In 12 h, an isochoric, medium, and reactive pupillary pattern was observed. Due to the suspicion of rocuronium-induced mydriasis, the drug was discontinued. An urgent head CT scan showed no structural changes. Laboratory tests showed anemia, elevated inflammatory markers, and acute renal failure (serum creatinine: 1.8 mg.dL −1). Bilateral mydriasis was observed in 48 h. Continuous infusion of 20 mg.h −1 rocuronium was started after 3 days of tracheal intubation to improve ventilator synchrony. He was sedated with ketamine 0.2 mg.kg −1.h −1, propofol mg.kg −1.h −1, and dexmedetomidine 0.5 mcg.kg −1.h −1. Case 2Ī 69-kg, 71-year-old male patient with a history of hypertension, diabetes, and dementia was admitted to an ICU with respiratory failure due to COVID-19 and intubated 12 days after the onset of symptoms. The patient was discharged from the hospital without neurological sequelae 42 days after the fixed mydriasis episode. Rocuronium was discontinued, leading to complete regression of the pupillary pattern 24 h after the discontinuation. Likewise, no structural changes were observed on Computed Tomography (CT) of the head. Laboratory tests did not show any changes that could justify the change in the pupillary pattern. She presented with fixed mydriasis not responding to light after 48 h of rocuronium infusion. A continuous infusion of rocuronium (15 mg.h −1) was started due to ventilator asynchrony after 1-week of mechanical ventilation. The patient was sedated with ketamine 0.2 mg.kg −1.h −1, fentanyl 50 mcg.h −1, and midazolam 5 mg.h −1. Case 1Ī previously hypertensive 50-kg, 65-year-old female patient (former smoker) was admitted to an Intensive Care Unit (ICU) with respiratory failure due to COVID-19 and underwent orotracheal intubation after 17 days of symptoms. After obtaining written consent from patients or patients’ relatives for reporting and publication, we describe three cases of mechanically ventilated COVID-19 patients with mydriasis who received continuous rocuronium infusion for respiratory parameter optimization. Non-reactive dilated pupils might represent an important warning sign for neurological complications, especially in unconscious mechanically ventilated patients when a more comprehensive neurological physical exam might not be possible. The differential diagnosis of fixed dilated pupils: a case report and review. Causes of mydriasis include parasympathetic nervous system block, sympathetic nervous system hyperstimulation, cerebral vascular injuries, and brain death. The presumed central nervous system effects of rocuronium in a neonate and its reversal with sugammadex. Bilateral dilated nonreactive pupils in a neonate after surgery. and in patients with immature BBB function. Bilateral dilated nonreactive pupils secondary to rocuronium infusion in an ARDS patient treated with ECMO therapy: a case report. Accordingly, mydriasis has been reported due to prolonged NMBA infusions in patients with disrupted BBB caused by severe systemic inflammation, 4 4 He H, Yu Z, Zhang J, et al. Activation of brain acetylcholine receptors by neuromuscular blocking drugs. 3 3 Cardone C, Szenohradszky J, Yost S, et al. However, NMBAs can impair cholinergic transmission in the Central Nervous System (CNS), producing autonomic dysfunction, excitotoxicity, seizures, and neuronal death, when the BBB becomes permeable due to pathological conditions. NMBAs are hydrophilic polar molecules that cannot normally cross the Blood-Brain Barrier (BBB). Mechanical ventilation parameters in critically ill COVID-19 patients: a scoping review. 2 2 Grasselli G, Cattaneo E, Florio G, et al. In contrast, only 22% of patients with “classic ARDS” need an NMBA for the same purpose. Currently, 88% of patients with Coronavirus Disease 2019 (COVID-19)-related ARDS under mechanical ventilation need an NMBA infusion to optimize oxygenation and ventilation. Neuromuscular blocking drugs in the critically ill. Although NMBA infusion improves oxygenation in moderately severe ARDS, its effect on mortality is contentious, as most studies have assessed infusions of only 48-hour duration and with cisatracurium. The routine use of Neuromuscular Blocking Agents (NMBAs) in patients under mechanical ventilation due to Acute Respiratory Distress Syndrome (ARDS) still causes debate.
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