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

Abstract

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.

Acute drug reaction to phenylephrine and tropicamide collyrium in a late-preterm newborn: a case report

“…A 2015 systemic review and metanalysis that included 916 participants showed that, in the adult population, 2.5% phenylephrine eye drops did not lead to clinically relevant change in blood pressure and heart rate, and 10% phenylephrine collyrium caused only short-lived blood pressure and heart rate rise [12]. Severe adverse events to phenylephrine collyrium are described mainly in relation to ophthalmological procedures, as reported by Abdelhalim et al [13]. The authors described the case of a 4-year-old boy who developed severe hypertension and acute pulmonary edema during retinal surgery (i.e., after surgical incision of the eye) due to systemic absorption of topical phenylephrine eye drops.…”

Influence of acute haemodynamic changes on the oxygen saturation during electro-convulsive therapy

“…The mechanism described included increased systemic vascular resistance resulting in increase in left ventricular ejection impedance and end-diastolic volumes and pressures. [11] ECT produces an acute dose-dependent increase in plasma norepinephrine levels and BP. [12] Studies in acute subarachnoid haemorrhage-induced pulmonary oedema have also shown a similar increase in plasma catecholamine levels.…”

Pulmonary oedema in ophthalmic surgeries under peribulbar anaesthesia: A retrospective analysis

“…This association of having co-morbid conditions has also been pointed out in previously published case reports. [ 4 , 5 , 8 ] In the previous case reports published,[ 9 , 10 ] one of the important reasons for the development of PE was the topical administration of phenyl epinephrine eye drops. Our dataset has no history of documented administration of these drops.…”