8/3/2019 Anisocoria Renal

1/3

Case Report

Intraoperative anisocoria in a child during renal

transplantation

C. REMPF1,2, K. HELMKE3, A. GOTTSCHALK1, F. FAROKHZAD2 and M. A. BURMEISTER21Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Knappschaftskrankenhaus Bochum Langendreer, Universityhospital, Bochum, Germany, 2Department of Anaesthesiology and 3Department of Paediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Anisocoria during anaesthesia may indicate a seriousneurological condition. Assessment by physical examina-tion and diagnostic imaging is limited during surgery andanaesthesia. We report a case of a boy undergoing renaltransplantation, who suffered from anisocoria during gen-

eral anaesthesia. A transcranial sonography was per-formed, showing no intracranial pathology. However,retinal hypoperfusion detected with orbital doppler sono-graphy was a plausible explanation for anisocoria.

Accepted for publication 28 August 2007

Key words: Anisocoria; transcranial sonography; centralartery blood flow.

r 2007 The Authors

Journal compilation r 2007 The Acta Anaesthesiologica Scandinavica Foundation

DEVELOPMENT of anisocoria during anaesthesiamay indicate a cerebrovascular event, a masslesion, cerebral trauma or oedema. Diagnosis ofintracranial pathology may require a cranial com-puted tomography scan, which is costly, time

consuming and requires the transfer of the patientto radiology. Interruption of surgery is sometimesnot possible. Anisocoria may be caused by im-paired ocular blood flow, which can result in blindness from ischaemic retinal cell damage.Evidence of elevated intracranial pressure andimpaired ocular blood flow can be obtained bycranial ultrasound in the operating room. Wereport a case of anisocoria in a child during renaltransplantation.

Case reportA 7-year-old boy was scheduled for a second renaltransplantation caused by renal failure due tosevere perinatal asphyxia. He further sufferedfrom convulsions as well as growth and mentalretardation. Renal support was initially performed by peritoneal dialysis complicated by peritonitis

and intermittent haemodialysis was necessary. Aprimary renal transplantation was performed 1year ago. The transplanted kidney was rejectedand explanted 6 weeks after the transplantation.Nine months later, the boy (ASA III; weight 17 kg,

height 100 cm) was admitted for a second trans-plantation. His medication consisted of nifedipine20 mg/day, prazosin 2 mg/day, ferric-II-ion 30 mg/day, rifampicin 50 mg/day and dimeticone 80 mg/day. The boy was normotensive pre-operatively(100/65 mmHg).

The boy was orally pre-medicated with midazo-lam (6.8 mg). An intravenous access (18 G) hadalready been established on the right-mid-forearmat the ward. After IV atropine (0.25 mg), generalanaesthesia was induced with IV etomidate (7 mg),sufentanil (7.5mg) and cis-atracurium (2 mg). Fol-

lowing intubation with a 5.0 mm tracheal tube,anaesthesia was maintained with 40% oxygen inair and end-tidal sevoflurane concentration at 2.23.5. Additional sufentanil and cis-atracurium wereadministered as needed. A central venous catheter(CVC) was inserted in the right jugular vein usingthe anterior approach. The pupil size and reaction before and after induction of anaesthesia andinsertion of the CVC were normal. The head ofthe supine-positioned patient was placed in a

This case occurred at the University hospital Hamburg Eppendorf,Germany.

307

Acta Anaesthesiol Scand 2008; 52: 307309Printed in Singapore. All rights reserved

r 2007 The Authors

Journal compilationr 2007 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2007.01505.x

8/3/2019 Anisocoria Renal

2/3

neutral forward position. His eyes were treatedwith an ophthalmic ointment (dexpanthenol eyesalve) and taped. Direct pressure on the eyes wasavoided during the whole procedure. Immunesuppression was started with prednisolone175 mg IV. According to institutional preference,fluid therapy was started with 0.9% saline in a

continuous-rate infusion of 99 ml/h to elevate thecentral venous and aterial pressures. Adhesionsled to prolonged surgery and fluid boli becamenecessery to keep haemodynamic variables within20% of values recorded before anaesthesia. A totalof 1500 ml NaCl 0.9% and 50 ml human albumin5% were infused over a period of 7 h. Centralvenous pressure (CVP) varied between 4 and11 mmHg. Systolic blood pressure remained be-tween 110 and 80 mmHg during surgery and theheart rate varied between 80 and 110 beats perminute. The lowest mean blood pressure was

50 mmHg. High potassium levels (6.3 mmol/l)were treated with glucose (20 ml G5% and 20 mlG20%) and insulin (10 IE). Additionally, calciumchloride (10%, 12 ml) and sodium bicarbonate(8.4%, 58 ml) were administered. Four hours afterinduction of anaesthesia the left pupil was foundto be larger than the right. However, mydriasisslowly developed on both sides, but was morepronounced for the left pupil. Both pupils reactedpoorly to direct light stimulus. The patientshowed a bilateral conjunctival chemosis. Addi-tional dosages of sufentanil (a total of 45 mg IV in

30 min) were administered and the exspiratoryconcentration of sevoflurane was increased from2.2 up to 3.0 vol%. The surgeons were informedand it was decided that the transplantation couldnot be interrupted for a computed tomographichead scan. A transcranial ultrasound was per-formed intraoperatively (Philips ATL-HDI 5000,12 MHz linear array probe; Phillips Medizin Sys-teme, Hamburg, Germany) by a paediatric radi-ologist. Intracranial ventricular dimensions andparenchyma were normal without any midlineshift. Cerebral blood flow velocity by transcranial

doppler mode in the major arteries of the circleof Willisi was not impaired. Orbital ultrasoundshowed no papilloedema and a normal diameterof the optic nerve sheath. Blood flow in bothcentral retinal arteries was severely impairedwith no holodiastolic and a reduced systolic flowvelocity (Fig. 1). The arterial pressure was in-creased with administration of norepinephrine(0.030.06mg/Kg min) and the pupil size andreaction returned to normal within a few minutes.

Sonography after surgery confirmed a normalcerebral and retinal perfusion without any intra-cranial pathology. On awaking, the boy did notrequire norepinephrine. After extubation, hisalertness did not differ from the status documen-ted before induction of anaesthesia and vision wasnot impaired.

Discussion

During renal re-transplantation we observed animpairment of retinal blood flow, indicated by amissing holodiastolic and reduced systolic flowvelocity that probably resulted in alteration of theafferent limb of the pupillary reflex leading toinitial anisocoria. There are two sources of bloodsupply to the retina (1). The central retinal arterysupplies blood to the inner layers and the chorio-cappillaris to the outer layers. Hence, the sphincterpupillae muscle is not innervated by parasym-pathic fibres arising in the EdingerWestphal nu-

cleus and the sympathetic nerve supply to thedilator pupillae muscle received intact nerveactivity via the superior cervical ganglion. Thepatients retinal vascular occlusive disease could be associated with the use of large volumes ofcrystalloids increasing intraoperative ocular pres-sure (2) and decreased retinal perfusion. More-over, decreased perfusion pressure in the retinamay be influenced by increased central venouspressure. In addition, a minimum mean systolic

Fig. 1. Orbital spectral waveforms obtained from the right arterycentralis retinae of the patient during surgery. The circulationof the right as well as the left eye (data not shown) wascharacterized by reduced blood flow velocity. During thediastolic phase, the blood flow velocity decreases continuouslyreaching zero value, and straight away there is a reversion of flow

direction.

C. Rempf et al.

308

8/3/2019 Anisocoria Renal

3/3

blood pressure of 50 mmHg may not be suffi-cient for retinal perfusion in a patient witharterial hypertension and potentially abnormalautoregulation. However, because the posteriorciliary arteries were not identified using colourDoppler sonography and an opthalmologicalexamination was not performed, we cannot distin-

guish between ischaemic optic neuropathy andischemia by impairment of retinal blood flow,even if a papilloedema was not detectable bysonography.

Cranial and orbital ultrasound should be con-sidered during surgery to screen for elevated in-tracranial pressure (3) when wake-up test oremergency computerized tomography of the brainare not possible.

References

1. Bill A. Blood circulation and fluid dynamics in the eye.Physiol Rev 1975; 55: 383417.

2. Abbott MA, McLaren AD, Algie T. Intra-ocular pressureduring cardiopulmonary bypass a comparison of crystalloidand colloid priming solutions. Anaesthesia 1994; 49: 3436.

3. Helmke K, Burdelski M, Hansen HC. Detection and mon-itoring of intracranial pressure dysregulation in liver failure

by ultrasound. Transplantation 2000;70

: 3925.Address:Dr Christian RempfDepartment of AnaesthesiologyIntensive Care Medicine and Pain TherapyKnappschaftskrankenhaus Bochum LangendreerUniversity hospitalIn der Schornau 23-2544892 BochumGermanye-mail: rempf@anaesthesia.de

Anisocoria during transplantation

309