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Lactic acidemia and bradyarrhythmia in a child sedated with propofol
S H Cray1, B H Robinson, P N Cox
1Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.
Insights
Propofol infusion in a pediatric intensive care unit (ICU) led to severe adverse reactions, including lactic acidemia and organ damage. Continuous veno-venous hemofiltration (CVVH) helped resolve these critical symptoms.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Toxicology
Background:
- Propofol is a widely used anesthetic and sedative agent in intensive care units (ICUs).
- Prolonged propofol infusion syndrome (PRIS) is a rare but serious complication associated with high-dose, long-term propofol administration.
- Understanding the specific risks and presentation of PRIS in pediatric patients is crucial for safe clinical practice.
Observation:
- A case report details a severe adverse reaction in an infant receiving continuous propofol infusion for sedation in a pediatric ICU.
- The infant presented with upper respiratory obstruction requiring mechanical ventilation.
- The patient developed metabolic derangements, including lipemia, green urine, severe lactic acidemia, and bradyarrhythmias, unresponsive to conventional support.
Findings:
- The patient's severe lactic acidemia and bradyarrhythmias resolved with continuous veno-venous hemofiltration (CVVH).
- Histological examination revealed liver and muscle necrosis consistent with a toxic insult, and reduced cytochrome C oxidase activity in muscle tissue.
- No evidence of systemic infection or underlying metabolic disease was found, suggesting propofol as the causative agent.
Implications:
- This case highlights the potential for severe toxicity from prolonged propofol infusions in critically ill children.
- The observed biochemical and histological abnormalities provide insights into the pathophysiology of propofol-induced toxicity.
- Clinicians should exercise caution with prolonged propofol sedation in pediatric patients and consider alternative agents or vigilant monitoring.
Objectives:
To describe a severe adverse reaction in a child who received an infusion of propofol for sedation in the intensive care unit (ICU). To describe the management and further investigation of this patient and review similar published reports.
Design:
Case report and literature review.
Setting:
Community hospital ICU and tertiary pediatric ICU.
Patient:
Infant with upper respiratory obstruction secondary to an esophageal foreign body who required tracheal intubation and mechanical ventilation.
Interventions:
Conventional cardiovascular and respiratory support. Continuous veno-venous hemofiltration (CVVH) and plasmapheresis.
Measurements And Main Results:
The patient received a propofol infusion at a mean rate of 10 mg/kg/hr for 50.5 hrs. He developed lipemia and green urine and subsequently, a progressive severe lactic acidemia and bradyarrhythmias unresponsive to conventional treatment. These abnormalities resolved with CVVH. He was encephalopathic and developed liver and muscle necrosis histologically compatible with a toxic insult. Examination of homogenized muscle tissue demonstrated a reduction in cytochrome C oxidase activity. There was no evidence of systemic infection or underlying metabolic disease. He eventually recovered completely.
Conclusion:
Propofol has been associated with severe adverse reactions in children receiving intensive care. The biochemical and histologic abnormalities described in this patient may guide further investigation. We advise against prolonged use of propofol for sedation in children.