Propofol-Related Infusion Syndrome: A Clinical Review

Abstract

Propofol-related infusion syndrome (PRIS) is a lethal condition characterized by multiple organ system failures. It can occur due to prolonged administration of propofol (an anesthetic) in mechanically intubated patients. The main presenting features of this condition include cardiovascular dysfunction with particular emphasis on impairment of cardiovascular contractility, metabolic acidosis, lactic acidosis, rhabdomyolysis, hyperkalaemia, lipidaemia, hepatomegaly, acute renal failure, and eventually mortality in most cases. The significant risk factors that predispose one to PRIS are: critical illnesses, increased serum catecholamines, steroid therapy, obesity, young age (significantly below three years), depleted carbohydrate stores in the body, increased serum lipids, and most importantly, heavy or extended dosage of propofol. The primary pathophysiology behind PRIS is the disruption of the mitochondrial respiratory chain that causes inhibition of adenosine triphosphate (ATP) synthesis and cellular hypoxia. Further, excess lipolysis of adipose tissue occurs, especially in critically ill patients where the energy source is lipid breakdown instead of carbohydrates. This process generates excess free fatty acids (FFAs) that cannot undergo adequate beta-oxidation. These FFAs contribute to the clinical pathology of PRIS. It requires prompt management as it is a fatal condition. The clinicians must observe the patient's electrocardiogram (ECG), serum creatine kinase, lipase, amylase, lactate, liver enzymes, and myoglobin levels in urine, under propofol sedation. Doctors should immediately stop propofol infusion upon noticing any abnormality in these parameters. The other essentials of management of various manifestations of PRIS will be discussed in this article, along with a detailed explanation of the condition, its risk factors, diagnosis, pathophysiology, and presenting features. This article aims to make clinicians more aware of the occurrence of this syndrome so that better ways to manage and treat this condition can be formulated in the future.

Keywords: beta-oxidation; catecholamines; cellular hypoxia; creatine kinase; critical illness; ecg; mitochondrial respiratory chain; myoglobin; propofol infusion syndrome; steroids.

Conflict of interest statement

The authors have declared that no competing interests exist.

Copyright © 2022, Singh et al.

Figures

Figure 1. Mechanism of action of propofol

Propofol acts by binding to the GABA receptors and increasing the duration of their action. This leads to prolonged opening of the central chloride channels that causes hyperpolarization of post-synaptic neurons, thereby making it difficult for an action potential to fire. (The figure shown above has been made by the authors of this article).

Figure 2. Risk factors for the development of PRIS

PRIS: Propofol-Related Infusion Syndrome (The figure shown above has been made by the authors of this article).

Figure 3. Pathophysiological mechanism of PRIS

FA - Fatty Acid, SCFA - Short Chain Fatty Acid, MCFA - Medium Chain Fatty Acid, LCFA - Long Chain Fatty Acid, FFA - Free Fatty Acid, CPT-1 - Carnitine Palmitoyl Transferase-1. (The figure shown above has been made by the authors of this article).