Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.54 no.6 Campinas Nov./Dec. 2004
Pulmonary edema after topic phenylephrine absorption during pediatric eye surgery. Case report*
Edema pulmonar después de absorción de fenilefrina tópica durante cirugía oftalmológica en niño. Relato de caso
Maria de Fátima Savioli Fischer, M.D.I; Eduardo Toshiyuki Moro, TSA, M.D.II; Válter Moreno Guasti, TSA, M.D.II; Clóvis Tadeu B da Costa, TSA, M.D.II; Fábio Scalet Soeiro, TSA, M.D.III; Luiz Carlos Bevilacqua dos Santos, M.D.IV; Renato Swensson Filho, M.D. IV
dos Hospitais Santa Lucinda e UNIMED
IIAnestesiologista dos Hospitais Santa Lucinda e UNIMED; Instrutor do CET/SBA do Conjunto Hospitalar de Sorocaba, PUC/SP
III Anestesiologista dos Hospitais Santa Lucinda e UNIMED, Co-responsável pelo CET/SBA do Conjunto Hospitalar de Sorocaba, PUC/SP
IVME1 do CET/SBA do Conjunto Hospitalar de Sorocaba, PUC/SP
OBJECTIVES: Topic phenylephrine solutions are commonly used in eye procedures
to promote capillary decongestion or pupil dilation. This article describes
a case of severe hypertension followed by pulmonary edema during strabismus
correction procedure. Possible cause of this complication might have been systemic
absorption of phenylephrine eyedrops. Our objective is to discuss preventive
means for such complication as well as the most adequate treatment.
CASE REPORT: Male patient, 12 years old, 50 kg, physical status ASA I, admitted for outpatient bilateral convergent strabismus correction. Patient was submitted to intravenous general anesthesia, which was maintained with continuous remifentanil and propofol infusion. After blepharus adjustment, 6 drops of topic 10% phenylephrine were applied. Five minutes after beginning of surgery, patient has developed hypertension and tachycardia, refractory to increased remifentanil and propofol dose, as well as to droperidol. Blood pressure and heart rate could be controlled after sevoflurane administration, but there has been oxygen saturation decrease with diffuse pulmonary rales by possible development of acute pulmonary edema. Furosemide was administered and anesthetic solutions were withdrawn. Patient presented progressive pulmonary improvement while blood pressure remained within normal values. Patient was discharged from PACU six hours after surgery with spontaneous ventilation in room air, and normal O2 saturation, pulmonary auscultation and blood pressure.
CONCLUSIONS: Topic phenylephrine should be cautiously administered before surgery and the anesthesiologist should be informed so that measures may be taken to prevent systemic absorption of large amounts. If there is absorption, preconized management should be followed, that is, decrease blood pressure without inducing myocardial depression, as it is the case with b-blockers or calcium channel blockers. Direct action vasodilators, or a-blockers, are the options for severe hypertension induced by systemic phenylephrine absorption.
Key Words: COMPLICATIONS: acute pulmonary edema, blood hypertension; SURGERY, Ophthalmologic: strabismus
Y OBJETIVOS: Soluciones tópicas de fenilefrina son usadas frecuentemente
en cirugía oftalmológica con el objetivo de promover descongestionamento
capilar o dilatación pupilar. Este artículo describe un caso de
hipertensión arterial grave seguida de edema pulmonar durante la cirugía
para corrección de estrabismo. La probable causa de esta complicación
fue la absorción sistémica de fenilefrina administrada por vía
tópica ocular. El objetivo del relato es la discusión de medios
de prevención de esta complicación, como también el tratamiento
RELATO DEL CASO: Paciente del sexo masculino, 12 años, 50 kg, estado físico ASA I, admitido en el centro quirúrgico para realización de corrección de estrabismo convergente bilateral en régimen ambulatorial. Fue sometido a la anestesia general venosa y a manutención, realizada con infusión continuada de remifentanil y propofol. Despues de colocación del blefaro, 6 gotas de fenilefrina a 10% fueron aplicadas por vía tópica. Decorridos 5 minutos del inicio de la cirugía, el paciente desarrolló hipertensión arterial y taquicardia, refractarias a la elevación de la dosis administrada de remifentanil y propofol, bien como a la administración de droperidol. El control de la presión arterial y de la frecuencia cardíaca fue posible después del empleo de sevoflurano, pero hubo disminución de la saturación de oxígeno y el aparecimiento de crepitaciones pulmonares difusas por probable desarrollo de edema pulmonar agudo. La furosemida fue administrada y los anestésicos fueron suspensos. El paciente presentó mejora progresiva del cuadro pulmonar, mientras los valores de presión arterial permanecían dentro de la normalidad. Recibió alta de la sala de recuperación pos-anestésica 6 horas después de la cirugía, cuando se presentaba en ventilación espontánea en aire ambiente, con saturación de O2, ausculta pulmonar y presión arterial normales.
CONCLUSIONES: La administración de fenilefrina tópica debe ser realizada con cautela, antes del inicio de la cirugía y con el conocimiento del anestesiologista, para que sean creadas medidas con el objetivo de evitar absorción sistémica en grande cantidad y, caso ésta ocurra, las conductas preconizadas deben ser seguidas, o sea, disminución de la presión arterial sin causar depresión miocárdica, como en el caso de la colocación de b-bloqueadores o bloqueadores del canal de calcio. Los vasodilatadores de acción directa o a-bloqueadores son las opciones delante de la hipertensión arterial grave consecuente de la absorción sistémica de fenilefrina.
Phenylephrine eyedrops are commonly used in eye procedures to promote capillary decongestion or pupil dilation. However, this has been associated to severe cardiovascular complications, some evolving to death, as the consequence of massive absorption of this a-adrenergic agonist 1-3. This article reports a case of acute pulmonary edema after possible systemic absorption of phenylephrine eyedrops in child submitted to general anesthesia for strabismus correction.
Male patient, 12 years old, 50 kg, physical status ASA I, admitted for outpatient bilateral convergent strabismus correction.
There were no complaints suggesting any disease during preanesthetic evaluation and physical evaluation was normal. Patient was premedicated with 3 mg intravenous midazolam (60 µg.kg-1) after venoclysis with 22G catheter and non-invasive blood pressure monitoring (every 5 minutes), in addition to pulse oximetry and cardioscopy in DII. Anesthesia was induced with remifentanil infusion (0.3 µg.kg-1.min-1) followed by bolus propofol (3 mg.kg-1) associated to mivacurium (0.2 mg.kg-1).
Intravenous 0.5 mg (10 µg.kg-1) atropine was also administered and hydration was maintained with 0.9% saline (2 mL.kg-1.min-1). After tracheal intubation with 6.5 mm endotracheal tube with and low pressure cuff, patient was placed under controlled ventilation in rebreathing system with tidal volume of 8 mL.kg-1, respiratory rate of 8 incursions per minute, and 50% FiO2 (oxygen and nitrous oxide). End tidal CO2 was monitored by capnography and maintained between 30 and 40 mmHg. Anesthesia was maintained with continuous remifentanil (0.2 µg.kg-1.min-1) and propofol (60 µg.kg-1.min-1) infusion.
After blepharus adjustment and beginning of surgery, 6 drops of 10% phenylephrine were administered by the nurse at ophthalmologists request, but without informing the anesthesiologist.
Five minutes after surgery beginning noninvasive blood pressure, previously around 100 x 50 mmHg, started recording values of approximately 200 x 140 mmHg and heart rate, previously around 75 beats per minute, recorded 130 to 140 beats per minute (sinus rhythm). Remifentanil infusion was increased to 0.5 µg.kg-1.min-1 and propofol to 100 µg.kg-1.min-1, however without blood pressure or heart rate decrease.
Intravenous 2.5 mg (50 µg.kg-1) droperidol was then administered but at this moment oxygen saturation was 88% and tracheal pressure had increased from 10 to 20 cmH2O. After manual ventilation and 100% oxygen administration, O2 saturation went to 92%. Pulmonary auscultation was normal and sevoflurane (3% concentration) was used to help controlling blood pressure which has reached values close to 100 x 70 mmHg after inhalational anesthetic administration.
At surgery completion, although hypertension and tachycardia were controlled, previously normal pulmonary auscultation presented diffuse rales while oxygen saturation was maintained close to 92% with manual ventilation and 100% FiO2. Intravenous furosemide (40 mg) was administered at the same time that anesthetic solutions were withdrawn. Patient presented progressive pulmonary improvement while blood pressure was maintained within normal values. Extubation was possible 30 minutes after surgery completion. Patient remained with spontaneous ventilation with oxygen under facial mask, with oxygen saturation between 92% and 95% and normal pulmonary auscultation.
Patient was discharged from PACU 6 hours after surgery, conscious, oriented, with spontaneous ventilation in room air, 96% O2 saturation and normal pulmonary auscultation. Blood pressure was maintained in approximately 100 x 60 mmHg during PACU stay.
Most common intraoperative hypertension causes include superficial anesthesia, hypercapnia, underlying hypertension (essential, pheochromocytoma, aortic coarctation), drugs (ketamine, ergotamine, adrenergics) or pre-eclampsia 4. Intraoperative clinical evolution suggests systemic absorption of phenylephrine eyedrops in sufficient amounts to induce severe hypertension and pulmonary edema.
Phenylephrine is a non-catecholamine, direct-action adrenergic considered pure a-agonist. It has potent arterial and venous vasoconstrictor effect 5 promoting blood shifting from peripheral to pulmonary circulation, which is less sensitive to vasoconstrictor effects, and promotes increased left ventricular filling pressure 6. Systemic vascular resistance increase induced by phenylephrine increases left ventricular ejection impedance as well as end pressure and diastolic volume 3.
High systemic concentrations may be reached after topic phenyleprine in the surgical field 6,7, and consequences may include hypertension, tachycardia, reflex bradycardia, ventricular arrhythmias and even cardiac arrest 7-10. This article presents a case of hypertension followed by acute pulmonary edema after possible absorption of high amounts of phenylephrine during surgical strabismus correction. Similar cases, however reported during ENT procedures, have provided enough reasons for the establishment of a committee made up of anesthesiologists, intensive care physicians, ENT specialists and pharmacologists to develop recommendations for the use of phenylephrine, and which resulted in the New York Guidelines on the Topical Use of Phenylephrine in the Operation Room 3.
From all cases of hypertension induced by systemic phenylephrine absorption analyzed by the committee, nine have evolved to pulmonary edema, five of whom had received b-blockers (labetalol or esmolol) to control intraoperative blood pressure. From these five patients, three have evolved to death, all after labetalol administration. It is possible that the short-action of esmolol may have contributed for the better evolution of patients receiving this b-blocker as compared to those receiving labetalol 3. In a different review 11 of 12 cases of cardiopulmonary complications after topic or submucosal phenylephrine in ENT surgeries, seven patients have received b-blockers, three of whom evolving to cardiac arrest, however without deaths.
Increased blood pressure induced by systemic a-agonists absorption may not require treatment since phenylephrine action is short. Severe hypertension should be promptly treated but therapy should not decrease myocardial contractility. So, b-blockers and calcium channel blockers should be avoided and replaced by direct action vasodilators, or a-blockers 3. In addition to epinephrine, isoproterenol and phosphodiesterase inhibitors, high glucagon doses (5 to 10 mg) may be used to treat b-blockers-induced hypotension and bradycardia 12-14. Positive inotropic glucagon action results in direct adenylcyclase stimulation 3.
In our case, we have administered droperidol, due to its a1 blocking action, and inhalational anesthetics (sevoflurane) for promoting systemic vascular resistance decrease although promoting also myocardial depression. Increased inhalational anesthetics concentration was common in described cases of hypertension and tachycardia induced by systemic phenylephrine absorption 3. This approach has been used in patients with good evolution but also in patients evolving to death. So, the role of inhalational anesthetics in developing myocardial dysfunction in patients with severe hypertension after topic phenylephrine absorption is not very clear 3. Furosemide was used to control pulmonary edema when blood pressure was within normal values, aiming at decreasing ventricular diastolic pressure.
Although not used in our case, positive end expiratory pressure (PEEP) is important ventilatory maneuver to handle oxygenation during acute pulmonary edema because it increases functional residual capacity (FCR), thus allowing the opening of closed pulmonary units with surfactant function loss, in addition to decreasing blood flow in poorly ventilated areas and promoting pulmonary water redistribution from alveoli to interstitium. However, there are disadvantages such as decreased cardiac output due to decreased venous return to the heart, and ventricular geometry changes 15.
Systemic eyedrops absorption takes place primarily in the lachrymal sac and nasopharyngeal mucosa. So, it may be decreased by lachrymal sac compression during phenylephrine administration followed by excess removal 16,17.
According to the New York Guidelines on the Topical Use of Phenylephrine in the Operation Room 3, initial topic phenylephrine dose should not exceed 0.5 mg in adults and 20 µg.kg-1 in children up to 25 kg. The committee suggests the replacement of 10% or 2.5% phenylephrine available in the market by 0.25% phenylephrine. In our case, patient has received 6 drops of 10% phenylephrine, equivalent to approximately 30 mg, that is, 60 times the maximum dose preconized for ENT procedures.
According to Baldwin et al. 7, 10% or 2.5% topic phenylephrine, or significantly higher than the concentration proposed for ENT procedures, is safe, since systemic absorption through intact conjunctiva and nasolachrymal duct is clearly lower, as compared to absorption after application in the surgical field of ENT procedures. So, in our case, in addition to administering 6 drops of 10% phenylephrine, since eyedrops were applied after surgery beginning, it is possible that systemic absorption was helped by the exposure of the surgical field to phenylephrine.
Topic phenylephrine should be cautiously administered, especially in elderly patients and/or those with risk factors for myocardial or brain ischemia, because they are less tolerant to the effects of its systemic absorption. Drug should always be administered before surgery and the anaesthesiologist should be informed so that measures may be taken to prevent massive systemic drug absorption. If there is absorption, preconized management should be followed, that is, decrease blood pressure without inducing myocardial depression, as it is the case with b-blockers or calcium channel blockers. Direct action vasodilators, or a-blockers, are the options for severe hypertension induced by systemic phenylephrine absorption.
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Dra. Maria de Fátima Savioli Fischer
Address: Rua Prof. Horácio Mesquita de Camargo 120/13 Campolin
ZIP: 18048-105 City: Sorocaba, Brazil
Submitted for publication
March 15, 2004
Accepted for publication June 17, 2004
* Received from Hospitais Santa Lucinda e UNIMED de Sorocaba, SP