Propofol-related infusion syndrome (PRIS) is a welldocumented yet rare complication of prolonged infusions of propofol. It is characterized by a myriad of metabolic abnormalities, including cardiac arrhythmias, rhabdomyolysis, acute kidney injury, metabolic acidosis, and other disturbances. First described in children receiving extended propofol infusions to maintain sedation while in the intensive care unit, PRIS has now been described in every age group. It typically results in death. Management of this potentially devastating complication involves supportive treatment of the metabolic problems encountered and discontinuing the use of propofol. We describe a patient with suspected PRIS who underwent a two-stage lumbar spine procedure with total intravenous anesthesia, using propofol as the anesthetic. At 6-weeks postoperatively, he could walk without assistive devices and did not require pain medication. Findings of the current case may help inform healthcare providers of the possibility of PRIS after spinal fusion, allowing for a potentially lifesaving diagnosis

Paterson, Andrew J

Pedri, Tony G

Wharton, Matthew G

English

University of New Mexico

101CASE REPORTS • UNMORJ VOL. 7 • 2018 101
Suspected Propofol-Related Infusion 
Syndrome After Lumbar Spinal Fusion With 
Total Intravenous Anesthesia: A Case Report
Tony G. Pedri, MD; Matthew G. Wharton, MD; Andrew J. Paterson, MD
Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, 
Albuquerque, New Mexico 
Corresponding Author Matthew G. Wharton. Department of Orthopaedics & Rehabilitation, 1 University of New 
Mexico MSC 10 5600, Albuquerque, NM 87131 (email: mwharton1@salud.unm.edu).
Funding The authors received no financial support for the research, authorship, and publication of this article.
Conflict of Interest The authors report no conflicts of interest.
Informed Consent The patient was informed that the data concerning his case would be submitted for publication, 
and he provided verbal consent.
ABSTRACT
Propofol-related infusion syndrome (PRIS) is a well-
documented yet rare complication of prolonged 
infusions of propofol. It is characterized by a myriad of 
metabolic abnormalities, including cardiac arrhythmias, 
rhabdomyolysis, acute kidney injury, metabolic acidosis, 
and other disturbances. First described in children 
receiving extended propofol infusions to maintain 
sedation while in the intensive care unit, PRIS has now 
been described in every age group. It typically results 
in death. Management of this potentially devastating 
complication involves supportive treatment of the 
metabolic problems encountered and discontinuing 
the use of propofol. We describe a patient with 
suspected PRIS who underwent a two-stage lumbar 
spine procedure with total intravenous anesthesia, using 
propofol as the anesthetic. At 6-weeks postoperatively, 
he could walk without assistive devices and did not 
require pain medication. Findings of the current case 
may help inform healthcare providers of the possibility 
of PRIS after spinal fusion, allowing for a potentially life-
saving diagnosis.
Keywords: Propofol-Related Infusion Syndrome, Lumbar 
Vertebrae, Spinal Fusion, Intravenous Anesthesia
INTRODUCTION
Propofol is a common medication used for its sedative 
properties in the intensive care unit and as an 
anesthetic agent in the operating room. It is typically 
well tolerated by patients and considered relatively 
safe. Propofol-related infusion syndrome (PRIS) is a 
well-documented complication of the use of propofol. 
The condition was initially described in children but has 
been observed in all age groups.1,2 Symptoms typically 
include cardiac arrhythmias, metabolic acidosis, 
acute kidney injury, rhabdomyolysis, and metabolic 
disturbances.3
Patients with this life-threatening condition are 
typically critically ill in intensive care units and receive 
prolonged infusions for more than 48 hours for 
sedation.4 Most patients described in studies died as 
a result. PRIS has rarely been noted in patients with 
short-term infusions as is typical with most surgical 
procedures. 
To our knowledge, PRIS has not been described 
in patients who underwent spinal fusion using total 
intravenous anesthesia. Surgical treatment of spinal 
deformity in adults is complex owing to combined 
anterior and posterior approaches for circumferential 
correction and fusion. It is associated with considerable 
complications and can be performed in a single day or 
staged fashion. Operating times range from 6 to 12 or 
more hours, with a common estimated blood loss of 
more than 2 L.5 Propofol is often used as the anesthetic 
because of it allows intraoperative neurophysiological 
monitoring. We present a patient who developed 
PRIS after lumbar spine decompression and fusion for 
treating lumbar degenerative scoliosis. 
CASE REPORT
A 60-year-old man presented with severe degenerative 
scoliosis of the lumbar spine with stenosis, neurogenic 
claudication, and radiculopathy (Figures 1 and 2). 
Nonoperative treatment was unsuccessful. Operative 
correction such as lateral interbody fusion with 
posterior spinal fusion was discussed with the patient. 
His medical history included alcohol abuse, tobacco 
abuse, hyperlipidemia, and chronic pain. He had no 
previous complications with surgical procedures but did 
report “difficulty waking up” after a remote procedure 
several years before, of which he said he did not 
remember the details. There was no family history of 
difficulties with anesthesia.
The patient was taken to the operating room and 
underwent anterior decompression and interbody fusion 
102 CASE REPORTS • UNMORJ VOL. 7 • 2018102
using an extreme lateral technique at the levels L2-L3, 
L3-L4, and L4-L5.6 While under the same anesthetic, 
he was repositioned and underwent posterior 
decompression and instrumented fusion of level L2-
L5. No intraoperative complications were noted, with 
successful correction of the complex degenerative 
scoliosis (Figures 3 and 4). 
Fgure 1. Preoperative lateral view of the lumbar spine, 
showing severe multilevel facet arthropathy and 
degenerative disc disease with anterolisthesis of levels 
L3-L4 and L4- L5.
Figure 2. Preoperative anteroposterior view 
of the lumbar spine, showing severe multilevel 
facet arthropathy, degenerative disc disease, and 
degenerative levoconvex scoliosis.
Figure 3. Lateral view of the lumbar spine, showing 
interbody fusions at levels L2-L3, L3-L4, and L4-L5 with 
posterior instrumentation at level L2-L5.
Figure 4. Anteroposterior view of the lumbar spine, 
showing interbody fusions at levels L2-L3, L3-L4, and 
L4-L5, with posterior instrumentation at level L2-L5.
103CASE REPORTS • UNMORJ VOL. 7 • 2018 103
Before incision, tranexamic acid was administered to 
minimize blood loss.7 The patient was in the operating 
room for about 10 hours and 48 minutes, with a total 
anesthesia time of 9 hours and 30 minutes and a mean 
propofol infusion rate of 6.8 mg/kg per hour. During 
the second stage of the procedure, an arterial blood 
gas was drawn that showed a mild metabolic acidosis 
to a pH of 7.31. At the completion of the procedure, the 
patient was awoken from anesthesia-induced sleep and 
extubated without observed complication. Estimated 
blood loss throughout the surgical procedure was 850 
mL, with urine output measured at 550 mL. A total of 
5000 mL of intravenous crystalloid was administered, 
and no blood products were given. Postoperatively, 
hematocrit volume was 0.3 (30%), down from a 
preoperative measurement of 0.4 (40%).
In the immediate postoperative period, the patient 
could move extremities on command but had decreased 
mental activity and was severely agitated, requiring 
restraints for safety. A cardiac arrhythmia comprising 
tachycardia with premature atrial complexes and ST 
segment changes were detected on continuous cardiac 
monitoring, and he was subsequently transferred 
to the intensive care unit. Results of initial workup 
revealed an acute kidney injury with a 0.36 increase 
in creatine levels, severe rhabdomyolysis, metabolic 
acidosis, and elevated troponins. No obvious cause of 
the sudden symptoms was identified. He was treated 
with close monitoring and aggressive resuscitation. The 
patient’s creatine kinase level peaked at 312.3 μkat/L 
(18,693 U/L), and the troponin I level elevated to 0.938 
μg/L. During the next 5 days, the patient’s metabolic 
abnormalities resolved, his kidney function returned 
to baseline levels, and his arrhythmia resolved without 
intervention. His mental activity improved considerably, 
and he was discharged to an inpatient rehabilitation 
facility. 
At his 6-week postoperative visit, the patient 
walked without assistive devices and did not require 
any pain medications. The previous symptoms caused 
by neurogenic claudication and radiculopathy were 
resolved. His mental activity was at its baseline level, 
with no reported residual effects of his prolonged 
hospital stay. He did report “very little recollection” of 
the several days after the operation.
DISCUSSION
PRIS is a rare but potentially life-threatening condition 
associated with the use of a common and relatively safe 
medication. It has been described mostly in patients 
undergoing prolonged sedation for treating critical 
illness such as respiratory failure or traumatic brain 
injuries.2 Bray8 described diagnostic criteria to include 
sudden bradycardia progressing to asystole in addition 
to one of either metabolic acidosis, derangement of 
liver function, lipemic plasma, or rhabdomyolysis. The 
definition now includes hypotension, acute kidney 
injury, hyperkalemia, and hypoxia.4 PRIS may be dose 
dependent, with patients most at risk who receive 
dosages higher than 4 mg/kg per hour for a prolonged 
duration.9 Treatment typically involves cessation of 
propofol and then treatment of the sequelae.9 PRIS 
often results in patient death. Many authors have tried 
to identify risk factors or develop screening tests to 
prevent PRIS.10,11
To our knowledge, PRIS has not been documented to 
occur after spinal fusion. PRIS is typically a diagnosis 
of exclusion because  many of the signs and symptoms 
often result from much more common pathological 
features. In our patient, there was concern he was 
under-resuscitated or suffering from medication 
withdrawal. Under-resuscitation was unlikely, however, 
because of standard levels of blood loss, adequate 
urine output, and only minor abnormalities found on 
intraoperative blood gas. Medication withdrawal was 
unlikely owing to near immediate onset of symptoms 
postoperatively and the failure to identify any offending 
agents initially during review of medical records, 
interviews with the patient’s friends and family, and 
discussion with the patient when the symptoms 
resolved.  
Our patient exhibited typical findings of PRIS. At 
our institution, degenerative scoliosis procedures with 
multiple stages are typically performed using one 
anesthetic agent. Our experience has been similar to 
that of others, in which this single prolonged procedure 
is safe. That is, major complications are rare, with 
similar outcomes to staged procedures performed 
during several days. These procedures are also usually 
performed with total intravenous anesthetic. A review 
of our patient’s medical history did not indicate the risk 
of developing PRIS. 
Although PRIS is rare, surgeons performing 
prolonged procedures with the use of continuous 
infusion of propofol should be aware of the condition. It 
can be difficult to diagnose, and delay in doing so may 
result in death of patients. 
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Suspected Propofol-Related Infusion Syndrome After Lumbar Spinal Fusion With Total Intravenous Anesthesia: A Case Report

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Suspected Propofol-Related Infusion Syndrome After Lumbar Spinal Fusion With Total Intravenous Anesthesia: A Case Report

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