(991) Propofol Infusion Syndrome in an Adolescent With Severe Traumatic Brain Injury

Introduction: Propofol infusion syndrome (PRIS) is a rare but potentially fatal condition associated with critically ill patients receiving high doses of propofol over an extended period. Propofol toxicity is multifactorial; one proposed mechanism is through mitochondrial uncoupling and lipolysis generating free fatty acids, which are suggested to be arrhythmogenic. We report a case of PRIS manifesting as profound cardiac rhythm disturbance.

Description: An otherwise healthy 13-year-old 85-kilogram male was admitted with severe traumatic brain injury following a fall from an all-terrain vehicle. Despite aggressive management, he developed elevated intracranial pressure for which a propofol infusion was started. He received propofol for 5 days, with approximately 48 hours of an infusion exceeding 7.5 mg/kg/hr. On hospital day 4, a pentobarbital infusion for management of refractory intracranial hypertension was titrated until burst suppression was achieved; propofol was weaned off over the next 24 hours. Four hours after propofol discontinuation, he developed diffuse ST-segment elevation evolving into a widened QRS complex. Labs were notable for acute kidney injury (AKI) with elevated troponin and creatinine kinase (CK). An echocardiogram showed left ventricular dysfunction, which was a change from normal function upon admission. He underwent cardiac catheterization that showed normal coronary anatomy. There was high concern for medication toxicity, specifically PRIS given the high-dose infusion, so he received therapeutic plasma exchange (TPE). He had resolution of telemetry changes, normalization of troponin and CK levels, and resolution of AKI after one TPE session.

Discussion: PRIS encompasses a spectrum of clinical and laboratory findings, including cardiac dysfunction. Although PRIS is a rare phenomenon, cardiac toxicity, including heart failure and rhythm disturbances, is one of the most common described in the literature. Traumatic brain injury has been associated with increased risk for PRIS in adults. Management includes immediate discontinuation of the medication, supportive care, and may include TPE for removal of propofol-bound triglycerides and excess long-chain fatty acids reducing arrhythmogenicity. PRIS is an avoidable complication of propofol for which clinicians should be vigilant.