Critical Care Scenarios Episode 92: PRIS and propylene glycol toxicity, with Jerry Snow
Sep 16, 2025
Join medical toxicologist Jerry Snow as he dives into the critical topic of propofol infusion syndrome (PRIS) and its associated risks. He explains how high doses can lead to mitochondrial dysfunction and key clinical signs to watch for, like elevated lactate and cardiac changes. The discussion shifts to propylene glycol toxicity from prolonged lorazepam infusions, outlining safe dosage thresholds and its metabolic implications. Jerry emphasizes early detection and the need for careful monitoring in critically ill patients. A must-listen for anyone in emergency medicine!
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Status Epilepticus Case Sparks Concern
- The podcast uses a status-epilepticus case on high-dose propofol to illustrate PRIS risk after several days.
- The team notices rising anion gap, green urine, and lactate 4.1, prompting concern for PRIS.
When PRIS Happens
- Propofol infusion syndrome (PRIS) is primarily seen with high-dose and prolonged propofol infusions in critically ill patients.
- Risk factors include high dose, >48 hours infusion, critical illness, catecholamines, steroids, and malnutrition.
PRIS Is Mitochondrial Energy Failure
- The leading hypothesis for PRIS is mitochondrial dysfunction impairing ATP production and fatty acid metabolism.
- Propofol appears to inhibit electron transport (complex II and IV) and fatty acid oxidation, causing cellular energy failure.