Drug detection in decomposed cadavers confirms testimonial evidence in a case of serial homicides.

Toxicology investigation on human's buried dead bodies is a rare and challenging task in the forensic field. As requested by the Judicial Authority, this work aimed to verify testimonial evidence that emerged during a criminal investigation involving multiple murder cases. The statements indicated an improper medical administration of one or more alleged drugs (propofol, morphine, diazepam, and midazolam) which presumably caused the deaths. Since the supposed crimes took place several years before, the task of the present work was to obtain results to support the charges. The analyses involved 18 biological samples taken from four exhumed bodies, three of which were female and one male, each buried in a different date and mode. Each sample was treated with specific purification and extraction techniques (LLE - SPE) after the addition of the deuterated analogs of the searched analytes (propofol-d17, morphine-d3, diazepam-d5, midazolam-d4) as internal standards. Afterwards, the extracts were subjected to qualitative analysis by gas chromatography-mass spectrometry-Electron Impact (GC/MS - EI), both in full scan and SIM mode. Propofol, morphine, and diazepam were identified in the corpses. It supports testimonials that were administered just before the deaths occurred.

Determination of Cyanide by Microdiffusion Technique Coupled to Spectrophotometry and GC/NPD and Propofol by Fast GC/MS-TOF in a Case of Poisoning.

A man was found dead in a hotel located near Rome (Italy). The man was still holding a syringe attached to a butterfly needle inserted in his left forearm vein. The syringe contained a cloudy pinkish fluid. In the hotel room the Police found a broken propofol glass vial plus four sealed ones, an opened NaCl plastic vial and six more still sealed, and a number of packed smaller disposable syringes and needles. An opened plastic bottle containing a white crystalline powder labeled as potassium cyanide was also found. Systematic toxicological analysis (STA), carried out on blood, urine and bile, evidenced only the presence of propofol in blood and bile. So the validated L-L extraction protocol and the GC/MS-TOF method for the confirmation of propofol in the biological fluids optimized in our laboratory was applied to blood, urine and bile. The concentration of propofol resulted to be 0.432 µg/mL in blood and 0.786 µg/mL in bile. The quantitative determination of cyanide in blood was carried out by microdiffusion technique coupled to spectrophotometric detection obtaining a cyanide concentration of 5.3 µg/mL. The quantitative determination was then confirmed by GC/NPD and the concentration of cyanide resulted to be 5.5 µg/mL in blood and 1.7 µg/mL in bile. Data emerging from autopsy findings, histopathological exams and the concentrations of cyanide suggested that death might be due to poisoning caused by cyanide, however, respiratory depression caused by propofol could not be excluded.

Death by Propofol.

Since its introduction in 1986, propofol ( two, 6-diisopropylphenol) , an intravenous sedative-hypnotic agent, has been utilized for the induction and maintenance of general anesthesia and conscious sedation in over 80 percent of cases; largely replacing thiopental ( sodium pentothal) over a decade ago. Unrestricted as a controlled substance, propofol's abuse potential emerged quickly and was highlighted by the death of pop singer, Michael Jackson, in 2009. In order to assess the epidemiological features of fatal propofol abuse, a descriptive analysis of the scientific literature was conducted using Internet search engines. Well-documented cases of fatal propofol abuse were stratified as unintentional or accidental deaths and as intentional deaths by suicides or homicides. Continuous variables were compared for differences by unpaired, two-tailed t-tests with statistical significance indicated by p-values less than 0.05. Of 21 fatal cases of propofol abuse, 18 (86 percent ) occurred in healthcare workers, mostly anesthesiologists and nurse anesthetists (n=14, 67 percent ). One case occurred in a layman who purchased propofol on the Internet. Seventeen deaths (81 percent ) were accidental; two were suicides (9.5 percent ) and two were homicides (9.5 percent ). Blood levels in intentional death cases were significantly greater than in accidental death cases (p less than 0.0001) all of which reflected initial therapeutic induction-level doses in the ranges of 2.0-2.5 mg/kg. Though lacking in analgesic effects, the abuse of propofol by young healthcare professionals, particularly operating room workers, has been significant; and likely underreported. Propofol is a dangerous drug with an evident abuse potential which often results in fatalities.

LC-MS/MS and GC-MS methods in propofol detection: Evaluation of the two analytical procedures.

Propofol is a short-acting hypnotic agent that is commonly used to induce and maintain anesthesia. Propofol abuse and its involvement in suicide deaths have increased in recent years, especially among healthcare personnel. An example is the suicide of a 61-year-old nurse found with a propofol drip in his left arm. We describe the postmortem concentration of propofol in various tissues (femoral and cardiac blood, bile, urine, brain, and liver) and in the drip. The toxicological analyses were performed through two analytical methods, differing in derivatization reaction and in instrumentation: silylation for gas chromatograph-mass spectrometer (GC-MS), as routinely performed in our laboratory for this kind of analyses (lower limits of quantification-LLOQ-in urine and blood: 0.3 and 5ng/ml); for liquid chromatograph-tandem mass spectrometer (LC-MS/MS) an innovative azo-coupling derivatization (LLOQ: 0.0004 and 0.1ng/ml). This latter produces an azo-derivative (molecular composition: C18H22ON2; molecular weight: 282Da) highly ionizable in electro-spray ion source, both in negative and positive ionizations. These two methods were compared to evaluate the effectiveness of this new LC-MS/MS analysis. An acidic hydrolysis (HCl 6N, 100°C, and 1h) was performed for the biological samples (1ml or 1g) irrespective of the analytical method applied. The drip content was extracted adding phosphate buffer (pH 8) and a dichloromethane/ethylacetate 8:2 (v:v) mixture. Derivatization steps were: silylation with N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA)+tetramethylammonium hydroxide (TMAH) for GC-MS; regarding LC-MS/MS, azo-coupling reaction with the aryl-diazonium salt (0-5°C, and 30min). The analyses were achieved in selected-ion monitoring for GC-MS (m/z, 235,250,73 propofol"; m/z, 252,267,27 propofol-d17) and in multiple reaction monitoring ([M-H](-): m/z 283→241,77, azo-propofol; m/z 299→251,77, azo-propofol-d17) for LC-MS/MS. Autopsy showed no significant findings. Propofol concentrations were (LC-MS/MS vs GC-MS, respectively): 15.1 vs 14.5mg/ml, drip content; 7.11 vs 6.07µg/ml, cardiac blood; 9.50 vs 7.19µg/ml, femoral blood; 0.64 vs 1.07µg/ml, bile; 0.042 vs 0.051µg/ml urine; 4.93 vs 5.89µg/g, brain; and 7.88 vs 6.80µg/g, liver. These values are comparable with the ones described in literature for death by acute propofol intoxication; the drip content is compatible with a diluted formulation of propofol available in Italy (20mg/ml injectable emulsion). The comparison shows an excellent fitting of the data (R(2): 0.9362). Toxicological results proved the cause of death as acute propofol intoxication. Furthermore, the new LC-MS/MS method showed an excellent effectiveness and reliability when compared to the routinely used GC-MS method.

Deaths from recreational use of propofol in Korea.

Propofol, a short-acting and sedative-hypnotic agent, induces and maintains anesthesia. Since it is known to produce mild euphoria and hallucinations, the recreational use of propofol has been a big issue in Korea. Furthermore, many deaths have occurred due to its abuse and misuse. In order to study the prevalence of abuse and deaths due to propofol, all autopsy cases conducted between 2005 and 2010 at the NFS (National Forensic Service, Korea) were monitored by checking its concentrations in the blood. Propofol was detected in 131 cases (0.88%) out of 14,673 autopsied cases within 6 years. Propofol alone was detected in 49 of 131 fatal cases, while the combination of drugs was detected with propofol in the remaining 82 cases. The concentrations of propofol from autopsied cases ranged from 0.05 to 8.83 mg/L (mean 1.66; median 0.9) and from 0.08 to 8.65 mg/L (mean 1.71; median 1.05) in the heart (n=31) and the femoral blood (n=32), respectively. The investigation of the ratio of heart to femoral blood and the difference between the concentrations in heart and femoral blood (n=15) from the same body revealed the ratio from 0.45 to 3.66 (mean 1.53; median 1.40). The autopsy resulted in accidental death after self-administration in 16 autopsied cases among 131 autopsied cases. In 16 cases, their ages ranged from 17 to 56 and 75% of them were in their 20's and 30's and 75% were female. Half of them were medical personnel including 19% of doctors and 38% of nurses. The combination of drugs was detected in 6 cases. Fluoxetine was detected in three and vecuronium was detected in two along with propofol. The cause of death in 14 cases was drug intoxication, while that in 2 cases was hanging. Due to its prevalence, Korea has become the first country that regulates propofol as a psychotropic substance.

Suicide by self-administration of a drug mixture (propofol, midazolam, and zolpidem) in an anesthesiologist: the first case report in Italy.

The authors report an unusual case of suicide of an anesthesiologist, in which the suicide manner and means depend upon the victim's occupation. This is the first case report published in Italy of a death involving propofol and other drugs. The anesthesiologist was found dead with an empty drip still inserted in the hand and another one near his body. Forensic and toxicological findings suggested that the cause of death was a respiratory depression due to a self-administration of a rapidly infused lethal drug mixture. Analytical drug quantification was performed by gas chromatography-mass spectrometry. Blood analysis revealed: zolpidem (0.86 µg/mL), propofol (0.30 µg/mL), midazolam (0.08 µg/mL), thiopental (0.03 µg/mL), and amitriptyline (0.07 µg/mL). Adipose tissue and hair analysis suggested a previous and repeated use of these drugs verifying the fact that in Italy recreational abuse of anesthetic and sedative agents in health care practitioners is becoming an increasing problem.

Behavioral and toxicological effects of propofol.

There is increasing concern about abuse of propofol, a widely-used surgical anesthetic and sedative that is currently not a controlled substance. The purpose of this study was to establish a rat model of the psychoactive effect of subanesthetic doses of propofol that could be useful for confirming abuse liability and for studying mechanisms of propofol abuse. Sprague-Dawley rats were trained to discriminate propofol (10 mg/kg, intraperitoneally) from vehicle (2% methylcellulose). Carisoprodol (100 mg/kg), chlordiazepoxide (10 mg/kg), and dizocilpine (0.1 mg/kg) were tested for substitution for the discriminative-stimulus effects of propofol (10 mg/kg), whereas pentylenetetrazol (10 mg/kg) was tested for antagonism of the discriminative-stimulus effects. Propofol (10 mg/kg) was tested for substitution in rats trained to discriminate carisoprodol from vehicle. Carisoprodol produced 59% propofol-appropriate responding, chlordiazepoxide produced 65% propofol-appropriate responding, and dizocilpine produced 34% propofol-appropriate responding. Pentylenetetrazol decreased propofol-appropriate responding to 41%. Propofol produced 52% carisoprodol-appropriate responding. Mortality rate during training of propofol (10 mg/kg) was 38%. Postmortem examination revealed cardiovascular abnormalities similar to those observed in propofol-infusion syndrome in humans. The results demonstrate that propofol can be trained as a discriminative stimulus. Its discriminative-stimulus effects were more similar to compounds promoting γ-aminobutyric acid-A receptor activity than to a compound inhibiting N-methyl-d-aspartate receptor activity. As propofol has discriminative-stimulus effects similar to known drugs of abuse, and occasions a high-mortality rate, its potential for continued abuse is of particular concern.

[Determination of propofol in human blood by GC-MS].

OBJECTIVE: To establish a gas chromatography-mass spectrometry (GC-MS) method for determination of propofol in human blood. METHODS: Propofol and 2-(tert-Butyl)-4,6-dimethylphenol (internal standard) were isolated from human blood samples with liquid-liquid ether extraction. The organic layer was collected after centrifugation and dried using the water bath. The extracted residue was analyzed by GC-MS. RESULTS: Propofol and the internal standard showed a good separation with a good linear concentration ranged from 0.02 to 10 microg/mL in blood. The linear function was y = 0.313 6 x-0.006 8 with the correlation coefficient of 0.9997. The precision of intra-day and inter-day were less than 4.8% and the lower limit of detection of propofol was 0.005 microg/mL. Propofol concentration of blood was 0.14 microg/mL using this method in the practice work. CONCLUSION: The GC-MS method is rapid, sensitive, reliable and suitable for qualitative and quantitative analysis propofol of blood in forensic toxicological analysis and clinical drug monitoring.

Determination of propofol in human blood by GC-MS / 法医学杂志

OBJECTIVE@#To establish a gas chromatography-mass spectrometry (GC-MS) method for determination of propofol in human blood.@*METHODS@#Propofol and 2-(tert-Butyl)-4,6-dimethylphenol (internal standard) were isolated from human blood samples with liquid-liquid ether extraction. The organic layer was collected after centrifugation and dried using the water bath. The extracted residue was analyzed by GC-MS.@*RESULTS@#Propofol and the internal standard showed a good separation with a good linear concentration ranged from 0.02 to 10 microg/mL in blood. The linear function was y = 0.313 6 x-0.006 8 with the correlation coefficient of 0.9997. The precision of intra-day and inter-day were less than 4.8% and the lower limit of detection of propofol was 0.005 microg/mL. Propofol concentration of blood was 0.14 microg/mL using this method in the practice work.@*CONCLUSION@#The GC-MS method is rapid, sensitive, reliable and suitable for qualitative and quantitative analysis propofol of blood in forensic toxicological analysis and clinical drug monitoring.

Multiple organ failure after an overdose of less than 0.4 mg/kg of colchicine: role of coingestants and drugs during intensive care management.

INTRODUCTION: Although the ingestion of a dose of colchicine lower than 0.5 mg/kg is usually complicated by a mortality rate less than 5%, severe complications may be associated with drug-drug interactions in case of overdose combining other drugs. CASE REPORT: A 33-year-old previously healthy woman was admitted after a drug overdose combining colchicine, atorvastatin, ibuprofen, diclofenac, and furosemide. The amount of colchicine ingested was exactly 20 mg, corresponding to 0.33 mg/kg. Despite this relatively low dose, she presented the clinical course that is usually seen with much larger colchicine ingestions. She developed acute renal and liver failure, acute lung injury, pancytopenia with sepsis, rhabdomyolysis, hypertriglyceridemia, and ultimately died on Day 14 from hyperammonemic encephalopathy, refractory hypoxemia, and cardiac arrhythmias. DISCUSSION: Serious drug-drug interactions may have complicated colchicine poisoning. In particular, atorvastatin, an inhibitor of P-glycoprotein and cytochrome P450 3A4, was likely responsible for an increased severity of rhabdomyolysis. In addition, propofol used for sedation during mechanical ventilation may have induced symptoms consistent with "propofol infusion syndrome," with further muscular injury and hypertriglyceridemia. The mechanism of death was unusual and similar to Reye's syndrome.

Brugada-like EKG pattern and myocardial effects in a chronic propofol abuser.

INTRODUCTION: Cases of death are reported due to medical use of propofol, whereas deaths due to recreational purpose are unusual. CASE REPORT: A 26-year-old Caucasian man, physician trainee in anesthesiology, was referred to an intensive care unit. The man was found unconscious in his bed with a butterfly-needle canalized into the vein of the left forearm and connected to an empty syringe. Transferred to the local hospital, the patient was monitored, and EKG showed typical Brugada features in V1-V3. Profound hypotension and metabolic acidosis were registered. Half an hour after admission, the patient developed prolonged QT interval, idioventricular rhythm, and ventricular fibrillation. Strong positive reaction for tumor necrosis factor alpha in cardiac myocytes and a diffuse apoptotic process in the heart specimens were observed. The multiple needle marks on the hands and forearms, and the propofol concentration in the hair examined (0.73 microg/g), led us to believe that the young man was a long-term propofol abuser. DISCUSSION: Development of the EKG pattern of ST-segment elevation in leads V1-V3 may be the first indicator of electrical instability and high risk for imminent sudden death. Whether this finding applies to other patients poisoned with propofol is unclear, but the association of sudden death and the acquired EKG pattern has been observed in other disease states. CONCLUSION: This article describes a fatal propofol-related death case because of recreational purpose; the EKG pattern, the cardiac morphology, and the expression of tumor necrosis factor alpha and apoptosis in cardiac tissue specimens are discussed to elucidate the mechanism of death.

Death from propofol: accident, suicide, or murder?

A 24-yr-old woman was found dead in her home from apparent propofol "toxicity." Her blood level of propofol was 4.3 microg/mL. She had no history of drug abuse and no evidence of such behavior at autopsy. The medical examiner and police investigators felt that she died from probable homicide. Attention was focused on a male registered nurse acquaintance, who had acquired propofol and other drugs in the course of his regular duties in a surgical intensive care unit. This is the first reported case of murder with propofol.

Lethal self administration of propofol (Diprivan). A case report and review of the literature.

The death of a female anaesthesiologist is reported. Although the situation at the scene indicated propofol overdose-related death, self-administration of such high doses of propofol was unlikely, given the pharmacological properties of this drug. The analysis of the situation at the scene and the toxicological analysis in which the blood and liver propofol concentrations were 2.40microg/ml and 0.56microg/g, respectively, supported the conclusion that the death was a consequence of propofol self-administration at therapeutic doses from a person who used the drug on chronic basis seeking to its euphoric effects. However, because the toxic concentrations of propofol in non-intubated patients may be different from those intubated and fully supported in the operating room or in the intensive care unit, a mere interpretation of the blood and tissue concentrations of propofol in the toxicological analysis can confirm the drug intake but it may be of limited diagnostic significance without taking into account this difference.

[Lethal mixed intoxication with propofol in a medical layman]. / Letale Propofol-Mischintoxikation bei einem medizinischen Laien.

The authors report on a drug fatality of a 21-year-old man with a propofol (2,6-di-isopropylphenol) dependency. Propofol was detected in tissues and body fluids using SPME-GC/MS methods. The postmortem concentrations of propofol were 364 ng/ml in urine, 71 ng/ml in heart blood and 79 ng/ml in femoral blood. The drug addict had only an autodidactic medical knowledge, but had inserted himself a permanent cannula for intravenous injection of propofol several times a day. The injection material was bought via online auctions from eBay. The case illustrates how job-related drug dependencies become indistinct due to the free access to information and goods via the Internet.

Death after re-exposure to propofol in a 3-year-old child: a case report.

This case report discusses the cause of death in a 3-year-old child who survived a high dose (20 mg x kg-1 x h-1) of propofol, infused over a period of 15 h, following which the patient developed a combined respiratory and metabolic acidosis, the oxygenation remaining normal. Bronchospasm was assumed to be the cause of hypercapnia. At this time the doctors in charge did not think of a possible side-effect of propofol. The administration of propofol was interrupted, the patient recovered within 13 h from the acidosis, woke up and required further sedation. A supposedly entirely safe infusion of 4 mg x kg-1 x h-1 propofol, as recommended in the literature for up to 48 h, was administered. After only 8 h intractable bradycardic dysrhythmias occurred. Although pharmacokinetic studies have pointed to a possible accumulation of propofol during continuous infusions, an interruption of an infusion for several hours has been considered sufficient for practically total clearance of the drug from the body. In this case re-exposure with a recommended dose of propofol was accompanied by bradycardia and dysrythmias that proved to be resistant to therapy and led to fatal cardiac insufficiency with a functioning artificial pacemaker in place. This case raises concerns about the safety of long-term infusions of propofol for sedation in children and possibly also in adults.

Death after excessive propofol abuse.

Abuse of the anaesthetic agent propofol (2,6-diisopropylphenol) is rare, but we report a case of a 26-year-old male nurse in which the autopsy showed unspecific signs of intoxication and criminological evidence pointed towards propofol abuse and/or overdose. Intravenously administered propofol is a fast and short-acting narcotic agent, therefore it seemed questionable whether the deceased would have been able to self-administer a lethal overdose before losing consciousness. The blood and brain concentrations corresponded to those found 1-2 min after bolus administration of a narcotic standard dose of 2.5 mg propofol/kg body weight. Extremely high propofol concentrations were found in the urine indicating excessive abuse before death. However, due to the short half-life of propofol, the cumulative effects of repeated injections should not be relevant for toxicity, since this would result in a blood level increase of only 1-2 micrograms/ml. Furthermore, the detection and quantitation of propofol in three different hair segments indicated chronic propofol abuse by the deceased. The results of the investigation suggest that death was not caused by a propofol overdose but by respiratory depression resulting from overly rapid injection.

The first fatal 2,6-di-isopropylphenol (propofol) poisoning in Singapore: a case report.

The propofol levels in the blood and tissues of a 37-year-old Chinese male suspected of having fatally self-administered an intravenous dose of 1600 mg of propofol (12.3-15.4 times the dose required for the induction of anaesthesia) were determined by headspace gas chromatography. The blood (femoral), liver, kidney and brain propofol levels were 2.5 micrograms/ml, 22 micrograms/g, 3.6 micrograms/g and 11.3 micrograms/g, respectively. The blood propofol level in the present case is 11.4 times and the liver propofol level is 15.7 times that of the first propofol overdose reported in the literature.