Pulmonary Edema following Instillation of Topical Phenylephrine Eyedrops in a Child under General Anesthesia

Jaichandran, VV; Viswanathan, Jagadeesh; Kannan, Rajagopal

doi:10.5301/ejo.2010.561

Cited by 10 publications

(5 citation statements)

References 6 publications

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“…Patients with hypertension, aneurysms, tachycardia, or cardiac disease must be treated with adequate caution 46. The use of phenylephrine 10% solution is not recommended (forbidden) for children and the elderly because of the increased risks of systemic toxicity 47,48…”

Section: Drug Classesmentioning

confidence: 99%

Systemic side effects of eye drops: a pharmacokinetic perspective

Farkouh¹,

Frigo²,

Czejka

2016

OPTH

184

131

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When administering eye drops, even when completely correctly applied, several routes of absorption are possible and excess amounts can sometimes cause an unwanted systemic bioavailability of the drops when not completely absorbed into the eye. Furthermore, the concentration of active ingredients in such medicinal preparations is usually very high, so that despite the correct application of the recommended dose, considerable amounts may be absorbed in an unwanted manner through various routes. Children are subject to a much higher risk of systemic side effects because ocular dosing is not weight adjusted and physiological development (eg, liver status) differs from that of adults. There is a lack of information about pediatric dosing in the current literature. This review summarizes the most important clinically relevant systemic side effects that may occur during ophthalmic eye treatments. In this review, we discuss general pharmacokinetic considerations as well as the advantages, disadvantages, and consequences of administering drugs from some important drug groups to the eye.

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Section: Drug Classesmentioning

confidence: 99%

Systemic side effects of eye drops: a pharmacokinetic perspective

Farkouh¹,

Frigo²,

Czejka

2016

OPTH

184

131

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“…Although serious morbidity associated with hypertension may be uncommon in children following systemic absorption of ocular phenylephrine, the incidence of an iatrogenic hypertensive crisis, acute left ventricular failure and pulmonary edema following topical phenylephrine given intraoperatively in children has been reported. [7–9] Phenylephrine is a sympathomimetic direct α-agonist and it has a powerful arterial and venous vasoconstrictor effect. [1] Induced hypertension by α-adrenergic stimulation can increase peripheral vascular resistance (increased afterload) and thus increase the left ventricular filling pressure.…”

Section: Discussionmentioning

confidence: 99%

“…[56] However, serious complications associated with hypertension were reported in pediatric patients following systemic absorption of topical phenylephrine. [7–9] We report a case of intraoperative severe hypertension and acute pulmonary edema occurring in a child submitted for retinal surgery after possible systemic absorption of topical phenylephrine eye drops.…”

Section: Introductionmentioning

confidence: 99%

Severe hypertension and pulmonary edema associated with systemic absorption of topical phenylephrine in a child during retinal surgery

et al. 2012

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Topical phenylephrine solutions are widely used in eye procedures to promote pupil dilation without cycloplegia. We report a case of intraoperative severe hypertension and acute pulmonary edema occurring in a child during retinal surgery after possible systemic absorption of topical phenylephrine eyedrops. Our objective is to discuss the proper treatment and preventive strategies for such a complication. A 4-year-old, male patient, 18.4 kg in weight, physical status ASA I was admitted for right retinal detachment surgery. Anesthesia was induced with sevoflurane in oxygen, followed by glycopyrrolate (5.0 μg/kg), propofol 25 mg, fentanyl 50 μg and cisatracurium 0.15 mg/kg given intravenously. Anesthesia was maintained with sevoflurane 2-2.5% in a mixture of nitrous oxide and oxygen (60%:40%). After incision, two drops of 10% aqueous phenylephrine were administered topically by the surgeon to the right eye for further pupil dilation. Few minutes later, the noninvasive blood pressure rose to 220/120 mmHg and the heart rate increased to 140 beats/min. Oxygen saturation (SpO2) dropped from 99% (with an inspired oxygen concentration (FiO2) of 0.4) to 82%. Auscultation revealed crepitations throughout the chest and a blood-stained frothy fluid was aspirated from the trachea with possible development of acute pulmonary edema. Hydralazine (5 mg) and furosemide (10 mg) were administered intravenously. Seven minutes later, the blood pressure returned to normal and the SpO2 increased to 92% on FiO2 of 1.0, with decreased intratracheal secretions. After approximately 20 minutes, the SpO2 had improved to 99%, with a FiO2 of 1.0 and the blood pressure was 109/63 mmHg and heart rate was 121 beats/min. The FiO2 gradually reduced back to 0.4 over 30 min with no further desaturation. The patient was discharged from the post anesthesia care unit 5 h after surgery with adequate spontaneous breathing, SpO2 99% on room air, normal blood pressure and pulmonary auscultation. Anesthesiologists and ophthalmologists should be aware of the possible cardiovascular side-effects of topical phenylephrine, and it should be used cautiously with appropriate intraoperative monitoring of hemodynamic variables. Moreover, preventive strategies to minimize systemic absorption of the drug should be taken.

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“…12 Systemic absorption of eyedrops may occur mainly through the nasolacrimal ducts or through the conjunctival veins, potentially causing serious unwanted systemic adverse effects (SAEs), such as hypertension, bradycardia, cardiac arrhythmia, pulmonary edema, and other life-threatening conditions, during ophthalmic surgery. [13][14][15][16][17][18][19] Higher doses of topical phenylephrine (eg, phenylephrine 10% eyedrops or using a sponge/pledget) are associated with significant SAEs. 16,19 Intracamerally administered medications could also reach the systemic circulation through these routes or through the intraocular circulation, raising the possibility of serious SAEs with the use of IC phenylephrine.…”

mentioning

confidence: 99%

Intracameral phenylephrine for surgical mydriasis and intraoperative floppy-iris syndrome: systemic adverse effects and optimal dose

Chua,

Varshney,

Eke

2024

J Cataract Refract Surg

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Phenylephrine, a potent sympathomimetic, induces mydriasis via iris dilator muscle contraction. Intracameral (IC) phenylephrine has been successfully used in cataract surgery for initial mydriasis, maintaining mydriasis, and management of intraoperative floppy iris syndrome. Serious systemic adverse events (mainly cardiovascular) have been described with topical phenylephrine drops, but we found very little evidence of such adverse events associated with IC phenylephrine use. However, we suspect under-reporting of such adverse events, as they may instead be ascribed to anxiety, positioning, anaesthesia, etc. Optimal dosage/concentrations for IC phenylephrine use in different purposes have not been fully studied. In the absence of robust evidence, we suggest that lower but effective IC phenylephrine concentrations are used: a lower concentration (0.31%), in conjunction with an anticholinergic and lidocaine, may be used for initial mydriasis. For management of intraoperative floppy iris syndrome, 0.31% may be effective, though a higher concentration (1-1.25%) may be required.

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Pulmonary Edema following Instillation of Topical Phenylephrine Eyedrops in a Child under General Anesthesia

Abstract: To produce maximum mydriasis, with minimum systemic effects, preventive strategies such as using the lowest drug concentration, punctual occlusion, eyelid closure, allowing adequate time for the pharmacologic effect to occur, and the use of microdrops in infants should be adopted.

Cited by 10 publications

References 6 publications

Systemic side effects of eye drops: a pharmacokinetic perspective

Systemic side effects of eye drops: a pharmacokinetic perspective

Severe hypertension and pulmonary edema associated with systemic absorption of topical phenylephrine in a child during retinal surgery

Intracameral phenylephrine for surgical mydriasis and intraoperative floppy-iris syndrome: systemic adverse effects and optimal dose

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