What are the management and prevention strategies for Propofol (propofol) infusion syndrome?

Management and Prevention of Propofol Infusion Syndrome

Early recognition and immediate discontinuation of propofol are the most critical interventions for managing propofol infusion syndrome (PRIS), with supportive care as the mainstay of treatment. 1

Clinical Features and Diagnosis

PRIS presents with a constellation of symptoms that can include:

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

Risk Factors

Key risk factors for developing PRIS include:

• Prolonged administration of high propofol doses (>70 μg/kg/min), though it can occur with lower doses 1
• Critical illness, particularly acute neurological or inflammatory conditions 2, 3
• Concomitant administration of catecholamines and/or corticosteroids 2, 3
• Carbohydrate depletion 3, 4
• Young age (particularly relevant in pediatric patients) 2, 5

Prevention Strategies

Dosing Considerations

• Limit propofol infusion rates to <5 mg/kg/hr (approximately 70-80 μg/kg/min) 2, 3
• Avoid prolonged infusions (>48 hours) when possible 2, 3
• Consider alternative sedatives for patients requiring long-term sedation 2, 3

Monitoring Protocol

• Implement a screening protocol with daily laboratory monitoring 6:
  • Serum creatine phosphokinase (CPK) - discontinue propofol if >5000 IU/L 6
  • Serum lactate levels - consider as an early warning sign 4
  • Arterial blood gases to detect metabolic acidosis 1, 3
  • Serum triglycerides 1
  • Cardiac monitoring 3, 5
  • Renal and liver function tests 1

High-Risk Patients

• For patients with acute neurological illnesses or inflammatory conditions:
  • Consider alternative sedatives such as dexmedetomidine 1
  • If propofol must be used, implement more frequent monitoring 2, 3
• Ensure adequate carbohydrate intake in critically ill patients to prevent reliance on lipid metabolism 3, 4

Management of Established PRIS

Immediate Actions

• Discontinue propofol infusion immediately upon suspicion of PRIS 1, 3
• Provide supportive care focused on organ dysfunction 1

Supportive Measures

• Hemodynamic support for cardiovascular dysfunction 3, 5
• Management of metabolic acidosis 1, 3
• Renal replacement therapy for acute kidney injury and to clear metabolites 3, 5
• Consider extracorporeal membrane oxygenation (ECMO) in refractory cases 3

Clinical Pitfalls and Caveats

• PRIS can be difficult to diagnose due to its variable presentation and overlap with common ICU complications 1
• The syndrome can progress even after discontinuation of propofol 1
• Mortality from PRIS is high (up to 33%) 1
• The incidence of PRIS with propofol infusions is approximately 1% 1
• Early signs such as unexplained metabolic acidosis should prompt immediate evaluation 3, 4
• PRIS can occur with low-dose infusions, not just high doses 1

Alternative Sedation Strategies

For patients requiring long-term sedation, consider:

• Dexmedetomidine, which has minimal respiratory depression and different mechanism of action 1
• Benzodiazepines, though monitoring for propylene glycol toxicity with lorazepam is necessary 1
• Combination therapy with reduced doses of multiple agents 1