Multiple drugs

Abstract

Propofol infusion syndrome and lack of efficacy: 4 case reports In a single-center, retrospective, consecutive case series 4 patients [2 males, 2 females] aged 17–28 years were described, who developed Propofol infusion syndrome (PRIS) while receiving analgosedation with propofol for external ventricular drain. Additionally, three patients exhibited lack of efficacy to norepinephrine while receiving treatment for cardiac arrest and the remaining one patient exhibited lack of efficacy to norepinephrine, epinephrine and dobutamine while receiving treatment for cardiogenic shock [routes and time to reactions onset not stated]. The patients, who had intracranial hypertension, traumatic brain injury with intracranial haemorrhage scheduled for external ventricular drain (EVD). Accordingly, the patients started receiving analgosedation with propofol infusion at dosage of 4.5-6.5 mg/kg/h. The total duration of propofol infusion was 4-7 days, midazolam and an unspecified opioids. In addition, one of the 4 patients received ketamine. Subsequently, all patients exhibited increasing vasopressor requirements with greenish discoloration of urine and mild rhabdomyolysis. All patients were started on norepinephrine ranging from 0.07-0.21 μg/kg/minutes. An ECG showed tachy-arrhythmias, type-1 Brugada pattern and prolongation of QTc. Additionally, in two of the 4 patients sinusoid pattern was noted. An echocardiography showed worst ejections fractions. Laboratory investigations of patients were significant with PRIS. Subsequently, all patients developed cardiac failure. Also, three of the 4 patients developed cardiac arrest. All patients were transferred to ICU and were placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for extracorporeal cardiopulmonary resuscitation (2 patients) and cardiogenic shock (2 patients). One of the 2 patients with cardiogenic shock was treated with epinephrine [adrenaline] and dobutamine. However, it was found that norepinephrine was found to be resistant to cardiac arrest in 3 patients and norepinephrine, epinephrine and dobutamine were found to be resistant to cardiogenic shock in one patient. Duration of VA-ECMO support was ranging from 1-5 days. After 4-7 days of ICU admission, the patients treatment with Propofol was discontinued. Additionally, all patients were placed on inotropic support for 1-6 days. During ECMO, 2 patients underwent mini-thoracotomy as a left ventricular venting technique along with laparotomy. Also, one of these 2 patients underwent amputation. Out of 4 patients, 2 patients developed acute kidney injury stage-3 and 2 patients developed acute kidney injury stage-2. Survival after veno-arterial ECMO score was ranging from -4 to 2. Within the first 72h of discontinuation of propofol, progressive resolution of QRS-widening and type-1 Brugada patterns was noted; however, prolonged diffuse STT-segment changes became persistent. The duration of ICU stay was ranging from 22-112 days. Eventually, all patients were discharged with good neurological outcome, functional independence and overall good self-reported quality-of-life.