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Literature Reviews

Intraoperative pulmonary oedema in a child following systemic absorbtion of phenylephrine eyedrops.
Baldwin FJ and Morley AP. Br J Anaesth 2002; 88:440-2

The authors present a case report of an 8 year old, 37.7 kg boy who was scheduled for surgery for repair of right retinal detachment. The child had undergone uneventful ophthalmic surgery in the past. Preoperative ocular medicine was prescribed as follows: four drops of phenylephrine 2.5% and cyclopentolate 1% to each eye, but this prescription was not followed.

Anesthesia was induced with sevoflurane in oxygen, supplemented with i.v. propofol 40 mg, vecuronium 4 mg, alfentanil 250 ug, and morphine 1.5 mg. The child also received odanestrone 3.5 mg i.v., and diclofenac 37.5 mg and paracetamol 500 mg suppositories. A size 3 laryngeal mask airway was placed and manual ventilation was commenced with 60% nitrous oxide and 1% isoflurane in oxygen. Subsequently, mechanical ventilation was commenced. Peak airway pressure was maintained at 20 cm H2O and end tidal carbon dioxide concentration was 5.3 kPa or less.

On the operating table, prior to incision, the surgeon noticed that the pupils were not dilated and therefore administered between two and five drops of 10% phenylephrine to the right eye, without the anesthesiologist's knowledge. Five minutes into surgery, traction on the extra ocular muscles precipitated bradycardia, 40 beats per min, and the child was given glycopyrolate 0.2 mg, which brought the heart rate to 80 beats per min.

Several minutes later, systolic blood pressure rose from 95 to 211 mm Hg and the heart rate increased from 80 to 160 beats per min. The electrocardiogram showed multifocal atrial and ventricular ectopic beats. On questioning by the anesthesiologist, the surgeon acknowledged the administration of phenylephrine drops. A diagnosis of hypertension and arrhythmia, secondary to systemic absorption of phenylephrine, was made. Intravenous labetalol was given in 5 mg increments to a total 25 mg over 10 minutes until the heart rate and blood pressure returned to normal. A few minutes later, tidal volume decreased and so did the oxygen saturation to 88%. Auscultation revealed scattered basal crepitations. Inspired oxygen was increased to 60%, with resultant increase in oxygen saturation. Inspired oxygen was again gradually reduced to 30%, with no further desaturation. Mechanical ventilation via the laryngeal mask airway was maintained. At the end of surgery, generalized crepitations were heard throughout the chest, and 100 ml of blood stained fluid was aspirated via the laryngeal mask. Neuromuscular block was reversed. Tidal volume and oxygen saturation were normal. A postoperative electrocardiogram was normal and cardiac enzymes were not raised. Chest x-ray showed pulmonary edema and a large gastric air bubble.

Comments: This case is a good reminder of the fact that anesthesiologists must be ever vigilant as to activities of the surgeon. Rapid actions on the part of the anesthesiologists avoided a potential disaster. If we notice something that can not be easily explained by our own maneuvers, then there should be no hesitancy in questioning the surgeon. Mechanical ventilation via laryngeal mask airway with peak pressure not above 20 cm H2O, may be is an accepted practice, but one has to be cautious, more so when there are complications. The large air bubble found in the patients stomach demonstrates the problem. The possibility of gastric regurgitation under these conditions was also considered by the authors. The authors also raise the point as to whether a pure alpha blocker should have been used for the hypertensive crisis. I think most of us would have used labetalol, as they did. Use of topical phenylephrine is not innocuous, and the amount used should be well regulated. Surgeons should be required to inform the anesthesiologist when they administer any medication to the patient prior to or during surgery. Recently, a fatal incident was reported following the nasal use of phenylephrine during surgery for adenoidectomy and tonsillectomy. Many an anesthesiologist also uses nasal phenylephrine prior to nasal intubation, once again, one has to be careful with regards to quantity administered!

Reviewed by Hoshang J. Khambatta, MD #include ./footer_include.iphtml