What is the treatment for propofol (2,6-diisopropylphenol) infusion syndrome?

Treatment of Propofol Infusion Syndrome

Early recognition and immediate discontinuation of propofol is the cornerstone of treatment for propofol infusion syndrome (PRIS), followed by aggressive supportive care. 1

Clinical Recognition

PRIS typically presents with:

• Worsening metabolic acidosis
• Hypertriglyceridemia
• Hypotension with increasing vasopressor requirements
• Cardiac arrhythmias
• Acute kidney injury
• Hyperkalemia
• Rhabdomyolysis
• Liver dysfunction 1

Treatment Algorithm

Immediate Actions

1. Discontinue propofol infusion immediately upon suspicion of PRIS 1, 2
2. Switch to alternative sedatives such as benzodiazepines or dexmedetomidine 1

Supportive Management

• Hemodynamic support:

  • Vasopressors and inotropes for hypotension and cardiac dysfunction
  • Consider extracorporeal membrane oxygenation (ECMO) for refractory cardiocirculatory failure 3

• Metabolic management:

  • Continuous renal replacement therapy (CRRT)/hemodialysis for metabolic acidosis, hyperkalemia, and renal failure 3
  • Sodium bicarbonate for severe acidosis

• Rhabdomyolysis management:

  • Aggressive fluid resuscitation
  • Monitoring of creatine kinase, myoglobin levels
  • Renal replacement therapy if needed

• Cardiac monitoring:

  • Continuous ECG monitoring
  • Serial cardiac enzymes
  • Echocardiography to assess cardiac function

Laboratory Monitoring

• Arterial blood gases
• Serum lactate
• Electrolytes, particularly potassium
• Creatine kinase
• Liver function tests
• Triglyceride levels
• Cardiac enzymes 4, 2

Special Considerations

Medication Continuation

• Pain medications (e.g., opioids) used before PRIS should be continued unless they show adverse effects 1
• All non-comfort medications should be evaluated and discontinued if not essential 1

Family Support

• Allow family members to be with the patient
• Provide clear communication about the condition and treatment plan
• Offer emotional support 1

Prognosis

The mortality from PRIS is high (up to 33%) and can occur even after discontinuing propofol infusion 1. Early recognition and aggressive supportive care are crucial for improving outcomes.

Prevention Strategies

• Limit propofol infusions to <48 hours when possible
• Maintain doses below 5 mg/kg/hr, particularly in patients with acute neurological or inflammatory illnesses 5
• Consider alternative sedatives for prolonged sedation requirements
• Monitor triglyceride levels during extended propofol use 6
• Use strict aseptic technique during handling of propofol 6
• Be particularly cautious in patients with risk factors:
  • Critical illness
  • Increased catecholamine levels
  • Steroid therapy
  • Carbohydrate depletion
  • Young age 4, 5

Remember that PRIS can occur even with low-dose propofol infusions when administered for prolonged periods, as demonstrated in recent case reports 7. The best management approach is prevention through careful patient selection and monitoring.