A 25 year old male presents with severe asthma exacerbation requiring intubation. His blood work and chest xray are unremarkable. You place the patient on a propofol drip but he fights the vent and requires increasingly high doses. The patient boards in the ED overnight, awaiting a bed in the MICU. The following morning his vitals remain stable, you check his VBG: ph 7.2, PCO2 40, lactate 8. What is the most likely diagnosis?

Answer: Propofol-related Infusion Syndrome (PRIS): Increased risk in younger patients, high doses >4mg/kg/hour, greater 48 duration infusion (reported as low as 24 hours), sepsis, pressors, exogenous glucocorticoids. Hallmark is metabolic acidosis, increased lactate, rhabdo, dysrhythmias.