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

Purpose To report a case of pulmonary edema, in a child under general anesthesia, due to iatrogenic acute hypertensive crisis following instillation of 1 drop of 5% phenylephrine eyedrops. Methods A 2-year-old boy was scheduled for examination of both eyes and enucleation of the left eye under general anesthesia. In the preoperative ward, 1 drop of 2.5% phenylephrine eyedrops was instilled 3 times by the nursing staff. The child was induced with the volatile agent Sevoflurane and intubated with Inj atracurium besylate 0.5 mg/kg IV. Anesthesia was maintained with N2O/oxygen (2:1)/Sevofurane 1.5% and Inj fentanyl 1 μg/kg IV. As the pupil was not dilated optimally for examination, 1 drop of 5% phenylephrine eyedrops was instilled. Approximately 10 minutes following its instillation, tachycardia and rise in blood pressure occurred. Auscultation of the chest revealed bilateral coarse crepitations and pink frothy secretions were noted in the Portex endotracheal tube. Results Pulmonary edema was effectively settled using positive pressure ventilation with 100% oxygen, Inj lasix 1 mg/kg IV, and Inj hydrocortisone 100 mg IV. The concentration of inhalational agent, Sevoflurane, was increased. Within about 15 minutes, both heart rate and blood pressure gradually returned to normal limits. Following surgery, the child was extubated, fully awake. Conclusions 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.