Skip to main content
SpringerLink
Log in

Propylene Glycol Toxicity Complicating Use of Barbiturate Coma

  • PRACTICAL PEARL
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Introduction

Barbiturate coma is a necessary medical therapy in certain instances, such as the treatment of refractory status epilepticus or severe intracranial hypertension, but its use is often wrought with serious complications. Potential complications include hemodynamic instability, respiratory depression, and immunosuppression with frequent nosocomial infections. High doses of barbiturates may also lead to the accumulation of propylene glycol, the vehicle used in the intravenous formulations of both pentobarbital and phenobarbital, thereby yielding another less-recognized complication of therapy.

Results

We present a case of propylene glycol toxicity associated with the use of high-dose intravenous pentobarbital and phenobarbital during the treatment of refractory status epilepticus.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma, Critical Care AANS/CNS. Anesthetics, analgesics, and sedatives. J Neurotrauma 2007;24:S71–6.

    Google Scholar 

  2. Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 1988;69:15–23.

    Article  PubMed  CAS  Google Scholar 

  3. Partinen M, Kovanen J, Nilsson E. Status epilepticus treated by barbiturate anaesthesia with continuous monitoring of cerebral function. BMJ 1981;282:520–1.

    PubMed  CAS  Google Scholar 

  4. Parviainen I, Uusaro A, Kalviainen R, Kaukanen E, Mervaala E, Ruokonen E. High-dose thiopental in the treatment of refractory status epilepticus in intensive care unit. Neurology 2002;59:1249–51.

    Article  PubMed  CAS  Google Scholar 

  5. Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia 2002;43:146–53.

    Article  PubMed  CAS  Google Scholar 

  6. Reves JG, Glass PSA, Lubarsky DA, McEvoy MD. Intravenous nonopioid anesthetics. In: Miller’s anesthesia. 6th ed. Philadelphia: Elsevier Inc; 2005. pp. 326–34.

  7. Schalen W, Messeter K, Nordstrom CH. Complications and side effects during thiopentone therapy in patients with severe head injuries. Acta Anaesthesiol Scan 1992;36:369–77.

    CAS  Google Scholar 

  8. Todd MM, Drummond JC, U HS. The hemodynamic consequences of high-dose thiopental anesthesia. Anesth Analg 1985;64:681–7.

  9. Eckstein JW, Hamilton WK, McCammond JM. The effect of thiopental on peripheral venous tone. Anesthesiology 1961;22:525–8.

    Article  PubMed  CAS  Google Scholar 

  10. Choi SD, Spaulding BC, Gross JB, Apfelbaum JL. Comparison of the ventilatory effects of etomidate and methohexital. Anesthesiology 1985;62:442–7.

    Article  PubMed  CAS  Google Scholar 

  11. Cairns CJ, Thomas B, Fletcher S, Parr MJ, Finfer SR. Life-threatening hyperkalemia following therapeutic barbiturate coma. Intensive Care Med 2002;28:1357–60.

    Article  PubMed  Google Scholar 

  12. Llompart-Pou JA, Perez-Barcena J, Raurich JM, et al. Effect of barbiturate coma on adrenal response in patients with traumatic brain injury. J Endocrinol Invest 2007;30:393–8.

    PubMed  CAS  Google Scholar 

  13. Eberhardt KEW, Thimm BM, Spring A, Maskos WR. Dose-dependent rate of nosocomial pulmonary infection in mechanically ventilated patients with brain edema receiving barbiturates: a prospective case study. Infection 1992;20:12–8.

    Article  PubMed  CAS  Google Scholar 

  14. Stover JF, Stocker R. Barbiturate coma may promote reversible bone marrow suppression in patients with severe isolated traumatic brain injury. Eur J Clin Pharmacol 1998;54:529–34.

    Article  PubMed  CAS  Google Scholar 

  15. Ploppa A, Kiefer RT, Nohe B, et al. Dose-dependent influence of barbiturates but not of propofol on human leukocyte phagocytosis of viable Staphylococcus aureus. Crit Care Med 2006;34:478–83.

    Article  PubMed  CAS  Google Scholar 

  16. Zar T, Graeber C, Perazella MA. Recognition, treatment, and prevention of propylene glycol toxicity. Semin Dialysis 2007;20:217–9.

    Article  Google Scholar 

  17. Tayar J, Jabbour G, Saggi SJ. Severe hyperosmolar metabolic acidosis due to a large dose of intravenous lorazepam. N Engl J Med 2002;346:1253–4.

    Article  PubMed  Google Scholar 

  18. Parker MG, Fraser GL, Watson DM, Riker RR. Removal of propylene glycol and correction of increased osmolar gap by hemodialysis in a patient on high dose lorazepam infusion therapy. Intensive Care Med 2002;28:81–4.

    Article  PubMed  Google Scholar 

  19. Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Crit Care Med 2004;32:1709–14.

    Article  PubMed  CAS  Google Scholar 

  20. Wilson KC, Reardon C, Theodore AC, Farber HW. Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series an prospective, observational pilot study. Chest 2005;128:1674–81.

    Article  PubMed  CAS  Google Scholar 

  21. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119–41.

    Article  PubMed  Google Scholar 

  22. Demey HE, Bossaert LL. Propylene glycol intoxication and nitroglycerin therapy. Crit Care Med 1987;15:540.

    Article  PubMed  CAS  Google Scholar 

  23. Wilson KC, Reardon C, Farber HW. Propylene glycol toxicity. N Engl J Med 2000;343:815.

    Article  PubMed  CAS  Google Scholar 

  24. Bedichek E, Kirschbaum B. A case of propylene glycol toxic reaction associated with etomidate infusion. Arch Intern Med 1991;151:2297–8.

    Article  PubMed  CAS  Google Scholar 

  25. Levy ML, Aranda M, Zelman V, Giannotta SL. Toxicity following continuous etomidate infusion for the control of refractory cerebral edema. Neurosurgery 1995;37:363–9.

    Article  PubMed  CAS  Google Scholar 

  26. Yorgin PD, Theodorou AA, Al-Uzri A, Davenport K, Boyer-Hassen LV, Johnson MI. Propylene glycol-induced proximal renal tubular cell injury. Am J Kidney Dis 1997;30:134–9.

    Article  PubMed  CAS  Google Scholar 

  27. Louis S, Kutt H, Macdowell F. The cardiocirculatory changes caused by intravenous dilantin and its solvent. Am Heart J 1967;74:523–9.

    Article  PubMed  CAS  Google Scholar 

  28. Yaucher NE, Fish JT, Smith HW, Wells JA. Propylene glycol associated renal toxicity from lorazepam infusion. Pharmacotherapy 2003;23:1094–9.

    Article  PubMed  CAS  Google Scholar 

  29. Verressen L. Nitroglycerin-induced intracranial hypertension. Crit Care Med 1986;14:753.

    Article  Google Scholar 

  30. Arulananthum K, Genel M. Central nervous system toxicity associated with ingestion of propylene glycol. J Pediatr 1978;93:515–6.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pharmacy, University of Virginia Health System, PO Box 800674, Charlottesville, VA, 22908-0674, USA

    Kathleen A. Bledsoe

  2. Departments of Critical Care Medicine & Clinical Neurosciences, Foothills Medical Center, University of Calgary, Room EG23J - 1403 29th St. N.W., Calgary, AB, Canada, T2N 2T9

    Andreas H. Kramer

Authors
  1. Kathleen A. Bledsoe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andreas H. Kramer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kathleen A. Bledsoe.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bledsoe, K.A., Kramer, A.H. Propylene Glycol Toxicity Complicating Use of Barbiturate Coma. Neurocrit Care 9, 122–124 (2008). https://doi.org/10.1007/s12028-008-9065-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-008-9065-z

Keywords

Search

Navigation