Propofol Infusion syndrome?

Julius Seizure · Oct 23, 2017

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?

Well, propofol can cause high triglycerides because it is a lipid preparation, but that isnt exactly why they think propofol infusion syndrome happens. It has to do with the fatty acids though (which, yes, are part of triglycerides).

Like PixieRN1 said, the etiology isn't totally understood but they think it might have something to do with impairment of the mitochondria and their job in breaking down fatty acids. Basically, the body can't break down (oxidize) the fatty acids and they build up and cause toxicity, acidosis, and muscle damage (this is where the rhabdomyolysis and cardiac damage/dysrhythmias come into play).

They don't know why it happens in the first place though - is it because some patients have bad mitochondria to being with, or are the mitochondria getting damaged/overworked?

hawaiicarl, BSN, RN · Oct 23, 2017

If patients have high trigs, we try to combo them with precedex/fentanyl to cut down the propofol dose. If it looks like we are in for the long haul, we'll switch to an ativan or a versed drip.

Cheers

BSN16 · Oct 24, 2017

propofol infusion syndrome is actually VERY rare (especially in adults) effecting about 1% of the population. Propofol is a GREAT drug, but propofol infusion syndrome has never once been brought up as a concern on any of my long term sedated patients. i have had patients with TBIs on propofol for WEEKS. same with ards, weeks on propofol. Usually concerns about propofol are delirium and BP issues.

BSN16 · Oct 24, 2017

propofol infusion syndrome is actually VERY rare (especially in adults) effecting about 1% of the population. Propofol is a GREAT drug, but propofol infusion syndrome has never once been brought up as a concern on any of my long term sedated patients. i have had patients with TBIs on propofol for WEEKS. same with ards, weeks on propofol. Usually concerns about propofol are delirium and BP issues.

i'd also like to add that other medications such as versed and ativan aren't great options either. Whats unique about propofol is it has a short half life and is metabolized fast and without too much consequence from the kidneys. Versed and ativan are metabolized by the liver and take a looooong time to wear off. I actually work with a lot of end stage liver and liver transplant and these medications are never given. propofol and fent always

RotorRunner · Oct 24, 2017

Flight nurse here. I do Versed and Fentanyl for nearly every sedation situation. Propofol is just too finicky, IMO. I never ever use it for peds. They respond well to benzos and opioids typically, and you don't get the dramatic drop in BP.

P.S. This is a personal preference...I'm only taking care of these patients for a short amount of time. Surely there are many different considerations in the hospital setting.

Pharmahaulic · Oct 24, 2017

Well, propofol can cause high triglycerides because it is a lipid preparation, but that isnt exactly why they think propofol infusion syndrome happens. It has to do with the fatty acids though (which, yes, are part of triglycerides).
Like PixieRN1 said, the etiology isn't totally understood but they think it might have something to do with impairment of the mitochondria and their job in breaking down fatty acids. Basically, the body can't break down (oxidize) the fatty acids and they build up and cause toxicity, acidosis, and muscle damage (this is where the rhabdomyolysis and cardiac damage/dysrhythmias come into play).
They don't know why it happens in the first place though - is it because some patients have bad mitochondria to being with, or are the mitochondria getting damaged/overworked?

This night be stupid, but as a treatment can they give something to help breakdown the fatty acids, or give carbohydrates or whatever to give the body a source of energy so that way they don't go Rhabdo and start breaking down muscles and tissues?

Pharmahaulic · Oct 24, 2017

Well, propofol can cause high triglycerides because it is a lipid preparation, but that isnt exactly why they think propofol infusion syndrome happens. It has to do with the fatty acids though (which, yes, are part of triglycerides).
Like PixieRN1 said, the etiology isn't totally understood but they think it might have something to do with impairment of the mitochondria and their job in breaking down fatty acids. Basically, the body can't break down (oxidize) the fatty acids and they build up and cause toxicity, acidosis, and muscle damage (this is where the rhabdomyolysis and cardiac damage/dysrhythmias come into play).
They don't know why it happens in the first place though - is it because some patients have bad mitochondria to being with, or are the mitochondria getting damaged/overworked?

This night be stupid, but as a treatment can they give something to help breakdown the fatty acids, or give carbohydrates or whatever to give the body a source of energy so that way they don't go Rhabdo and start breaking down muscles and tissues?

Julius Seizure · Oct 24, 2017

This night be stupid, but as a treatment can they give something to help breakdown the fatty acids, or give carbohydrates or whatever to give the body a source of energy so that way they don't go Rhabdo and start breaking down muscles and tissues?

:) Actually some DO think high carbs help! There's at least a few journal articles that has been written about it (but it's hard to study something that occurs rarely and that you don't really want to induce on purpose).

"Adults have larger carbohydrate stores and require lower doses of propofol for sedation than children, which might account for the rarity of this syndrome in adults. The mean total daily calorific intake in our case was only 167Â·1 kJoules/kg (39Â·8 kcals/kg), with a carbohydrate intake of 0Â·9 mg/kg per min on day 1, 2Â·6 mg/kg per min on day 2, 2Â·4 mg/kg per min on day 3, and 4Â·2 mg/kg per min on day 4, which would be insufficient to prevent fat metabolism. A carbohydrate intake of 6â€“8 mg/kg per min should provide adequate calories to suppress fat metabolism in critically ill children. We suggest that such carbohydrate intake might prevent propofol infusion syndrome."

Wolf A., Weir P., Segar P., Stone J., and Shield J. (2001). Impaired fatty acid oxidation in propofol infusion syndrome. Lancet, 357, pp. 606-607.

See also:

EB Stelow, VP Johari, SA Smith, JT Crosson, FS Apple. (2000). Propofol-associated rhabdomyolysis with cardiac involvement in adults: chemical and anatomic findings. Clin Chem, 46, pp. 577-581.

(apologies for the poor citation format...I mostly just copy/pasted)

LovingLife123 · Oct 24, 2017

Flight nurse here. I do Versed and Fentanyl for nearly every sedation situation. Propofol is just too finicky, IMO. I never ever use it for peds. They respond well to benzos and opioids typically, and you don't get the dramatic drop in BP.
P.S. This is a personal preference...I'm only taking care of these patients for a short amount of time. Surely there are many different considerations in the hospital setting.

I would think most of your patients that need sedated are way too unstable to use propofol. Just like you said, it drops BP quickly. I would be very hesitant to use it out in the field as well.

DaveICURN · Oct 24, 2017

In our unit we have Sedation Vacations ordered every 24 hours of sedation. We titrate down the propofol using the rule of 5 until off. We then wake the Pt and assess mental status and let the pt know about their condition. If the pt tolerates well, we may use other medications to maintain a therapeutic response. if not, then we place Pt back under full sedation and try again tomorrow.

MunoRN, RN · Oct 24, 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 on to 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. And after we had done everything, it looked like a slaughterhouse.
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. When they got there and went to his bedside, the screams were so loud you could hear them outside of the unit; a kind of gulping, sucking air, life emptying scream that wouldn't end. He had been a normal kid on the playground with no medical history 72 hours before...His organs couldn't be salvaged either.
It was a god-awful loss.
My philosophy: Don't f*** with propofol outside of evidence-based practice. At least in pediatrics!!!

There's not really any evidence base for using a set time based limit on propofol infusions, Propofol Infusion Syndrome (PRIS) can occur at any duration of infusion. The incidence does increase with the dose and duration of the infusion, and that increase in risk should be incorporated into the benefit/risk decision as well as the plan for monitoring for PRIS, but a set time limit is not particularly beneficial.

Some hospitals do choose to use a set time limit, I personally find this to be counterproductive as it causes clinicians to rely on the time limit to prevent PRIS, potentially making it less likely to be spotted early.

As with everything, it's a balance of risk and benefit. To take your example above, propofol is a powerful anti-epileptic, and in some cases all other medications have been ineffective and it's the only thing that will keep a patient out of status. You could reduce the likelihood of PRIS by turning off the propofol at 24 hours, allowing the patient to be in status epilepticus which will likely result in permanent neurological injury or death, or avoid status epilepticus with propofol which has a much smaller risk of injury and death.

PixieRN1 · Oct 24, 2017

There's not really any evidence base for using a set time based limit on propofol infusions, Propofol Infusion Syndrome (PRIS) can occur at any duration of infusion. The incidence does increase with the dose and duration of the infusion, and that increase in risk should be incorporated into the benefit/risk decision as well as the plan for monitoring for PRIS, but a set time limit is not particularly beneficial.
Some hospitals do choose to use a set time limit, I personally find this to be counterproductive as it causes clinicians to rely on the time limit to prevent PRIS, potentially making it less likely to be spotted early.
As with everything, it's a balance of risk and benefit. To take your example above, propofol is a powerful anti-epileptic, and in some cases all other medications have been ineffective and it's the only thing that will keep a patient out of status. You could reduce the likelihood of PRIS by turning off the propofol at 24 hours, allowing the patient to be in status epilepticus which will likely result in permanent neurological injury or death, or avoid status epilepticus with propofol which has a much smaller risk of injury and death.

The problem in this case wasn't that nothing was effective, it's just that propofol was MORE effective. Peds is a different beast. Brains are much more elastic and can tolerate much more hypoxia and insults than the adult brain. Having mostly reduced and significantly less intenseâ€ seizures on another protocol is proven safer in peds than strictly relying on propofol. Tolerating a few seizures a day is preferred over having no seizures on propofol. However, length and duration of course is highly pertinent.

This example was a clear-cut case of mismanagement. Last I heard, the family was litigating the outside hospital.