Electrocardiographic changes predicting sudden death in propofol-related infusion syndrome

Abstract

Background: The occurrence of metabolic acidosis, rhabdomyolysis, hyperkalemia, and sudden cardiac death after long-term, high-dose propofol infusion has been referred to as propofol infusion syndrome (PRIS).

Objectives: The purpose of this study was to explore the ECG abnormalities observed in a patient with PRIS in order to identify possible pathophysiologic mechanisms of the syndrome.

Methods: ECG changes in the index case were characterized by down-sloping ST-segment elevation in precordial leads V1 to V3 (Brugada-like ECG pattern). We subsequently assessed the relationship between this ECG pattern and the propofol infusion rate, the development of arrhythmias, and the occurrence of sudden death in a previously described cohort of 67 head-injured patients, seven of whom had been identified as having PRIS.

Results: Six of the PRIS patients developed the ECG pattern of ST-segment elevation in leads V1 to V3 and died within hours of irrecoverable electrical storm. This ECG pattern was the first aberration recorded hours before the death of these patients. ECGs that were available for 30 of 60 unaffected patients exhibited a normal pattern. None of the 60 patients developed ventricular arrhythmias.

Conclusion: Our findings indicate that development of an acquired Brugada-like ECG pattern in severely head-injured patients is a sign of cardiac electrical instability that predicts imminent cardiac death. Future studies will determine whether such an ECG pattern also predicts imminent cardiac arrhythmia in other patient populations.

Figure 1

A: ECG of our index patient at the time of diagnosis of propofol infusion syndrome. Note ST-segment elevation in right precordial lead V₂, consistent with a typical Brugada-like ECG pattern. B: ECG of index patient 12 hours after withdrawal of propofol. Note that, despite the still abnormal ST segments, inverted T waves, and prolonged QT interval, the ST segment in lead V₂ is dramatically decreased compared with the previous ECG (panel A).

Figure 2

Twelve-lead ECGs of the seven patients with propofol infusion syndrome in the neurosurgical intensive care unit. With the exception of patient 2, all patients show a coved-type ST-segment elevation in the right precordial leads.

Figure 3

Serial ECGs of three of the patients with propofol infusion syndrome. ST-segment elevation in precordial leads V₁ to V₃ precedes any other ECG abnormality. After development of ST-segment elevation over the following hours, the ECG degenerates into wide-complex tachycardia, idioventricular rhythm, and ventricular fibrillation.