Rapid Development of Propofol Infusion Syndrome After Short-Term Exposure

We describe a 34-year-old man with well-controlled epilepsy and severe autism spectrum disorder (ASD) complicated by self-injurious behaviors who developed green urine, hypertriglyceridemia, and metabolic acidosis concerning for propofol-related infusion syndrome (PRIS) in less than 48 hours of sedation with propofol following left-eye scleral buckle surgery. The patient required multimodal and continuous sedation to prevent postoperative trauma to the surgical site. The patient required a dexmedetomidine infusion at 1.5 mcg/kg/hour and a fentanyl infusion maintained between 50 and 100 mcg/hr in addition to propofol maintained at 70-100 mcg/kg/min. Approximately 24-30 hours after the initiation of a propofol infusion at 80-100 mcg/kg/min, he developed green urine without evidence of infection. Laboratory evaluation showed a rise in serum triglycerides from 305 mg/dL to 569 mg/dL overnight. Despite no initial acidosis, reduction of the propofol dose was followed by the onset of profound metabolic acidosis (values: pH 7.36, HCO₃ 15.8, pCO2 29) and creatine kinase (CK) elevation to 4,283 U/L. The constellation of findings raised clinical concern for early or atypical PRIS. This case highlights the diagnostic challenges of distinguishing early PRIS manifestations in patients requiring unusually high and sustained sedation and underscores the importance of vigilance even at propofol doses typically considered safe.