Rocuronium-Induced Dilated Nonreactive Pupils in a Patient With Coronavirus Disease 2019: A Case Report

Rodrigues, Elba da Paixão; Costa, G.; Braga, Douglas de Araújo Ramos; Pinto, José Roberto Aparecido dos Santos; Lessa, Marcos Adriano

doi:10.1213/xaa.0000000000001491

Cited by 4 publications

(3 citation statements)

References 15 publications

(20 reference statements)

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“…Several reports have described that neurological symptoms, such as meningitis and encephalopathy, occur after COVID-19 infection, even with a negative spinal fluid SARS-CoV-2 PCR test [ 11 – 13 ]. In fact, a case of pupil dilatation caused by the muscle relaxant rocuronium has been reported in a patient with COVID-19 [ 14 ]. Normally, rocuronium does not pass through the BBB.…”

Section: Discussionmentioning

confidence: 99%

Cefepime-induced encephalopathy in a COVID-19 patient: a case report

Nakamura

Yatabe²,

Kuriyama

et al. 2022

J Anesth

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Prolonged neurological symptoms such as “brain fog” and cognitive impairment have occurred after coronavirus disease 2019 (COVID-19) infection. In this report, we describe impaired consciousness caused by cefepime hydrochloride (CFPM) in a patient with cognitive sequalae of COVID-19. A 56-year-old male patient was diagnosed with penile abscess after COVID-19 infection, and a blood culture detected two drug-resistant Pseudomonas aeruginosa strains. Therefore, CFPM 2 g × twice/day was administered on day 71 after intensive care unit admission. Approximately 48 h after CFPM administration, the patient showed disturbances in consciousness. Contrast-enhanced computed tomography, magnetic resonance imaging, and spinal fluid examination revealed no obvious abnormalities. Therefore, CFPM-induced neurotoxicity was suspected. CFPM was discontinued and ceftazidime 2 g × three times/day was initiated. The patient's consciousness improved 30 h after the final administration of CFPM. Serum CFPM concentrations were 14.2, 21.7, 21.7, and 11.9 μg/mL on days 1, 2, and 3 after the initiation of CFPM and on the day after CFPM was discontinued, respectively. In conclusion , intensivists should pay attention to new neurological symptoms such as CFPM-induced encephalopathy in patients with prolonged neurological symptoms after COVID-19 infection.

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Section: Discussionmentioning

confidence: 99%

Cefepime-induced encephalopathy in a COVID-19 patient: a case report

Nakamura

Yatabe²,

Kuriyama

et al. 2022

J Anesth

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“…After the observation of this finding, rocuronium infusion was terminated and the pupil size and reactions returned to normal approximately after 12 hours. 12 Sugammadex is a newly developed pharmacological agent to reverse the neuromuscular blockade. It forms stable complexes with steroidal NMBAs, particularly with rocuronium.…”

Section: Discussionmentioning

confidence: 99%

Bilateral Non-Reactive Fixed and Dilated Pupils Caused by Rocuronium and Successfully Reversed with Sugammadex: A Case Report and Literature Review

Karabacak¹,

BALIK²,

KURUŞCU³

et al. 2022

Turkiye Klinikleri J Anest Reanim

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Coronavirus disease-2019 (COVID-19) is a serious viral infection, which may cause various clinical conditions ranging from mild-to-moderate symptoms to fatal consequences. 1 Rocuronium is a neuromuscular blocking agent (NMBA). It is widely used in general anesthesia and also recommended as an infusion therapy in patients with acute respiratory distress syndrome (ARDS), who require intensive respiratory support. 2 Although fixed and dilated pupils were mentioned in a few case reports, it was considered as not a very frequent side effect of rocuronium. 3,4 In this case report, we presented a patient, who was treated with rocuronium infusion due to the COVID-19 related ARDS and developed bilateral fixed and dilated pupils.

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“…Drug-related pupil dilation is also a common factor, and numerous drugs can disrupt the balance of the sympatheticsystem, influencing pupil size to varying degrees. Sympathetic-activated medicines, such as adrenalin, norepinephrine, and ephedrine, can excite the sympathetic nervous system, directly leading to mydriasis 9 ; atropine, scopolamine, and ipratropium can antagonize the function of the vagus nerve to induce dilation of pupils [14][15][16][17] ; papaverine, as an opioid derivative, is mainly used to resist against vasospasm in clinic, whereas Zhou et al 18 reported that its toxic and side effects could also lead to transient dilatation of pupils; studies demonstrated that anesthetics, such as propofol and rocuronium, may also cause dilation of pupils in some patients 19,20 ; for instance, in 2017, Korf et al 21 reported a case of transient dilated pupils caused by inhalation of the sevoflurane. Sevoflurane, propofol, and rocuronium were all used in both cases.…”

Section: Anestheticsmentioning

confidence: 99%

Bilateral Transient Dilated and Fixed Pupils After Microvascular Decompression: Rare Clinical Experience

Wang

Fan

et al. 2023

Journal of Craniofacial Surgery

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Microvascular decompression (MVD) has a satisfactory safety, and it is the only surgical treatment for neurovascular compression diseases, such as hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia, from the perspective of etiology. Bilateral dilated and fixed pupils have long been regarded as a sign of life threatening, which is common in patients with cerebral herniation due to cranial hypertension. However, transient dilated pupils after MVD have not been previously reported. Here, we presented 2 patients with bilateral transient dilated and fixed pupils after MVD and discussed the possible etiologies through the literature review. Physical examination of both patients showed bilateral pupils were normal and without a medical history of pupil dilation. They underwent MVD under general anesthesia and used propofol and sevoflurane. In both cases, the vertebral artery was displaced, and Teflon pads were inserted between the vertebral artery and the brain stem. Postoperation, we found transient bilateral mydriasis without light reflection in both patients. The emergency head computed tomography revealed no obvious signs of hemorrhage and cerebral herniation. About 1 hour later, this phenomenon disappeared. Therefore, the authors think if MVD is successfully carried out, bilateral transient mydriasis may not necessarily indicate brain stem hemorrhage, cerebral herniation, and other emergency conditions, which can be recovered within a short time. The causes could be related to stimulation of the sympathetic pathway in the brain stem during MVD and side effects of anesthetics.

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Rocuronium-Induced Dilated Nonreactive Pupils in a Patient With Coronavirus Disease 2019: A Case Report

Cited by 4 publications

References 15 publications

Cefepime-induced encephalopathy in a COVID-19 patient: a case report

Cefepime-induced encephalopathy in a COVID-19 patient: a case report

Bilateral Non-Reactive Fixed and Dilated Pupils Caused by Rocuronium and Successfully Reversed with Sugammadex: A Case Report and Literature Review

Bilateral Transient Dilated and Fixed Pupils After Microvascular Decompression: Rare Clinical Experience

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