University Of Miami - Jackson Memorial Hospital Miami, Florida, United States
Background/Case Studies: Propofol is the preferred sedative agent for critically ill patients requiring mechanical ventilation. Propofol-induced hypertriglyceridemia (HTG) is a well described side effect especially in patients requiring prolong infusion. Early recognition in the ICU setting is critical to initiate effective therapy. The role of plasmapheresis as an early/adjuvant approach in propofol-induce hypertriglyceridemia (HTG) is unknown and its indication is not listed in the ASFA guidelines. Reported here is a case where the triglyceride level significantly improved after one therapeutic plasma exchange (TPE).
Study
Design/Methods: A 64 year old male with medical history suspected of ETOH versus hepatitis cirrhosis who was found unresponsive at home in large volume hematemesis. He was admitted to ER and subsequently transferred to medical ICU with hemorrhagic shock secondary to variceal bleeding requiring massive transfusion protocol, vasopressors, intravenous octreotide and insertion of a Blakemore tube for stabilization. The patient was placed in mechanical ventilation and sedated for ventilatory synchrony with propofol and fentanyl drips. His renal function worsens with markedly elevated ammonia levels and severe lactic acidosis requiring Continuous Veno-Venous Hemofiltration (CVVHDF) a type of Continuous Renal Replacement Therapy (CRRT). On hospital day four, the CRRT circuit was noted to be clotted with a dense yellow fluid. At the time, his serum triglyceride (TG) level was detected at 1107 mg/dL raising concern for propofol-induced hypertriglyceridemia. No evidence of pancreatitis was identified by imaging. Therapeutic plasma exchange was requested by critical care team.
Results/Findings: TG level decreased from1107 mg/dL to 829 mg/dL within the first 12H after propofol was switched to dexmedetomidine (Precedex). Subsequently, therapeutic plasma exchange was performed the same day aiming for a rapid decrease in triglyceride level. After 1.0 plasma volume exchanged the TG level successfully normalized to 80 mg/dL.
Conclusions: Therapeutic Plasma Exchange may be of value in treating patients with elevated TG associated with prolong propofol infusion in critically ill patients. Plasmapheresis might be an effective early adjuvant therapy to mitigate propofol-induced hypertriglyceridemia, enhance cost-effectiveness and safety.
