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LETTERS TO THE EDITOR

Fully Dilated, Nonreactive Pupils During Cardiac Anesthesia

Thomas R. Hegi, MD^*, Rolf W. Schupbach, MD^*, Urspeter Masche, MD, and Edith R. Schmid, MD^*

*Institute of Anesthesiology and Department of Internal Medicine University Hospital of Zurich CH-8091 Zurich, Switzerland

It is our practice to monitor pupil size during cardiac anesthesia, because unequal pupils are predictors of major cerebral deficit (1). We observed fixed and fully dilated pupils at the end of an otherwise uneventful coronary artery bypass graft procedure in a 62-yr-old male patient. We immediately performed computed tomography of the brain and Doppler ultrasonography of the extra- and intracerebral arteries, which showed no relevant pathology. The pupil size and reaction returned to normal within 5 h, and no neurological deficit was evident at that time.

Preoperatively, the patient was treated with the selective serotonin reuptake inhibitor citalopram 20 mg per day in addition to usual cardiac medications. Anesthesia (total doses) was performed with fentanyl (3.3 mg), flunitrazepam (1.8 mg), and pancuronium (16 mg) and was supplemented with isoflurane before and propofol (100–400 mg/h) during and after normothermic cardiopulmonary bypass. Mean arterial pressure was maintained >50 mm Hg with phenylephrine during cardiopulmonary bypass. No topical eye medications, mucosal vasoconstrictors (2), or anticholinergics were used before or during anesthesia (3).

We postulate that the mydriasis was the effect of the selective serotonin reuptake inhibitor citalopram, which partially blocks norepinephrine reuptake (4) and thus inhibits the Eddinger-Westphal nucleus via an ₂-effect (5) in the setting of light anesthesia at the end of the procedure. Anesthesiologists should be aware of this possible pharmacologic cause for dilated pupils in cardiac surgery patients.

References

1. Woodall NM, Maryniak JK, Gilston A. Pupillary signs during cardiac surgery. Anaesthesia 1989;44:885–8.[Web of Science][Medline]
2. Prielipp RC. Unilateral mydriasis after induction of anaesthesia. Can J Anaesth 1994;41:140–3.[Web of Science][Medline]
3. Thiele EA, Riviello JJ. Scopolamine patch-induced unilateral mydriasis. Pediatrics 1995;96:525.[Abstract/Free Full Text]
4. Noble S, Benfield P. Citalopram a review of its pharmacology, clinical efficacy and tolerability in the treatment of depression. CNS Drugs 1997;8:410–31.[Web of Science]
5. Szabadi E, Bradshaw CM. Autonomic pharmacology of ₂-adrenoceptors. Psychopharmacol 1996;10 (Suppl 3):6–18.

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