6.7 PRIS Flashcards
a) What is propofol-related infusion syndrome (PRIS)?
● PRIS was first described in the paediatric population but increasingly it is seen in adult intensive care patients.
● A rare and fatal condition.
● Seen in children and also adults receiving a high dose (>5mg/kg/hr) of a propofol infusion and/or for more than 48 hours.
● Defined as acute refractory bradycardia leading to asystolic cardiac arrest in patients receiving a propofol infusion and in the presence of one or more of following:
- metabolic acidosis — base deficit >10mmol/L;
- rhabdomyolysis or myoglobinuria;
- plasma lipaemia;
- hepatomegaly/fatty liver.
b) What are the clinical effects of PRIS?
● Metabolic acidosis —
as a result of renal failure and increased lactate
production.
● Cardiac changes —
initial arrhythmias such as atrial fibrillation,
supraventricular tachycardias, bundle branch blocks, bradycardias and eventually asystole.
● Lipidaemia —
lipid metabolism is impaired due to increased
sympathetic stimulation,
high circulating cortisol and growth
hormone levels.
There is also a blockade of
mitochondrial fatty acid oxidation.
● Rhabdomyolysis —
from necrosis of skeletal and cardiac muscle.
Leads to increased serum creatine kinase levels and myoglobinuria.
● Hepatomegaly, elevated liver enzymes.
● Acute kidney injury.
c) List the risk factors for PRIS.
● Major head injuries.
● Sepsis.
● High exogenous/endogenous catecholamine and glucocorticoid levels.
● Low carbohydrate to high lipid intake.
● Inborn errors of fatty acid oxidation
d) What specific laboratory findings might be expected in a case of PRIS?
● Hyperkalaemia.
● Lipidaemia.
● Elevated liver enzymes.
● Raised lactate.
● Acute kidney injury
(elevated serum creatinine).
e) How may PRIS be prevented?
● Avoid using propofol doses of >5mg/kg/hr
for more than 48 hours.
● Use other sedative agents in combination with propofol.
● Monitor serum creatine kinase, lactate and pH if using prolonged infusions.
f) How would you manage PRIS?
● Discontinue the propofol infusion.
● Cardiovascular support with inotropes/vasopressors.
● Renal replacement therapy.
● Management of metabolic/electrolyte abnormalities.
● ECMO.
