Chia-Chi Kung

Shy-Hong Chen

Si-Tun Fung

Journal of the Formosan Medical Association

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Endotoxemia due to propofol contamination in four consecutive patients

Chen, Shy-Hong

Kung, Chia-Chi

Fung, Si-Tun

Elsevier - Publisher Connector 

Journal of the Formosan Medical Association (2014) 113, 328e329Available online at www.sciencedirect.com
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journal homepage: www.j fma-onl ine.comCORRESPONDENCEEndotoxemia due to propofol contamination
in four consecutive patientsShy-Hong Chen, Chia-Chi Kung, Si-Tun Fung*Department of Anesthesiology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City,
Taiwan, ROCReceived 10 May 2013; received in revised form 22 August 2013; accepted 28 August 2013Due to its preparation as a lipid emulsion, propofol, it
supports the growth of microorganisms,1 and febrile illness
and sepsis have been reported when strict guidelines for its
preparation are not followed.2,3 We report four patients
who experienced endotoxemia after propofol injection.
Four patients were scheduled for gastroscopy and colo-
noscopy. Four syringes of propofol, four syringes of mid-
azolam, and four syringes of fentanyl were prepared from
one ampule of propofol (Anesvan, 20 mL/200 mg/ampule;
Chi Sheng Chemical Corporation, Hsinchu, Taiwan), two
ampules of midazolam, and two ampules of fentanyl,
respectively, by an anesthesiologist under sterile condi-
tions. Each syringe was dedicated to an individual patient
without cross-usage. Ampules of propofol were stored at
20e22C, and were received in boxes sealed by the manu-
facturer and were not expired. Gastroscopy was performed
first, and prior to the colonoscopy an additional 20 mg of
propofol (from the remaining propofol in the syringe) was
administered. The total examination time was approxi-
mately 2 hours.
Shortly after arriving in the recovery room, all four
patient exhibited chills, increased body temperatures
(38.3e41.7C), and tachycardia (heart rate > 100 beats/Conflicts of interest: The authors have no conflicts of interest
relevant to this article.
* Corresponding author. No. 25, Lane 442, Section 1, Jingguo
Road, East District, Hsinchu City 300, Taiwan.
E-mail address: sitong78@gmail.com (S.-T. Fung).
0929-6646/$ - see front matter Copyright ª 2013, Elsevier Taiwan LLC
http://dx.doi.org/10.1016/j.jfma.2013.08.012minute). Due to a suspicion of propofol contamination, the
residual propofol was collected and stored in a refrigerator.
Leukocytosis and elevated C-reactive protein was noted in
all patients, but no evidence of disseminated intravascular
coagulation or sepsis was found. The patients were treated
with antibiotics and supportive care, and all symptoms had
resolved by the third day. All culture results were negative.
Patients were subsequently discharged in good condition.
The residual propofol was sent for endotoxin testing
(EMO Biomedicine Corporation, New Taipei City, Taiwan).
The endotoxin concentrations of the four syringes of pro-
pofol were 1484.5 endotoxin units (EU)/mL, 2809.3 EU/mL,
1859.3 EU/mL, and 957.9 EU/mL. A separate syringe with
residual propofol from an unrelated procedure was also
tested, and the endotoxin concentration was <5 EU/mL.
Propofol is a white, oil-in-water emulsion that contains
no preservatives or antimicrobial agents. Because of its
lipid base, propofol supports the growth of bacteria and
thus the potential for endotoxin contamination exists.4
Endotoxin is a complex of lipopolysaccharides derived
from the outer cell membrane of Gram-negative bacteria,
and is liberated when the bacteria die. Endotoxin causes
the release of proinflammatory mediators such as tumor
necrosis factor and interleukin-1 from monocytes and
macrophages resulting in septicemia syndrome. Because of
its resistance to extreme temperatures and pH values,
endotoxin is almost impossible to destroy with normal
sterilization procedures.4 Although self-limited febrile-
syndromes have been reported after propofol& Formosan Medical Association. All rights reserved.
Endotoxemia from propofol contamination 329administration, little evidence has been provided that they
are due to endotoxin.5 In the four cases presented here, the
common denominator was the single propofol ampule, and
laboratory testing of the propofol syringes indicated high
levels of endotoxin.
In conclusion, although propofol is considered safe
adherence to strict guidelines for its preparation and
administration must be followed. Propofol-related fever is
more common, but endotoxemia should be considered in
the diagnosis of febrile illness after propofol use.
References
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3. Muller AE, Huisman I, Roos PJ, Rietveld AP, Klein J, Harbers JB,
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Endotoxemia due to propofol contamination in four consecutive patients 

Endotoxemia due to propofol contamination in four consecutive patients

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