1511: A Case of Brash (Bradycardia, Renal Failure, Av Blockade, Shock, Hyperkalemia) Syndrome

Abstract

INTRODUCTION:Propofol infusion syndrome (PRIS) is characterized by rhabdomyolysis, hyperkalemia, renal, cardiac, and liver dysfunction, and lactic acidosis associated with prolonged infusion or high dosages of propofol. PRIS is due to mitochondrial dysfunction leading to fatty acid oxidation and electron transport chain impairment as well as calcium channel and b-adrenergic receptor blockade. Risk factors include carbohydrate store depletion, critical illness, and co-administration of catecholamines and glucocorticoids. DESCRIPTION:A 46-year-old female with decompensated cirrhosis from primary sclerosing cholangitis underwent liver transplant and was placed on a propofol infusion (up to 50 mcg/kg/min) intra-and post-operatively. On post-operative day (POD) 1, she had runs of ventricular tachycardia with hyperkalemia of 6.1mmol/L and a lactic acidosis of 9.0 mmol/L with no vasopressor requirement. Hemodialysis was initiated. On POD 3, her lactate peaked at 15 mmol/L and a creatinine kinase (CK) was 74,840 U/L on minimal norepinephrine and epinephrine. CT scan revealed postoperative changes with no signs of ischemic bowel. Liver doppler ultrasound was normal. Echocardiogram revealed left ventricular ejection fraction (LVEF) of 35% and severe right ventricular dysfunction. Exploratory laparotomy revealed no anastomotic stenoses, hepatic congestion, or ischemic bowel. Propofol was discontinued at this time due to concern for PRIS. CK peaked on POD 4 at 135,900 U/L, with AST/ ALT at 18,440/4,571 U/L and bilirubin at 6.7 mg/dL. Insulin and 20% dextrose infusions were initiated to optimize glycolysis. Liver biopsy demonstrated 70% parenchymal necrosis, and she was re-listed for transplant. Over the next few days her rhabdomyolysis, liver function and cardiac function began to improve.