Key Points
- Suspect PRIS with acidosis + rhabdomyolysis in patients on high‑dose/prolonged propofol.
- Stop propofol immediately and provide organ‑supportive care.
- Adhere to dose (<4 mg/kg/h) and duration (<48 h) thresholds when feasible.
Algorithm
- Primary survey and stabilization; focused history and exam.
- Order high‑yield tests first; escalate imaging as indicated.
- Initiate disease‑specific therapy and supportive care.
- Reassess clinical response; arrange consultation and disposition.
Clinical Synopsis & Reasoning
Critically ill patient on high‑dose or prolonged propofol sedation develops unexplained metabolic acidosis, rhabdomyolysis, acute kidney injury, and cardiac dysfunction—concerning for propofol‑related infusion syndrome (PRIS). Risk rises with doses ≥4 mg/kg/h or durations >48 h, catecholamines, steroids, and critical illness. Monitor CK, triglycerides, lactate, EKG, renal and hepatic indices. Exclude alternative causes of shock and acidosis.
Treatment Strategy & Disposition
Immediately discontinue propofol; switch to alternative sedatives (e.g., dexmedetomidine, midazolam). Aggressive supportive care: fluids, vasopressors, treat arrhythmias, correct electrolyte derangements; consider renal replacement therapy for severe acidosis/AKI and ECMO for refractory cardiogenic shock. Prevention: adhere to dose/duration limits; avoid combination risk factors where possible.
Epidemiology / Risk Factors
- Epidemiology varies by setting; see citations for details.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CK, Lactate, ABG | Identify rhabdomyolysis and acidosis | ↑CK, metabolic acidosis | Trending guides therapy |
| BMP, LFTs | Organ injury surveillance | AKI, ↑AST/ALT | — |
| Triglycerides | Marker and risk signal | ↑TG | — |
| ECG/Telemetry | Arrhythmia detection | Bradyarrhythmias | — |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Dexmedetomidine | α2‑agonist | Minutes | Sedation alternative | Bradycardia, hypotension |
| Midazolam | Benzodiazepine GABA‑A agonist | Minutes | Sedation alternative | Delirium, hypotension |
| Sodium bicarbonate | Buffer | Immediate | Severe acidosis (select cases) | Paradoxical CNS acidosis, volume load |
Prognosis / Complications
- Prognosis depends on timeliness of diagnosis, comorbid disease, and response to therapy.
Patient Education / Counseling
- Explain expected course, warning signs requiring urgent care, and follow‑up testing.
- Review medication use, interactions, and monitoring parameters.