Category: Professional Posters
Purpose: Propofol is a relatively safe agent recommended for sedation of mechanically ventilated critically ill patients. Some concerns have recently been risen, such as PRIS (propofol-related infusion syndrome), hypertriglyceridemia and zinc deficiency. Monitoring includes daily CPK and lactate for PRIS, triglyceride levels at baseline and every 3-7 days thereafter for hypertriglyceridemia, and zinc levels in major sepsis and/or burns, diarrhea, or propofol use beyond 5 days. A protocol for propofol administration exists, but only advocates CPK monitoring. The aim of this study is to assess the percentage of compliance with proper safety monitoring practices of CPK, lactate, TG and zinc levels.
Methods: This is a single-center retrospective study based in the American University of Beirut Medical Center, whereby mechanically ventilated and critically ill patients receiving propofol for sedation were included through a chart-review process from January 2016 to May 2019. Exclusion criteria included uncontrolled and untreated hypertriglyceridemia, documented history of pancreatitis within the past 6 months, history of familial mitochondrial disease, zinc deficiency, hypersensitivity to propofol or any component of the formulation, eggs, egg products, soybeans, or soy products, documented pre-existing rhabdomyolysis, and propofol use for indications other than sedation. PRIS was defined as metabolic acidosis plus cardiac dysfunction and one of the following: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy. Risk factors collected included serious neurological injury, sepsis, concurrent use of vasoconstrictors, steroids and/or inotropes, as well as administration of propofol at a dose greater than 4-5 mg/kg/h or 67-83 mcg/kg/min for more than 48 hours. On the other hand, hypertriglyceridemia was defined as TG ≥ 500 mg and pancreatitis which was also monitored, was defined as amylase ≥ 125 IU/L and lipase ≥ 60 IU/L with an abdominal computed tomography scan or clinical examination consistent with pancreatitis. As for zinc deficiency, patients predisposed to deficiency including those on prolonged propofol therapy (>5 days), and patients with severe sepsis, diarrhea or burns were monitored for levels < 84 mcg/dL.
Results: From January 2016 till May 2019, a total of 382 patients received propofol, of which only 52 could be assessed. 69% of patients were male, and 56% were above 65 years of age. Findings showed that 54% of patients received propofol at a starting infusion rate of 5 mcg/kg/min, and 86% had propofol titrated at a maximum of 5-10 mcg/kg/min. The maximum infusion rate was 48 hours in 47%. As for the institutional order set, it was utilized in 58% of cases. CPK was taken prior to/at baseline in 12% of patients, and daily in 10%, while lactate was taken in 58% prior to/at baseline and daily in 38%. PRIS occurred in 1 patient, but was not detected at the time. Moreover, baseline TG was taken in 21% of patients, and periodically in 25%, with one patient found to develop hypertriglyceridemia. Lastly, zinc levels were not drawn for any patient even though 46% of patients had a risk factor, and 10% received propofol > 5 days.
Conclusion: Propofol monitoring was found to be sub-optimal, and steps should be taken in order to ensure safe and optimal administration of this agent. Although the aforementioned adverse events may be infrequent, preventing or reducing their occurrence is crucial, since PRIS is associated with a high risk of mortality, hypertriglyceridemia increases the risk of pancreatitis, and zinc deficiency increases the risk of innate immune suppression and secondary infection. Future plans for improvement may include updating and enforcing the use of order sets at the institution, as well as providing proper education on adequate monitoring to health-care practitioners involved.