Hospital Pharmacy - July/August 2018 - 220

776857
research-article2018

HPXXXX10.1177/0018578718776857Hospital PharmacyMancano

ISMP Adverse Drug Reactions
Hospital Pharmacy
2018, Vol. 53(4) 220-222
© The Author(s) 2018
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https://doi.org/10.1177/0018578718776857
DOI: 10.1177/0018578718776857
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ISMP Adverse Drug Reactions

Propofol-Related Infusion Syndrome (PRIS)1,2
Ivermectin-Induced Stevens-Johnson Syndrome
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis From Fexofenadine
Memantine-Related Drug Eruption
Michael A. Mancano1

Propofol-Related Infusion Syndrome
(PRIS)1,2
Propofol-related infusion syndrome (PRIS) is a rare but often
lethal complication associated with the use of propofol. The
most common risk group for the development of PRIS are
young, critically ill patients after neurosurgery while receiving
vasopressors with the administration of propofol at a mean
dose ≥4 to 5 mg/kg/h, over more than 48 hours duration. The
clinical symptoms of PRIS include unexplained metabolic acidosis, rhabdomyolysis, renal failure, fever, hyperlipidemia,
hyperkalemia, hepatomegaly, arrhythmia, and rapidly progressive cardiac failure. Proposed laboratory markers to monitor
for patients with PRIS include lactate, troponin, creatine kinase,
myoglobin, triglycerides, and the analysis of acylcarnitines.
The analysis of acylcarnitines has become widely accepted as a
helpful instrument to confirm the diagnosis of PRIS.
Patient 11 was a 30-year-old woman who underwent laparoscopic surgery with sedation provided by a propofol infusion at an average hourly rate of 3.3 mg/kg for approximately
6 hours. Three hours later, the patient demonstrated a mild
unpredictable hypotension of 90/60 mm Hg for which dopamine was initiated for blood pressure support. At this time, a
blood glucose measurement was 58 mg/dL (normal range,
70-110 mg/dL) followed by an arterial blood gas revealing
metabolic acidosis with measurements of pH 6.91 (normal
range, 7.33-7.45), pCO2 44 mm Hg (normal range, 35-45
mm Hg), pO2 104 mm Hg (normal range, 75-105 mm Hg),
and blood glucose of 38 mg/dL. Over the next few hours, the
patient's arterial pH ranged from 7.06 to 7.49 with a blood
glucose of 198 to 216 mg/dL and an elevated lactate level.
The patient remained unresponsive 3 hours after the conclusion of the propofol infusion, and a neurological examination
yielded suspected brain damage. The patient subsequently
had an magnetic resonance imaging (MRI) of the head,
which revealed prominent bilateral lesions in the basal ganglia, temporal lobe, and cerebellum. The possible causes of
bilateral basal ganglia MRI abnormalities include hypoxicischemic, toxic and metabolic, infectious, immune-mediated,
mitochondrial, and neurodegenerative disorders.

Ten hours after the onset of this event, the patient had a
creatinine kinase of 1644 IU/L (normal range, woman ≤170
IU/L). Two days later, the patient had a brain natriuretic peptide level of 1270 pg/mL (normal range, <100 pg/mL) which
is suggestive of heart failure. It should be noted that the
patient did not experience arrhythmias or hypoxia throughout their surgical procedure. The combination of lactic acidosis, elevated creatine kinase, and cardiac insufficiency in the
context of propofol anesthesia suggested the diagnosis of
propofol-related infusion syndrome (PRIS). As PRIS has
been associated with mitochondrial DNA (mtDNA) mutations, a complete mtDNA sequencing was conducted and
revealed no abnormalities. The patient's relatives refused
further investigation and the patient eventually died due to
refractory circulatory failure 16 days from the onset of her
condition.
Patient 22 was a 19-year-old previously healthy man who
was admitted to the hospital with left-sided hemiparesis after
first-time alcohol intoxication. His medical history was negative for any disease state, allergies, or drug abuse. A large
intracerebral hemorrhage was discovered on computed
tomography (CT) scan and the patient was sent for surgery.
The patient was intubated and propofol 5 mg/kg/h was initiated. Surgery included a craniotomy with resection of an
arterious-venous malformation and evacuation of the intracerebral hemorrhage.
During the first 4 days, postoperatively the patient experienced inflammation, impaired coagulation, continuously elevated intracranial pressure, diabetes insipidus, and brain
edema. On the fifth postoperative day, the patient underwent a
second surgery to release intracranial pressure. After surgery,
the patient experienced tachyarrhythmias with a heart rate of
130 to 140 bpm. Elevated doses of catecholamines were
1

Temple University School of Pharmacy, Philadelphia, PA, USA

Corresponding Author:
Michael A. Mancano, Chair and Clinical Professor, Department of
Pharmacy Practice, Temple University School of Pharmacy, Philadelphia,
PA 19019, USA.
Email: michael.mancano@temple.edu

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