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Refractory atrial fibrillation with rapid ventricular response as a heralding sign of propofol infusion syndrome in a patient with COVID-19
  1. Madiha Naqsh Siddiqui1,
  2. Elizabeth Henley1 and
  3. Bing Xue2
  1. 1Internal medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
  2. 2Critical care/Pulmonology, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Madiha Naqsh Siddiqui; madihanaqshsiddiqui{at}


A woman in her 40s was transferred to the medical intensive care unit due to severe COVID-19 infection causing respiratory failure. Her respiratory failure worsened rapidly, requiring intubation and continuous sedation with fentanyl and propofol infusions. She required progressive increases in the rates of the propofol infusion, as well as addition of midazolam and cisatracurium due to ventilator dyssynchrony. To support the high sedative doses, norepinephrine was administered as a continuous infusion. She developed atrial fibrillation with rapid ventricular response, with rates ranging between 180 and 200 s which did not respond to intravenous adenosine, metoprolol, synchronised cardioversion or amiodarone. A blood draw revealed lipaemia, and triglyceride levels were noted to be elevated to 2018. The patient developed high-grade fevers up to 105.3 and acute renal failure with severe mixed respiratory and metabolic acidosis, indicating propofol-related infusion syndrome. Propofol was promptly discontinued. An insulin-dextrose infusion was initiated which improved patient’s fevers and hypertriglyceridaemia.

  • Arrhythmias
  • COVID-19
  • Adult intensive care
  • Unwanted effects / adverse reactions

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  • Contributors MNS (conceptualisation; writing—original draft; writing—review and editing). EH (conceptualisation; writing—original draft). BX (conceptualisation; supervision)

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.