Monitoring biochemical parameters as an early sign of propofol infusion syndrome: false feeling of security.
OBJECTIVE
The aim of this report is to describe a fatal case of propofol infusion syndrome (PRIS), despite regular screening for this syndrome and immediate discontinuation of the infusion after the first signs of biochemical derangement.


METHODS
Case report.


METHODS
Pediatric intensive care unit.


METHODS
A 17-year-old patient admitted after sustaining a traumatic brain injury.


METHODS
Treatment for traumatic brain injury was given with mechanical ventilation, inotropic support, mannitol, and sedation with propofol. Blood gases and serum levels of lactate and creatine kinase were monitored frequently to screen for PRIS.


RESULTS
Propofol infusion was stopped immediately after the first signs of biochemical derangement. The patient died despite supportive treatment with intra-aortic balloon pump and cardiopulmonary resuscitation.


CONCLUSIONS
This case report demonstrates that frequent monitoring of biochemical parameters, as suggested in literature, cannot always prevent death due to PRIS.
Veldhoen
Esther S
ES
Department of Pediatrics, The Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands. e.s.veldhoen@umcutrecht.nl
Hartman
Barend J
BJ
van Gestel
Josephus P J
JP
D000293:Adolescent; D018686:Anesthetics, Intravenous / Q000009:adverse effects* / Q000097:blood; D001930:Brain Injuries / Q000378:metabolism / Q000628:therapy*; D016903:Drug Monitoring; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D015742:Propofol / Q000009:adverse effects* / Q000097:blood
D018686:Anesthetics, Intravenous; D015742:Propofol