Restarting propofol following successful management of propofol infusion syndrome: a case report

Abstract

: Propofol infusion syndrome (PRIS) is a rare and potentially fatal complication seen in high-dose (>5 mg/kg/h) or prolonged (>48 h) propofol infusions. PRIS presents as a constellation of symptoms, including anion-gap metabolic acidosis, elevated lactate, cardiogenic shock, rhabdomyolysis, arrhythmia, among other biochemical abnormalities. The current standard of care focuses on early recognition, propofol cessation, and supportive management. Case reports have shown evidence for several novel therapeutic interventions, including plasmapheresis, dialysis, and extracorporeal membrane oxygenation. There has yet to be a documented case demonstrating a trial of reinitiating propofol following successful PRIS management. We present the case of a previously healthy 20-year-old male that presented to the emergency department with new-onset refractory status epilepticus, secondary to suspected autoimmune encephalitis. Despite multiple immunomodulators, anesthetic therapies, and anti-epileptic agents, he exhibited ongoing refractory seizure activity on continuous electroencephalogram monitoring. Propofol boluses were the only therapy to offer seizure burst suppression, prompting uptitration of the infusion. The patient subsequently developed hemodynamic instability and multiple biochemical abnormalities consistent with PRIS. He was managed with one round of plasmapheresis, later followed by a session of sustained-low efficiency dialysis (SLED). This therapeutic combination was successful in managing PRIS and restoring hemodynamic stability. After stopping the propofol infusion, he developed near constant electrographic seizures, with breakthrough clinical seizures despite multiple other therapeutic interventions. Propofol was later restarted for seizure control, with no further recurrence of PRIS. This case provides support for novel therapeutic modalities, plasmapheresis and SLED, when managing PRIS. This case also marks the first successful attempt at restarting propofol following PRIS.