A CASE OF PROPOFOL-RELATED INFUSION SYNDROME IN SARS-COV-2

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Propofol-related infusion syndrome (PRIS) is a rare and serious effect of propofol infusion for sedation in critically ill patients. Though there has been an association seen with higher doses of propofol and prolonged infusion times, usually greater than 24 to 48 hours. CASE PRESENTATION: We present a case of an 86-year-old man with history of bradycardia and an implanted permanent pacemaker who was admitted for acute hypoxic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. Throughout hospital stay, this patient had progressively increasing oxygen requirements with appropriate escalation in level of care to the ICU. Due to increasing hypoxia despite non-invasive ventilation, the patient was intubated on day 4 of hospitalization, placed on vasopressors and started on sedation, which included continuous propofol infusion. On day 6 of hospitalization, the patient developed worsening hypotension requiring increased levels of sedation and significant lab abnormalities compared to labs collected the day prior. The patient was noted to have elevated potassium to 5.8 mmol/L, creatinine elevation to 2.41 mg/dL from 1.36 mg/dL, and elevated AST of 184 U/L and ALT of 95 U/L from normal levels. Lactate was 4.5, and creatinine kinase was 1317. Six hours later, repeat liver function tests revealed AST of 2078 U/L and ALT of 966 U/L. In the setting of sudden onset rhabdomyolysis, acute kidney injury, and lactic acidosis, there was concern for PRIS and propofol was discontinued. After extended discussion with the family, aggressive measures including dialysis were declined, and patient died. Of interest, the patient's pacemaker likely prevented the patient from developing bradycardia, classically seen in PRIS. DISCUSSION: Challenges with sedation of intubated patients with SARS-CoV-2 have been clinically observed and deeper sedation levels have been required to promote ventilator synchrony. Propofol continues to be a first-line sedative in critically ill patients, including SARS-CoV-2 patients. These patients require sedation higher infusion rates compared and are therefore at higher risk. Our patient was maintained on 20mcg/kg/min for 27 hours, then subsequently on 45 mcg/kg/min for 34 hours thereafter. Therefore, our patient was at increased risk of PRIS given propofol infusion at high doses was maintained for longer than 24 hours. Moreover, the concurrent use of vasopressors placed him at increased risk. CONCLUSIONS: Although propofol is recommended as a first-line anesthetic agent in critically ill patients with SARS-CoV-2 requiring sedation, the multiorgan failure resulting from PRIS is potentially fatal. Early recognition is crucial for management, which includes discontinuing propofol infusion and hemodialysis if indicated. REFERENCE #1: Hanidziar D, Bittner EA. Sedation of Mechanically Ventilated COVID-19 Patients: Challenges and Special Considerations. Anesth Analg. 2020;131(1):e40-e41. doi:10.1213/ANE.0000000000004887 REFERENCE #2: Payen JF, Chanques G, Futier E, Velly L, Jaber S, Constantin JM. Sedation for critically ill patients with COVID-19: Which specificities? One size does not fit all. Anaesth Crit Care Pain Med. 2020;39(3):341-343. doi:10.1016/j.accpm.2020.04.010 REFERENCE #3: Yamamoto K. Risk of propofol use for sedation in COVID-19 patient. Anaesthesiology Intensive Therapy. 2020;52(4):354-355. doi:10.5114/ait.2020.100477. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response