Propofol toxicity? Green urine?

[deemo21]

Hello all, I transported a patient from a community hospital to my larger facility vented and sedated on a small dose of propofol at 15mL/hr (10mg/mL). He was awake but calm. There were no complications during transport, but when I got to the SICU they looked at his urine and said he is having propofol toxicity. His urine had a very slight green tint that I did not notice. In a brief lit search I found a paper that said it did not have any clinical significance and was not related to renal damage. When the propofol stopped within 2-4 hrs the urine became normal again. Has anyone encountered this? Is this really propofol toxicity? He had none of the signs of propofol infusion syndrome and had only been on it for <24 hrs at a low dose. He had swallowed his dentures and they were stuck in his lower esophagus and had been unable to be retrieved by ENT or and EGD.

I tried to post this in the clinical section but was having difficulty.

[PaSSiNG GaS]

I've taken care of plenty of patients on propofol gtts where the urine turned green. Doesn't mean they are having a propofol syndrome. Check an abg and if no acidosis I wouldn't worry too much. It happens


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[bettermj]

Just tell them "thank God you are here!" and walk away.

[ABCRn]

We see the green tint often. Doesn't mean PRIS. Here is CE article you can print and leave with them.....
http://ccn.aacnjournals.org/content/28/3/18.full

also from medscape CE
Propofol is metabolized in the liver and excreted in urine predominantly as the 1-glucuronide, 4-glucuronide, and 4-sulfate conjugates of 2,6-diisopropyl-1,4 quinol.^[18] Green discoloration of urine is attributed to the presence of these phenolic metabolites. In addition to urine, reports of green discoloration of the hair and liver after propofol administration implicate these phenols.^{[19, 20]} The metabolites do not reflect or alter renal function.^[10] Although they are of no clinical significance, they do serve as an indicator of relative urine pH where alkalinization increases and acidification decreases formation of these phenolic deriva-tives.^[

[deemo21]

Thank you all for the helpful info! I did read the medscape study. I had not seen the AACN article. Thank you.

[Teillard]

Hello all, I transported a patient from a community hospital to my larger facility vented and sedated on a small dose of propofol at 15mL/hr (10mg/mL). He was awake but calm. There were no complications during transport, but when I got to the SICU they looked at his urine and said he is having propofol toxicity. His urine had a very slight green tint that I did not notice. In a brief lit search I found a paper that said it did not have any clinical significance and was not related to renal damage. When the propofol stopped within 2-4 hrs the urine became normal again. Has anyone encountered this? Is this really propofol toxicity? He had none of the signs of propofol infusion syndrome and had only been on it for <24 hrs at a low dose. He had swallowed his dentures and they were stuck in his lower esophagus and had been unable to be retrieved by ENT or and EGD.

You can really show your mettle as an aspiring anesthetist by explaining that there really is no such thing as propofol toxicity. Misuse by people not prepared to deal with the consequences of using the agent, maybe. PRIS is an adverse reaction to the drug, not toxicity.

[ethernaut]

You can really show your mettle as an aspiring anesthetist by explaining that there really is no such thing as propofol toxicity. Misuse by people not prepared to deal with the consequences of using the agent, maybe. PRIS is an adverse reaction to the drug, not toxicity.

while I don't disagree with what you propose, PRIS has been argued as 'toxiciy'. adverse rxn vs toxicity is argumentative in this situation.

[Teillard]

while I don't disagree with what you propose, PRIS has been argued as 'toxiciy'. adverse rxn vs toxicity is argumentative in this situation.

Ok, fair enough. One of the hats we CRNA's wear is "pharmacologic expert". Where has pris "been argued" as 'toxicity'? Can you defend it? in my pharmacology training, "toxicity" has always meant adverse effects secondary to overdose. Also, while you're at it Ether, for our young (and not so young) aspirants, distinguish between "adverse reaction" and "overdose". To wit: What is the difference between an adverse reaction to fentanyl and an overdose of fentanyl?

[ethernaut]

Ok, fair enough. One of the hats we CRNA's wear is "pharmacologic expert". Where has pris "been argued" as 'toxicity'? Can you defend it? in my pharmacology training, "toxicity" has always meant adverse effects secondary to overdose. Also, while you're at it Ether, for our young (and not so young) aspirants, distinguish between "adverse reaction" and "overdose". To wit: What is the difference between an adverse reaction to fentanyl and an overdose of fentanyl?

sure, i agree we are 'pharmocolic experts'. we have to be. as for the argument of toxicity vs adverse effect, i can only attest to what i've read in the past and what grand rounds has shown me. let me get some info and i'll pass along what i find out.

as to defining what adverse effect is, or what overdose is, i think there are some similarities and overlapping. i see it as a grey area, but.. let me posit this.. if an overdose of fentanyl, let's say, causes severe bradycardia, severe hypotension and ultimately asystole, who's to say that an accumulated dose (or even one time dose) can't cause similar reactions? i think we think of overdose as a volume/amount issue, and adverse effect regardless of volume/amount, but i think it goes 'deeper' than that. none the less, i almost took your questions as a tad rhetorical, as they easily can be.

[Teillard]

sure, i agree we are 'pharmocolic experts'. we have to be. as for the argument of toxicity vs adverse effect, i can only attest to what i've read in the past and what grand rounds has shown me. let me get some info and i'll pass along what i find out.

as to defining what adverse effect is, or what overdose is, i think there are some similarities and overlapping. i see it as a grey area, but.. let me posit this.. if an overdose of fentanyl, let's say, causes severe bradycardia, severe hypotension and ultimately asystole, who's to say that an accumulated dose (or even one time dose) can't cause similar reactions? i think we think of overdose as a volume/amount issue, and adverse effect regardless of volume/amount, but i think it goes 'deeper' than that. none the less, i almost took your questions as a tad rhetorical, as they easily can be.

Teasing out minutia, splitting hairs, and beating dead horses have a place in refining a point. We're teaching here. I know you know the big picture and I also know people casually throw out terms that they think mean one thing, but mean another. Discussions like these are valuable even though on their face, they may appear trivial. Thanks for playing along, E.