Propofol infusion syndrome

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The propofol infusion syndrome (PRIS) is a very rare symptom complex severe adverse drug reactions , as a result of intravenous application of anesthetic propofol may occur. In addition to initiating and maintaining anesthesia in anesthesia, propofol is also widely used as a sedative in intensive care medicine , with the dosage and duration of sedation being kept as low as possible in modern intensive care medicine. The propofol infusion syndrome is characterized by disorders of the cardiovascular system, rhabdomyolysis and lactic acidosis , among other things .

frequency

Propofol infusion syndrome is a very rare, life-threatening complication of anesthesia with propofol. A total of 45 cases had been published by 2004. According to a prospective study, the incidence in adult ICU patients who have been treated with propofol for at least 24 hours is 1.1 percent, and the mortality rate is 18%.

Propofol infusion syndrome can occur especially with long-term infusion of propofol or with very high doses. However, the complication has already been described with propofol anesthesia lasting about 5 hours. Children are particularly at risk of developing such a syndrome.

Emergence

The origin of the propofol infusion syndrome has not been clarified in detail. Several factors play a role, the main cause probably being a disturbed fatty acid metabolism with decoupling from the respiratory chain . High-dose and long-lasting propofol infusions favor the development of a PRIS. It is unclear whether the medium dose or very high doses in the short term favor the development.

Clinical appearance

A propofol infusion syndrome usually results in heart failure and arrhythmia, as well as metabolic acidosis . In addition, rhabdomyolysis and acute kidney insufficiency or acute kidney failure occur relatively frequently, and less often hypertriglyceridemia.

Brugada- like changes in the EKG are typical for cardiac arrhythmias . Furthermore, the it can atrioventricular blocks , broadening of the QRS complex and bradycardia come. The latter can lead to asystole .

Metabolic acidosis is caused by lactic acidosis and the consequences of kidney failure. The damage to the heart muscle can be shown by increases in cardiac enzymes . With rhabdomyolysis, the creatine kinase and myoglobin in the serum rise and myoglobin can be detected in the urine ( myoglobinuria ). The kidney failure is likely caused by the increased myoglobin.

therapy

The most important measure in the presence of a propofol infusion syndrome is to stop sedation with propofol immediately and switch to another sedative. Even if the symptoms recover or improve after discontinuation of propofol, renewed use is not recommended, as an accumulation and redistribution of propofol is suspected, especially after long-term use . The latter can lead to a significantly longer influence on the metabolism than is to be expected with the short half-life of propofol.

In addition, supporting measures may have to be taken. These include the administration of fluids and catecholamines to maintain a sufficiently high blood pressure, the treatment of bradycardia - if medication is not sufficient, possibly with pacemaker stimulation - and the compensation of metabolic acidosis. The use of a kidney replacement procedure ( hemofiltration or hemodialysis ) should also be considered at an early stage, since severe cases have been described in which this treatment option no longer worked. Continuous hemofiltration in particular often leads to a rapid improvement in symptoms, possibly because a suspected metabolite of propofol can be dialyzed. A sufficient intake of calories in the form of carbohydrates is also recommended in view of the suspected fatty acid oxidation disorder.

literature

Individual evidence

  1. ↑ a b c Frank Wappler: The Propofol Infusion Syndrome: Clinic, pathophysiology and therapy of a rare complication . Deutsches Ärzteblatt 2006; 103 (11): A-705 / B-601 / C-581. Online version .
  2. ↑ Hans Walter Striebel: The anesthesia. Basics and practice Schattauer Verlag, 2010, ISBN 978-3794526369 , p. 146.
  3. ↑ a b R. J. Roberts, JF Barletta et al. a .: Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study. In: Critical care. Volume 13, Number 5, 2009, p. R169, ISSN  1466-609X . doi : 10.1186 / cc8145 . PMID 19874582 . PMC 2784401 (free full text).
  4. ^ A b Ne-Hooi Will Loh et al .: Propofol infusion syndrome . Continuing Education in Anesthesia, Critical Care & Pain. February 20, 2013 doi : 10.1093 / bjaceaccp / mkt007
  5. ↑ a b J. Motsch, J. Roggenbach: Propofol infusion syndrome. In: The anesthesiologist. Volume 53, Number 10, October 2004, pp. 1009-1022, ISSN  0003-2417 . doi : 10.1007 / s00101-004-0756-3 . PMID 15448937 . (Review).

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