The following data refer to a 28-year-old male who is day 5 in ICU following a severe traumatic
brain injury. He has no other injuries and has been heavily sedated with infusions of fentanyl, midazolam and propofol since admission. Over the last four hours he has become increasingly bradycardic and hypotensive, and has not responded to fluid loading or repeated doses of atropine.
|Parameter||Patient Value||Normal Adult Range|
|Sodium||138 mmol/L||135 – 145|
|Potassium||5.1 mmol/L*||3.5 – 4.5|
|Chloride||100 mmol/L||95 – 105|
|Bicarbonate||11 mmol/L*||22 – 26|
|Urea||29 mmol/L*||2.9 – 8.2|
|Creatinine||310 μmol/L*||70 – 120|
|Calcium (corrected)||1.71 mmol/L*||2.10 – 2.55|
|Phosphate||2.31 mmol/L*||0.65 – 1.45|
|Creatine Kinase||25,000 U/L*||0 – 270|
|Lactate||5.1 mmol/L*||< 2.0|
Give the most likely diagnosis and the rationale for your answer.
Propofol Infusion Syndrome.
Rationale: Biochemistry consistent with rhabdomyolysis. No other injuries to account for
it. Refractory bradycardia and hypotensive suggestive. History of high dose propofol
(Partial credit given for rhabdomyolysis, raised ICP and coning)
Propofol infusion syndrome is not the first thing I would think of when confronted with a trauma patient who has suddenly become hypotensive and bradycardic. And the raised CK does not help (as if rhabdomyolysis is unknown in trauma patients). However, the college threw in the "refractory to atropine" thing, which arouses concern.
Propofol infusion syndrome is discussed elsewhere.
It is well covered in an article by Prof Kam.
Clinical features of propofol infusion syndrome
- Acute bradycardia leading to asystole.
- A prelude to the bradycardia is a sudden onset RBBB with ST elevation in V1-V3; Kam’s article has the picture of this ECG.
- Heart failure, cardiogenic shock
- Metabolic acidosis (HAGMA) with raised lactate (and also due to fatty acids)
- Fatty liver and hepatomegaly
- Raised plasma malonylcarnitine and C5-acylcarnitine
Kam, P. C. A., and D. Cardone. "Propofol infusion syndrome." Anaesthesia62.7 (2007): 690-701.
Marinella, Mark A. "Lactic acidosis associated with propofol." CHEST Journal109.1 (1996): 292-292.
Vasile, Beatrice, et al. "The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome." Intensive care medicine 29.9 (2003): 1417-1425.
Schenkman KA, Yan S. Propofol impairment of mitochondrial respiration in isolated perfused guinea pig hearts determined by reflectance spectroscopy. Critical Care Medicine 2000; 28: 172–7.
Fodale, Vincenzo, and Enza La Monaca. "Propofol Infusion Syndrome." Drug Safety 31.4 (2008): 293-303.
Da-Silva, Shonola S., et al. "Partial-exchange blood transfusion: an effective method for preventing mortality in a child with propofol infusion syndrome." Pediatrics 125.6 (2010): e1493-e1499.
Uezono, Shoichi, et al. "Acquired carnitine deficiency: a clinical model for propofol infusion syndrome?." The Journal of the American Society of Anesthesiologists 103.4 (2005): 909-909.
Mirrakhimov, Aibek E., et al. "Propofol Infusion Syndrome in Adults: A Clinical Update." Critical care research and practice 2015 (2015).