• Esther S Veldhoen, Barend J Hartman, and Josephus P J van Gestel.
• Department of Pediatrics, The Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands. e.s.veldhoen@umcutrecht.nl
• Pediatr Crit Care Me. 2009 Mar 1;10(2):e19-21.

ObjectiveThe aim of this report is to describe a fatal case of propofol infusion syndrome (PRIS), despite regular screening for this syndrome and immediate discontinuation of the infusion after the first signs of biochemical derangement.DesignCase report.SettingPediatric intensive care unit.PatientA 17-year-old patient admitted after sustaining a traumatic brain injury.InterventionsTreatment for traumatic brain injury was given with mechanical ventilation, inotropic support, mannitol, and sedation with propofol. Blood gases and serum levels of lactate and creatine kinase were monitored frequently to screen for PRIS.Measurements And Main ResultsPropofol infusion was stopped immediately after the first signs of biochemical derangement. The patient died despite supportive treatment with intra-aortic balloon pump and cardiopulmonary resuscitation.ConclusionsThis case report demonstrates that frequent monitoring of biochemical parameters, as suggested in literature, cannot always prevent death due to PRIS.

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