2026 Southeastern Residency Conference

Title: Complications Associated with Prolonged High-Rate Propofol Infusion in ICU Patients 

Authors: Phuongloan Hoang, Brook Jacobs, Rupal Sheth 

Background/Purpose: 
Propofol is a highly lipophilic sedative hypnotic that exerts its effects by stimulating γ-aminobutyric acid (GABA) receptors. It is widely used in the intensive care unit (ICU) for sedation, ventilator synchrony, oxygen optimization, and management of status epilepticus. Advantages include its fast onset and short duration of action. Propofol administration may lead to propofol-related infusion syndrome (PRIS), a rare but potentially fatal complication characterized by metabolic acidosis, cardiac abnormalities, hypotension, acute kidney injury, hepatic dysfunction, and electrolyte disturbances. Diagnosis is challenging because these features overlap with propofol’s expected pharmacologic effects and manifestations of critical illness. PRIS most often occurs with higher infusion rates, prolonged exposure, and concomitant vasopressor therapy. 

Within our health system, the standard continuous infusion range for propofol is between 5 to 80 mcg/kg/min using the ALARIS pump. A soft stop at 50 mcg/kg/min was previously implemented as a safeguard to reduce the risk of PRIS and other potential complications. While this threshold provides an additional layer of safety, concerns arose regarding whether this 50 mcg/kg/min soft stop may have been overly conservative, particularly since PRIS has been reported at lower infusion rates which suggests that risk is not strictly dose-dependent. Maintaining this limit could potentially restrict treatment options unnecessarily, especially for patients who have high sedation requirements and might benefit from higher infusion rates.  Additionally, if adverse safety events are not being observed, reevaluating the threshold could help to reduce alert fatigue for nursing staff, supporting both patient care and workflow efficiency. Recently, a decision was made to raise the soft stop to 60 mcg/kg/min. This study aims to evaluate the incidence of presumed PRIS and to assess whether it is safe to raise the upper dosing threshold for propofol infusions.   

Methods: 
This study was a multicenter, retrospective cohort study that included patients aged ≥18 who received continuous propofol infusions for ≥24 hours at our institution from April through September 2025.  Patients were eligible if they received continuous propofol infusions for ≥24 hours and were grouped based on average propofol infusion rates (<50 mcg/kg/min and ≥50 mcg/kg/min). The primary outcome is the incidence of presumed PRIS defined as the development of 3 or more criteria after the initiation of propofol therapy, one of which must be hypertriglyceridemia or rhabdomyolysis, or a diagnosis of PRIS found in patient’s chart. Secondary outcomes included presumed PRIS incidence in patients receiving propofol at 50-60 mcg/kg/min, ICU length of stay, and initiation of vasopressors or renal replacement therapy.  

Results: 
Of 54 patients, the incidence of overall presumed PRIS was 1.9% (n=1). This patient belonged to the  propofol <50 mcg/kg/min group. Of the four cases that would have met criteria for presumed PRIS (7.4%), three of these cases were excluded due to timing of clinical findings. In those who received continuous propofol infusion for ≥24 hours, secondary outcomes were not statistically significant between the <50 mcg/kg/min and ≥50 mcg/kg/min groups. 

Conclusion: 
Consistent with previous studies, the incidence of presumed PRIS incidence was low in our patient population. Secondary outcomes were not statistically significant. Further studies are needed to determine a clinically meaningful difference in PRIS rates between dosage groups.