1173

Abstract

Case Reports: High dose infusions of propofol have been associated with metabolic derangements resulting in multisystem organ failure. Cardiac derangements associated with this syndrome include bradyarrhythmias, coved type ST elevations, global hypokinesia and biventricular failure. We present a case of refractory ventricular tachycardia as an unusual manifestation of propofol infusion syndrome in a trauma patient. A twenty five year old male presented to the surgical ICU after being involved in a roll over motor vehicle accident. The patient was intubated at the scene. Neurological injuries included a comminuted left pterygoidal fracture and depression in the region of the greater sphenoid wing with an underlying 6 mm left subdural hematoma. Neurosurgery placed a subarachnoid bolt to continuously monitor his intracranial pressures (ICP). A propofol infusion was started at 50 mcg/kg/min and increased to 200 mcg/kg/min over the next two days. On the third day, metabolic acidosis was noted on an arterial blood gas. The patient had an elevated lactate of 11.1mmol/L and creatine kinase levels increased from 1160 to 10000 IU/L. The propofol infusion was discontinued and propofol infusion syndrome was suspected. Shortly afterwards, wide complex tachycardia at a rate of 130s was noted on EKG. Metoprolol was given and an amiodarone infusion was started after a bolus dose. The patient remained in ventricular tachycardia and became hypotensive. He was started on a phenylephrine infusion and given epinephrine pushes to support his blood pressure. Cardioversion was performed with increasing energy with no success. 100mg of lidocaine was given. Cardiology was consulted emergently and the shock vector was adjusted. An attempt was also made to pace terminate transcutaneously. Over the course of time, the patient became oliguric and hyperkalemic. Continuous renal replacement therapy was initiated to correct electrolyte abnormalities that may be contributing to refractory ventricular tachycardia. Vasopressin infusion was also started. Twelve hours after the initial rhythm change, the patient became asystolic. Chest compressions were started and ACLS protocol was instituted. Resuscitative measures continued for thirty minutes without success, after which he was pronounced dead. Refractory ventricular tachycardia is an uncommon and potentially fatal manifestation of propofol infusion syndrome. Prolonged infusion at high doses may predispose to this complication among trauma patients.