Propofol Infusion syndrome?

PixieRN1 · Oct 23, 2017

I don't know how it works in adults, but the risk of this is sky-high in pediatrics. We NEVER EVER EVER EVER use it for more than 24 hours. Ever. Adults I believe is no high dose therapy (4 mg/kg/hr) longer than 48 hours.

We will move earth, wind, and fire to find any other combo that will work remotely well enough to substitute.

Even if we know propofol would keep things copacetic and in the comfort zone and switching would be less than ideal, darn tooting we switch.

My philosophy: Don't **** with propofol outside of evidence-based practice. At least in pediatrics!!!

Pharmahaulic · Oct 23, 2017

I don't know how it works in adults, but the risk of this is sky-high in pediatrics. We NEVER EVER EVER EVER use it for more than 24 hours. Ever. Adults I believe is no high dose therapy (4 mg/kg/hr) longer than 48 hours.
We will move earth, wind, and fire to find any other combo that will work remotely well enough to substitute.
Even if we know propofol would keep things copacetic and in the comfort zone and switching would be less than ideal, darn tooting we switch.
We actually had a patient Life Flighted to us because he developed this syndrome; it was a 12 year old boy in status epilepticus. He had been on a propofol drip for 48 hours in another hospital system because he was refractory to all other anti seizure meds/drips. He had no seizures on the propofol drip as they were running it.
He rapidly crashed and burned at around the 40 hour mark. He developed rhabdomyolysis, renal failure, and severe liver failure. His first sign was a new-onset right bundle branch block, according to his records.
He was being flown in for hemodialysis and potential ECMO. In reality, they should have transported him after 24 hours on propofol without success weaning him. You just don't do propofol drips a second longer than recommended in peds. And if you do, you better be in a facility with dialysis and ECMO.
He had a cardiac arrest in flight on the chopper. He arrived while being coded to our unit and was immediately crashed into ECMO. We had the circuit up and running before they touched down. He was on ECMO within 15 minutes of arrival. He ended up hemorrhaging profusely (coags were shot) and blew his pupils after about 30 minutes on the circuit. He bled out everywhere; the floor was dripping in blood.
He was a beautiful little boy. Just beautiful.
I don't know what his outcome would have been from his status epilepticus, but I feel certain he would have had a better shot if they had shut off the propofol at an appropriate time and converted to something else, even if his seizures were less well managed. You just can't let a kid sit on a propofol drip like that.
He died before his family could finish the drive down. His organs couldn't be salvaged. It was a god-awful loss.
My philosophy: Don't f*** with propofol outside of evidence-based practice. At least in pediatrics!!!

I'm so sorry to hear this! Do they know what it is that causes this rare condition?

I know that they were working on a different propofol formulation or prodrug of propofol that would have the same effects but without the risks... it was called Lusedra or whatever. Do you know anything about this?

In the case with this boy, could they have tried a barbiturate anesthetic like thiopental?

AceOfHearts<3 · Oct 23, 2017

Adult ICU RN here- I've had patients on propofol for several days when other meds have not worked or contributed to too much hemodynamic instability (bradycardia, etc). Per protocol we automatically start trending triglyceride levels.

Monitor Triglycerides To Avoid Propofol Infusion Syndrome - Anesthesiology News

PixieRN1 · Oct 23, 2017

I'm so sorry to hear this! Do they know what it is that causes this rare condition?
I know that they were working on a different propofol formulation or prodrug of propofol that would have the same effects but without the risks... it was called Lusedra or whatever. Do you know anything about this?
In the case with this boy, could they have tried a barbiturate anesthetic like thiopental?

The etiology is poorly understood; it's thought to be related to direct mitochondrial respiratory chain inhibition and/or impaired mitochondrial fatty acid metabolism. Acute neurological injury is a predisposing risk factor, so that didn't help my patient either.

As for Thiopental, it has precious little research in the pediatric population, aside from some surgical uses as an induction agent to reduce ICP in certain surgeries. So I personally have never seen it used in the PICU.

Kids on propofol are supposed to have routine lipid panels done, as well as CMPs, lactics, CKs, and ABGs. I don't know what the policy was at the outlying hospital. The problem is, in my experience, once you figure out what is wrong, it's awfully hard to swing the pendulum back in the right direction in these kids. Especially if the hospital doesn't have the equipment to handle the complications. When they crash, they crash hard, fast, and often don't like to cue you in.

I do know that propofol infusions are much safer in adults, although the risk is there. In peds, we are just very clever in creating cocktails that can avoid a prolonged propofol infusion.

Once you've seen someone die from propofol infusion syndrome, you never want to see it again.

dogmombyday, RN · Oct 23, 2017

Adult ICU RN here- I've had patients on propofol for several days when other meds have not worked or contributed to too much hemodynamic instability (bradycardia, etc). Per protocol we automatically start trending triglyceride levels.
Second that. I've seen patients on my unit stay on propofol for extended periods simply because nothing else works for their situation, but we trend their triglycerides. Usually seems to be the ones whose bodies don't love fentanyl, at least for me.

Pharmahaulic · Oct 23, 2017

Adult ICU RN here- I've had patients on propofol for several days when other meds have not worked or contributed to too much hemodynamic instability (bradycardia, etc). Per protocol we automatically start trending triglyceride levels.
Monitor Triglycerides To Avoid Propofol Infusion Syndrome - Anesthesiology News

So propofol infusion syndrome is caused by elevated triglycerides? If a sedated patient under propofol is monitored and u notice a change in triglyceride levels, what do you do?

Julius Seizure · Oct 23, 2017

In peds we would rather just keep cranking up the opioid and benzo. Sometimes they like to switch back and forth between combos if things aren't cutting it too (like going from fent/versed to morphine/ativan). Add precedex, I like precedex. You could do pentobarb if you were desperate I guess, but I've never seen it get to that. Just keep going up on the opioid and benzo and give PRN doses. I've also seen additional PRNs used, like haldol, but rarely.

LovingLife123 · Oct 23, 2017

We use a lot of propofol. I'm also an adult icu nurse. We also trend triglycerides and watch out for things like urine turning green. We use fentanyl and prop together. Sometimes a patient will be switched to fentanyl/versed drips, and in rare cases a morphine/Ativan drip is used. That's more long term though as you can't really do sedation vacations and breathing trials with Ativan. I've r centky started to see ketamine used more and more. But propofol is our go to.

I will adjust my fentanyl before propofol always. But the problem comes is when you have people who are not at all opiate naive and they need a ton of fentanyl to begin with. Then you end up using more propofol to get the sedating effect.

You just have to be vigilant in your dosing and observations on your patient.

Pharmahaulic · Oct 23, 2017

In peds we would rather just keep cranking up the opioid and benzo. Sometimes they like to switch back and forth between combos if things aren't cutting it too (like going from fent/versed to morphine/ativan). Add precedex, I like precedex. You could do pentobarb if you were desperate I guess, but I've never seen it get to that. Just keep going up on the opioid and benzo and give PRN doses. I've also seen additional PRNs used, like haldol, but rarely.

Isnt there a limits on the dosage of benzos you can give though? Like even if you have reached the max dose and not getting the optimal response, you can't just keep giving more right?

Castiela · Oct 23, 2017

We also trend triglycerides, ck, and bun/cr for patients receiving protocol for >24hrs in adult icu. If values start to change, that's when we will switch to a different sedative

Julius Seizure · Oct 23, 2017

Isnt there a limits on the dosage of benzos you can give though? Like even if you have reached the max dose and not getting the optimal response, you can't just keep giving more right?

Well, when using a lot of benzos, delirium is definitely a concern, so its not ideal to just crank it up sky-high. My preference would be to increase the opioid vs. the benzo.

However, for both the "max dose" is really limited by hemodynamics - if they are hypotensive, you have reached max dose. Otherwise, technically you can "titrate to desired effect" (in the words of UpToDate). The goal is still to use the lowest dose you can, of course.