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Propofol infusion syndrome (PRIS)

Propofol infusion syndrome (PRIS). Ri 曾杏榕 /Vs 葉育彰. Outline. Introduction Etiology Pathophysiology Therapy Prophylaxis. PRIS Definition. Acute bradycardia with resistance to treatment, progressive. Lipemic plasma with fatty liver enlargement Metabolic acidosis with BE<-10

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Propofol infusion syndrome (PRIS)

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  1. Propofol infusion syndrome (PRIS) Ri 曾杏榕/Vs 葉育彰

  2. Outline • Introduction • Etiology • Pathophysiology • Therapy • Prophylaxis

  3. PRIS Definition • Acute bradycardia with resistance to treatment, progressive. • Lipemic plasma with fatty liver enlargement • Metabolic acidosis with BE<-10 • Rhabdomyolysis • Circulatory failure, death

  4. PRIS Definition • Simple name for a complex syndrome • Priming factors: critical illness • Triggering factors: high-dose propofol, catecholamines, and steroid.

  5. Symptoms and Signs • Lactic acidosis • Arrhythmia, hypotension • Renal, cardiac, and circulation failure • EKG change, V1-V3 ST elevation • Oligouria, elevated CK

  6. Risk Factors • Airway infection • Severe head injury • High dose and long-term propofol sedation • Elevated catecholamine and steroid level

  7. Risk Factors • High dose and long term use of propofol • High dose (children): >4mg/kg/hr • High dose (adult): >5mg/kg/hr • Long term: >48 hr • Still safe to use

  8. 小孩子以ARF與LA為最明顯的特徵 outcome的話 24病人中 只有九個人活下來 死亡率超接近三分之二 用propofol的時間最長可以到190個小時 最短只要五個小時就會產生PRIS

  9. 成人的話 LA一樣是最常見的症狀 另外與小孩子不同的就是RML的發生率變高 ARF反而沒有那麼常見 死亡率: 13/14 遠比小兒的死亡率高

  10. Coincidence or Not? • Extreme rare, coincidence? • No clear causality is available • Pathophysiological mechanisms are plausible • Different institute with the similar consistency and temporal relationship

  11. Fat Metabolism • Low carbohydrate supply is a risk factor for PRIS • Free fatty acid: proarrhythmogenic risk factor • Inhibition of oxidation by propofol lead to increased FFA level.

  12. FatMetabolism • Long chain FFA: • unable to enter • Med and short • chain FFA: • Unable to be utilized

  13. Respiratory Chain • Uncoupled oxidative phosphorylation and energy production in mitochondria • Antagonize adrenoreceptor binding and calcium-channel proteins • Causes the lack of response to catecholamines

  14. Catecholamine andPropofol Vicious Cycle

  15. Catecholamine andPropofol Vicious Cycle

  16. Therapy • Non-specific therapy: • Quit propofol infusion • Hemodynamic stabilization • ECMO support if available • H/D for elimination remaining propofol • Carbohydrate substitution • Early diagnosis

  17. Recommendation in Use • <4mg/kg/hr in children • <5mg/mg/hr in adult (<4 mg/kg/hr if head injury) • Caution when use propofol for more than 48 hr • Consider propofol substitutions

  18. Take home message • Keep PRIS in mind, although it’s rare • Head injury patients and children are susceptible • Use low dose propofol, and be cautious when long-term use • If PRIS happens, ECMO and H/D may be helpful

  19. Thanks for your attention

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