 6, 7.