Metabolic acidosis with propofol

These cases are important because, unlike previous reports of metabolic acidosis after propofol infusion, the patients had no documented infections and, in at least one case, extensive investigation showed no other causes of the acidosis. The role of propofol in causing the metabolic problems appears to have been more likely in these than in previous reports. In the first three cases the doses of propofol used, both per hour and in all, were extremely high compared with normal therapeutic practice. The subject has also been reviewed, and it was pointed out that, although suggestive, the association of fatal metabolic acidosis with propofol infusion in sick patients is as yet unproven and to date hinges on 11 case reports of patients who had multiple problems (55). 

An 18-year-old man suffered multiple trauma (70). He was sedated for 98 hours with propofol 530-700 mg/ hour. On day 5 he developed a metabolic acidosis with hyperkalemia and his serum was Upemic. An... 

Propofol infusion syndrome has been described and may result in severe metabolic acidosis, cardiac dysrhythmias, cardiovascular collapse, rhabdomyolysis, and death. The risk may be increased with concomitant catecholamine infusions or when the dose exceeds... 

Propofol is very lipid soluble, has a large volume of distribution, and has a rapid onset of action. It has comparable efficacy to midazolam for refractory GCSE. It has been associated with metabolic acidosis, hemodynamic instability, and bradyarrhythmias that are refractory to treatment. 

Propofol infusion syndrome can present with one component only, such as lactic acidosis (954) or rhabdomyolysis (955) (see below). It has been suggested that patients who are susceptible to metabolic acidosis or rhabdomyolysis after propofol administration may have subclinical forms of mitochondrial diseases that affect either the respiratory chain complex or fatty acid oxidation (956). In order to minimize the development of propofol infusion syndrome as a potentially lethal complication, a maximum dose of 3 mg/kg/hour has been recommended for sedation in intensive care patients. 

Burow BK, Johnson ME, Packer DL. Metabolic acidosis associated with propofol in the absence of other causative factors. Anesthesiology 2004 101 239-41. 

Funston JS, Prough DS. Two reports of propofol anesthesia associated with metabolic acidosis in adults. Anesthesiology 2004 101 6-8. 

A 47-year-old woman had an infusion of propofol 200 micrograms/kg/minute for 4 days. On day 2 she developed hematuria, and laboratory investigations showed renal insufficiency with hyperkalemic metabolic acidosis. She died as a result of rhabdomyolysis with cardiac involvement. 

Five adults with head injuries inexplicably had fatal cardiac arrests in a neurosurgical intensive care unit after the introduction of a sedation formulation containing an increased concentration of propofol (72). There were striking similarities with the previously reported syndrome of myocardial failure, metabolic acidosis, and rhabdomyolysis in children who received high-dose propofol infusions for more than 48 hours. 

Propofol infusion syndrome Propofol infusion syndrome has been reported in children and adults after short-term high-dose propofol. It presents with variations of severe metabolic acidosis, rhabdomyolysis, myoglobinuria, cardiac failure, and death. The pathophysiology is unknown, but genetic predisposition, mitochondrial inhibition, and increases in serum free fatty acids are believed to play a role. Catecholamines and corticosteroids may act as triggering agents. 

In an analysis of 1139 patients with suspected propofol infusion syndrome in adults (mean age 52 years) and children (mean age 9 years), the presenting symptoms included cardiac (43%), hypotension (34%), rhabdomyolysis (27%), hepatic (24%), renal (24%), metabolic acidosis (20%), hypoxia (18%), and hyperthermia (12%) [74 ]. Propofol infusion ranges exceeded 5 mg/kg/hour in 129 cases in which the dose was reported. Regrettably, two important variables with respect to the propofol infusion syndrome, dosage and timing of propofol infusion, were not recorded in about 90% of papers. Multivariate logistic regression analysis identified... 

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