IPRATROPIUM BROMIDE NEBULIZER-ASSOCIATED ANISOCORIA

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Anisocoria, is a rare clinical sign with a long list of differential diagnoses. It is often treated as a form of intracranial pathology until proven otherwise. However, if a patient lacks additional ocular abnormalities or neurological deficits, it is less likely that this clinical sign is due to intracranial pathology. Here, we present a patient with COPD exacerbation who developed anisocoria after inhaled ipratropium bromide treatment. CASE PRESENTATION: 71-year-old female was admitted to the intensive care unit for acute hypoxic respiratory failure due to a COPD exacerbation and pneumonia. The patient was intubated and started on broad spectrum antibiotics. She was later extubated to BiPAP and subsequently transferred to the general medical floor. While on BiPAP, she was receiving nebulized Ipratropium bromide/albuterol sulfate every 4 hours. Shortly after starting one of her nebulizer treatments, the rapid response team was called to evaluate to the patient for a new onset fixed and dilated left pupil. She did not have any other neurological deficits and a CT head was negative for acute intracranial pathology. After further evaluation, the BiPAP face mask was found to have a faulty seal. Patient was given a new face mask with minimal leaks, and the mydriasis resolved within 12 hours. DISCUSSION: Anisocoria is a clinical sign that can warrant concern. Rare but life-threatening diagnoses include uncal herniation, intracranial hemorrhage/mass or posterior-communicating artery aneurysm, that each impair adjacent parasympathetic innervation leading to unopposed sympathetic innervation of the iris. Consequently, this clinical sign is often treated as intracranial pathology until proven otherwise. However, in the absence of other ocular abnormalities or neurological deficits, it is unlikely that this clinical sign is due to intracranial pathology. Pharmacological causes should initially be considered. Ocular anticholinergics that cause temporary mydriasis include atropine, scopolamine, hyoscyamine, and often mis-directed aerosolized ipratropium bromide. In our patient, the mydriasis was a result of nebulized ipratropium with unintentional contact the eye by an improperly fitted nebulizer mask. The use of the pilocarpine eye drop test can help confirm a pharmacological muscarinic blockade if pilocarpine has no miotic effect. Additionally, the subsequent resolution of anisocoria 2-48 hours after discontinuation of nebulized anticholinergic is further support. An alternative diagnosis should be pursued if the pilocarpine test causes miosis, if the mydriasis becomes fixed and persistent, or if there are additional ocular or neurological abnormalities. CONCLUSIONS: With the widespread use of nebulized treatments, it is essential to be aware of this sign as it is important to consider these reversible causes as a potential diagnosis that guides subsequent management. Reference #1: Chaudhry P, Friedman DI, Yu W. Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit. Indian J Crit Care Med. 2014;18(3):176-7. Reference #2: Yalcin S, Pampal K, Erden A, Oba S, Bilgin S. Do we really need to panic in all anisocoria cases in critical care?. Indian J Anaesth. 2010;54(4):365-6. Reference #3: Yalcin S, Pampal K, Erden A, Oba S, Bilgin S. Do we really need to panic in all anisocoria cases in critical care?. Indian J Anaesth. 2010;54(4):365-6. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by M Bakir, source=Web Response No relevant relationships by SarahGrace Carbrey, source=Web Response No relevant relationships by Abdisamad Ibrahim, source=Web Response No relevant relationships by Thamer Sartawi, source=Web Response