Skip to main content

Propofol infusion syndrome: early blood purification to the rescue?

The Original Article was published on 01 December 2015

We read with interest the comprehensive review of Krajčová et al. [1] on propofol infusion syndrome (PRIS). Of particular importance is the high (51 %!) associated mortality which is mainly determined by cardiac failure, therapy-resistant bradyarrhythmia, metabolic acidosis, and rhabdomyolysis [1]. The authors provide a detailed insight on the pathophysiologic mechanism(s) underlying PRIS but do not discuss therapy, probably because therapeutic options are limited and merely supportive. Basically, propofol should be withdrawn immediately and adequate hemodynamic support must be ensured. Patients who develop rhabdomyolysis-associated acute kidney injury (AKI) are treated with hemodialysis or hemofiltration. Extracorporeal membrane oxygenation was life-saving in two patients [2]. A recent case report described rapid hemodynamic improvement and resolution of lactic acidosis after one single session of plasma exchange [3].

We suggest that early initiation of continuous renal replacement therapy (CRRT), even in the absence of well-established indications such as AKI, metabolic acidosis, or hyperkalemia, might add a survival benefit. Propofol undergoes hepatic metabolization and is rapidly cleared by the kidneys as propofol-glucuronide and 2,6-diisopropyl-1,4-quinol sulfo- and glucuro-conjugates [4]. Unlike the highly lipophilic parent drug, these toxic water-soluble metabolites can be eliminated by CRRT. Caution is needed, however, when implementing such a strategy. Prolonged PRIS-related cardiogenic shock with severely compromised hepatic and muscle perfusion may dramatically reduce mitochondrial citrate metabolism and result in citrate accumulation. As citrate is increasingly used for regional anticoagulation during CRRT, tight monitoring of the ionized/total calcium ratio is imperative to obviate metabolic complications related to citrate intoxication. A ratio exceeding 2.25 strongly suggests citrate overdose and requires replacing citrate by unfractionated heparin [5].


AKI, acute kidney injury; CRRT, continuous renal replacement therapy; PRIS, propofol infusion syndrome


  1. Krajčová A, Waldauf P, Anděl M, Duška F. Propofol infusion syndrome: a structured review of experimental studies and 153 published case reports. Crit Care. 2015;19:398.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Fudickar A, Bein B. Propofol infusion syndrome: update of clinical manifestation and pathophysiology. Minerva Anestesiol. 2009;75:339–44.

    CAS  PubMed  Google Scholar 

  3. Levin PD, Levin V, Weissman C, Sprung CL, Rund D. Therapeutic plasma exchange as treatment for propofol infusion syndrome. J Clin Apher. 2015;30:311–3.

    Article  PubMed  Google Scholar 

  4. Favetta P, Degoute CS, Perdrix JP, Dufresne C, Boulieu R, Guitton J. Propofol metabolites in man following propofol induction and maintenance. Br J Anaesth. 2002;88:653–8.

    Article  CAS  PubMed  Google Scholar 

  5. Oudemans-van Straaten HM, Ostermann M. Bench-to-bedside review: Citrate for continuous renal replacement therapy, from science to practice. Crit Care. 2012;16:249.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Authors’ contributions

PMH and HDS designed the paper, participated in drafting the manuscript, and have read and approved the final version.

Competing interests

The authors declare that they have no competing interests.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Patrick M. Honore.

Additional information

See related research by Krajčová et al.,

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Honore, P.M., Spapen, H.D. Propofol infusion syndrome: early blood purification to the rescue?. Crit Care 20, 197 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: