SESSION TYPE: Critical Care Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Propofol infusion syndrome (PRIS) is marked by metabolic acidosis, cardiac dysfunction and rhabdomyolysis. Along with volume expansion, usage of continuous renal replacement therapy (CRRT) has been shown to be advantageous in patients with rhabdomyolysis and oliguric renal failure. We discuss a case in which two continuous veno-venous hemofiltration (CVVH) pumps were applied in a patient with severe PRIS.
CASE PRESENTATION: A 19 year old female sustained severe head trauma after a motor vehicle accident. Her subsequent intracranial hypertension was managed medically including infusion of propofol at 80-100mcg/kg/min. On hospital day four she developed hypotension and intractable intracranial hypertension. She underwent a left decompressive hemicraniectomy. After surgery she became oliguric with a myoglobinemia of 40,000ng/ml. Her propofol was discontinued due to the concern for PRIS. She was started on CVVH with ultrafiltration of 6L/hr and 50 kDa pore size filter. Her myoglobin levels decreased. She subsequently developed abdominal compartment syndrome and underwent decompressive laparotomy. She intermittently required catecholamine infusion. Two days later serum myoglobin climbed above 100,000 ng/ml, despite her initial improvement and being free from propofol for five days. A second CVVH pump was started with a total ultrafiltration approaching 14L/hr. At the peak of her CVVH treatment, analysis of the ultrafiltrate revealed removal of 2.6gm of myoglobin per day. She required 16 days of CVVH treatment before her myoglobin levels normalized. A muscle biopsy done at the time of her initial laparotomy revealed a necrotizing myopathy making PRIS the most likely cause. Her renal function returned and she was discharged to rehabilitation.
DISCUSSION: This case represents rhabdomyolysis in the setting of PRIS, its severity marked by the persistence of the myoglobinemia despite aggressive hemofiltration. Due to the continuous distribution of myoglobin from the muscle to the circulation, continuous filtration is likely to be of benefit in the setting of rhabdomyolysis with renal failure.
CONCLUSIONS: In this case using very high ultrafiltrate volumes created the daily clearance of myoglobin which was necessary to resolve the myoglobinemia. Though this level of myoglobin clearance has been previously demonstrated with the use of a larger pore size filter, this high volume therapy allowed for aggressive clearance without the need for albumin replacement.
1) Naka. T et al. “Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report” Critical care (2005): R90-95.
2) Casserly, B et al. “Propofol Infusion Syndrome: An unusual cause of renal failure” American Journal of Kidney Diseases 44.6 (2004): E98-E101.
DISCLOSURE: The following authors have nothing to disclose: Blaine Kenaa, Laurie Punch, Deborah Stein, Thomas Scalea
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