Central anticholinergic syndrome secondary to atropine eye drops: A case study.

Atropine eye drops are frequently used in the treatment of keratitis and during ophthalmic surgery. We described a rare complication of central anticholinergic syndrome secondary to atropine eye drops.

[The safety of atropine for myopia prevention and control].

Atropine is a classical drug with a wide use in clinical practice. In ophthalmology, atropine can be used for cycloplegia before optometry, and the treatment of amblyopia, iridocyclitis, malignant glaucoma, etc. In recent years, the "old drugs with new application " research and application of atropine for myopia prevention and control has become a hotspot and the efficacy of atropine has been preliminarily recognized. However, before the widely used in clinical, the safety of atropine draws attention. Researches concerning side effects of atropine were searched. The most common problem is photophobia due to dilated pupils, followed by poor near visual acuity, allergy and inflammation, local irritation. Other side effects include withdraw rebound, dry eyes, elevation of intraocular pressure, system reactions, photic damage and toxicity. Among them, some side effects are theoretical yet, and the long-term effects of some side reactions are not clear. Further research and exploration is needed to serve clinical evidence. At present, investigational usage for myopia prevention and control in clinical trials of atropine can be beneficial. Safety observation and efficacy evaluation are equally important in the course of application. (Chin J Ophthalmol, 2021, 57: 299-304).

Physostigmine Reversal of Dysarthria and Delirium After Iatrogenic Atropine Overdose From a Dental Procedure.

BACKGROUND: Sublingual atropine, dosed at 0.4-0.8 mg, is used by dentists as an antisialogogue to facilitate and increase the speed of procedures. Concentrated ophthalmic atropine drops (10 mg/mL) are commonly used off-label for this purpose. These highly concentrated drops may result in medication errors, atropine toxicity, and the antimuscarinic toxidrome. We report a case of a man who suffered acute delirium and dysarthria (from dry mouth) after an iatrogenic overdose from a dental procedure. His symptoms were initially interpreted as a stroke, but they completely resolved with physostigmine. CASE REPORT: A 57-year-old man presented with acute dysarthria and delirium after a dental procedure; 4 hours earlier he was fitted for a temporary replacement of some premolar/molar teeth. He received sublingual atropine to assist in gingival drying for molding of his prosthesis, but a calculation error resulted in the administration of approximately 113 mg. A stroke evaluation was initially planned; however, 2.5 mg of intravenous physostigmine completely reversed his symptoms. His symptoms reoccurred and were successfully treated twice more with physostigmine; the patient was observed overnight with no additional symptoms and safely discharged the next morning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ophthalmic atropine drops are highly concentrated and may cause an overdose after ingestion of small amounts. This novel case highlights the importance of considering antimuscarinic poisoning in cases of acute delirium or dysarthria after dental procedures and stands as a reminder to inquire about the use of atropine drops in such cases. Timely recognition of the antimuscarinic toxidrome and appropriate use of physostigmine may prevent unnecessary testing while providing an effective therapy. This case also highlights the need for observation after resolution of delirium treated with physostigmine.

A rare complication of topical atropine for treatment of eccrine hidrocystoma: Pharmacological fixed dilated pupils.

Multiple eccrine hidrocystoma (EH) has been treated with topical atropine with variable results. However, in rare cases, anticholinergic side effects have been seen after the use of the topical form of this drug. We presented a 50-year-old woman who developed recent onset of visual disturbance and photophobia from 2 weeks prior. The diagnosis of topical atropine-induced bilateral mydriasis was made. We reported a recognized but often overlooked case of bilateral mydriasis caused by application of topical 1% atropine for treatment of multiple EH.

Treatment of drooling with sublingual atropine sulfate in children and adolescents with cerebral palsy / Tratamento da sialorreia com sulfato de atropina via sublingual em crianças e adolescentes com paralisia cerebral

ABSTRACT Atropine sulfate blocks the muscarinic receptors in the salivary glands and leads to reduced saliva production. There are no published studies about its use in children with cerebral palsy. Objective To report the effect of sublingual atropine sulfate to treat drooling in children with cerebral palsy by comparing the results of the Drooling Impact Scale in a non-controlled open clinical trial. Results Twenty-five children were assessed. The difference in the mean scores of the pre- and post-treatment scales reached statistical significance. There was a low frequency of side effects compared to studies with other anticholinergics. Conclusion The use of sublingual atropine sulfate seems to be safe and there is a reduction in the Drooling Impact Scale score, which suggests efficacy in the treatment of drooling in children and adolescents with cerebral palsy. Our results should be replicated in randomized, placebo-controlled studies with larger numbers of participants.

RESUMO O sulfato de atropina bloqueia os receptores muscarínicos nas glândulas salivares reduzindo a produção de saliva. Não há estudos publicados relativos ao seu uso para tratamento da sialorreia em crianças com paralisia cerebral. Objetivo Relatar o efeito do sulfato de atropina sublingual no tratamento da sialorreia em crianças com paralisia cerebral a partir da comparação dos resultados da Drooling Impact Scale em ensaio clínico aberto não controlado. Resultados Vinte e cinco crianças foram avaliadas. A diferença das pontuações médias nas escalas pré-tratamento e pós-tratamento atingiu significância estatística. Houve baixa frequência de efeitos colaterais em relação a outros anticolinérgicos. Conclusão O uso de sulfato de atropina sublingual parece ser seguro e está relacionado a uma redução na pontuação da Drooling Impact Scale, o que sugere eficácia no tratamento da sialorreia em crianças com paralisia cerebral. Nossos resultados devem ser replicados em estudos randomizados, placebo controlados, com maior número de participantes.

Transient symptomatic worsening by atropine in opsoclonus-myoclonus syndrome.

Opsoclonus-myoclonus syndrome (OMS) is characterized by abnormal eye and systemic involuntary movements, as well as cerebellar ataxia. Some sedatives and anesthetics worsen movements associated with OMS, while there is no known report of a negative effect of atropine. We report on sedation in two patients with OMS. Involuntary movements were transiently worsened after using atropine with midazolam or thiamylal in both, but were not seen when atropine was not used. We speculated that atropine has the potential to exacerbate involuntary movements in OMS due to vulnerability to this agent via unknown mechanisms.

Central anticholinergic syndrome vs. idiosyncratic reaction triggered by a small IV dose of atropine.

A 58-year-old male was scheduled to undergo radical gastrectomy for cancer under general anesthesia. The patient developed agitation and irregular breathing after receiving a single dose of atropine (0.5 mg) to treat bradycardia immediately prior to induction of anesthesia. Within 5 min after the atropine injection, the patient became unresponsive with facial flushing and diaphoresis. When a drop in oxygen saturation was observed, a laryngeal mask airway was inserted after administering a small bolus dose of propofol (80 mg) and the patient was ventilated with 100% oxygen. Physostigmine was not administered because of the relatively low dose of atropine and the fact that his symptoms were not totally consistent with central anticholinergic syndrome (CAS). The differential diagnosis at the time also included an acute cardiovascular event and an idiosyncratic reaction to atropine. The patient fully recovered within 80 min from this highly unusual reaction to a single 0.5 mg IV dose of atropine.

Do small doses of atropine (<0.1 mg) cause bradycardia in young children?

OBJECTIVE: To determine the heart rate response to atropine (<0.1 mg) in anaesthetised young infants. DESIGN: Prospective, observational and controlled. SETTING: Elective surgery. PATIENTS: Sixty unpremedicated healthy infants less than 15 kg were enrolled. Standard monitoring was applied. Anaesthesia was induced by mask with nitrous oxide (66%) and oxygen (33%) followed by sevoflurane (8%). INTERVENTIONS: Intravenous (IV) atropine (5 µg/kg) was flushed into a fast flowing IV. The ECG was recorded continuously from 30 s before the atropine until 5 min afterwards. MAIN OUTCOME MEASURES: The incidence of bradycardia and arrhythmias was determined from the ECGs by a blinded observer. RESULTS: The median (IQR) age was 6.5 (4-12) months and the mean (95% CI) weight was 8.6 (8.1 to 9.1) kg. The mean (95% CI) dose of atropine was 40.9 (37.3 to 44) µg. Bradycardia did not occur. Two infants developed premature atrial contractions and one developed a premature ventricular contraction. When compared with baseline values, heart rate increased by 7% 30 s after atropine, 14% 1 min after atropine and 25% 5 min after atropine. Twenty-nine infants (48%) experienced tachycardia (>20% above baseline rate) after atropine lasting 222.7 s (range 27.9-286). The change in heart rate 5 min after atropine was inversely related to the baseline heart rate. CONCLUSIONS: The upper 95% CI for the occurrence of bradycardia in the entire population of infants based on a zero incidence in this study is 5%. These results rebut the notion that atropine <0.1 mg IV causes bradycardia in young infants. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov #NCT01819064.

Atropine sulfate for treatment of bradycardia in a patient with morbid obesity: what may happen when you least expect it.

A 74-year-old morbidly obese man was scheduled for surgical repair of an incisional ventral hernia. Anaesthesia was induced with propofol and fentanyl, and maintained with desflurane. A second dose of fentanyl 0.2 mg, given before starting surgery, resulted in sinus bradycardia and mild decrease of arterial blood pressure. Atropine sulfate 0.5 mg was administered. One minute later, the ECG rhythm on the monitor changed to third degree atrioventricular block with a ventricular response rate of 40 beats/min associated with marked hypotension. Isoproterenol 0.02 mg reverted the atrioventricular block to sinus rhythm. Cardiac enzymes and ECG ruled out acute myocardial ischaemia. The surgical procedure and the recovery from anaesthesia were uneventful. The patient was discharged from the hospital on the fifth postoperative day. For the treatment of bradycardia atropine sulfate should be adjusted at least to lean body weight in order to avoid paradoxical heart rate response in patients with obesity.

Comparison of sugammadex and conventional reversal on postoperative nausea and vomiting: a randomized, blinded trial.

STUDY OBJECTIVE: To determine whether the new selective binding agent sugammadex causes less postoperative nausea and vomiting (PONV) than the cholinesterase inhibitor neostigmine. DESIGN: Prospective, randomized, double-blinded study. SETTING: University-affiliated hospital. PATIENTS: One hundred American Society of Anesthesiologists physical status 1 and 2 patients scheduled for extremity surgery. INTERVENTIONS: Patients were randomly assigned to neostigmine (70 µg/kg) and atropine (0.4 mg per mg neostigmine) or sugammadex 2 mg/kg for neuromuscular antagonism at the end of anesthesia, when 4 twitches in response to train-of-four stimulation were visible with fade. MEASUREMENTS: We recorded PONV, recovery parameters, antiemetic consumption, and side effects. MAIN RESULTS: Nausea and vomiting scores were lower in the sugammadex patients upon arrival in the postanesthesia care unit (med: 0 [min-max, 0-3] vs med: 0 [min-max, 0-3]; P < .05), but thereafter low and comparable. Postoperative antiemetic and analgesic consumption were similar in each group. Extubation (median [interquartile range], 3 [1-3.25] vs 4 [1-3.25]; P < .001) first eye opening (4 [3-7.25] vs 7 [5-11]; P < .001), and head lift (4 [2-7.25] vs 8 [11-25]; P < .001) in minutes were shorter in patients given sugammadex. Postoperative heart rates were significantly lower in all measured times patients given neostigmine. CONCLUSIONS: Nondepolarizing neuromuscular blocking antagonism with sugammadex speeds recovery of neuromuscular strength but only slightly and transiently reduces PONV compared with neostigmine and atropine.

A comprehensive evaluation of the efficacy of leading oxime therapies in guinea pigs exposed to organophosphorus chemical warfare agents or pesticides.

The currently fielded pre-hospital therapeutic regimen for the treatment of organophosphorus (OP) poisoning in the United States (U.S.) is the administration of atropine in combination with an oxime antidote (2-PAM Cl) to reactivate inhibited acetylcholinesterase (AChE). Depending on clinical symptoms, an anticonvulsant, e.g., diazepam, may also be administered. Unfortunately, 2-PAM Cl does not offer sufficient protection across the range of OP threat agents, and there is some question as to whether it is the most effective oxime compound available. The objective of the present study is to identify an oxime antidote, under standardized and comparable conditions, that offers protection at the FDA approved human equivalent dose (HED) of 2-PAM Cl against tabun (GA), sarin (GB), soman (GD), cyclosarin (GF), and VX, and the pesticides paraoxon, chlorpyrifos oxon, and phorate oxon. Male Hartley guinea pigs were subcutaneously challenged with a lethal level of OP and treated at approximately 1 min post challenge with atropine followed by equimolar oxime therapy (2-PAM Cl, HI-6 DMS, obidoxime Cl2, TMB-4, MMB4-DMS, HLö-7 DMS, MINA, and RS194B) or therapeutic-index (TI) level therapy (HI-6 DMS, MMB4-DMS, MINA, and RS194B). Clinical signs of toxicity were observed for 24 h post challenge and blood cholinesterase [AChE and butyrylcholinesterase (BChE)] activity was analyzed utilizing a modified Ellman's method. When the oxime is standardized against the HED of 2-PAM Cl for guinea pigs, the evidence from clinical observations, lethality, quality of life (QOL) scores, and cholinesterase reactivation rates across all OPs indicated that MMB4 DMS and HLö-7 DMS were the two most consistently efficacious oximes.

Anesthesia treatment in cases of infant epiglottis cyst emergency extirpation operations.

Congenital epiglottic cyst is a rare embryonic disease. As a congenital laryngeal mucocele, its clinical manifestations include repeated sudden dyspneic respiration and even suffocation accompanied by laryngeal stridor after birth. During food intake, bucking and vomiting is a key feature. Delay in diagnosis and treatment of the disease affects growth and the development of neonatorum leading to suffocation and death. This study was designed to investigate the safety of anesthesia in infants with congenital epiglottic cyst during operation to reduce the occurrence of its complications. The treatment of operations on 12 infants with congenital epiglottic cysts were retrospectively analyzed. Twelve cases of infants with epiglottic cysts received emergency enucleation. Owing to adequate preanesthetic preparation, cystectomies were successfully performed with microwave cauterization under suspension laryngoscopy. None of the 12 patients showed apparent suffocation during anesthesia, the surgical results were good, and after 6 months to 1 year of follow-up, the disease had not recurred. Because of the acute onset of the disease and its severe symptoms and complications, attention should be paid to improve preoperative preparation. Careful selection of proper anesthesia is the key to achieving a successful operation.

Minimally invasive surfactant therapy with a gastric tube is as effective as the intubation, surfactant, and extubation technique in preterm babies.

AIM: Preterm infants requiring surfactant replacement have been treated using the INSURE technique, which requires sedation and comprises tracheal intubation, surfactant instillation and extubation. However, minimally invasive surfactant therapy (MIST) does not require sedation, minimises airway injury and avoids placing positive pressure ventilation on an immature lung. This study compared the feasibility of the two techniques and the outcomes in preterm babies with respiratory distress syndrome (RDS). METHODS: Preterm infants with RDS prospectively received surfactant via a gastric tube placed in the trachea by direct laryngoscopy with no sedation. Technique-related complications and respiratory outcomes were analysed. RESULTS: We compared 44 patients who received MIST with a historic cohort of 31 patients who received INSURE. This showed no differences in the rate of intubation and mechanical ventilation in the first 72 h, or secondary respiratory outcomes and relevant morbidities, between the babies who received INSURE and those who received MIST. More babies in the MIST group (35%) needed a second dose of surfactant than the INSURE group (6.5%) (p < 0.0001). CONCLUSION: Surfactant administration using MIST, with no sedation, is feasible in preterm infants with RDS. No significant differences in secondary respiratory outcomes were found between the MIST and INSURE techniques.

Feasibility, safety and accuracy of regadenoson-atropine (REGAT) stress echocardiography for the diagnosis of coronary artery disease: an angiographic correlative study.

Regadenoson (REG), a selective A2A receptor vasodilator, has not been widely evaluated in stress echocardiography (SE). We report results of 45 patients participating in REG + atropine (REGAT) SE protocol conducted in a single-center prospective trial. The REGAT study enrolled subjects before a clinically indicated cardiac catheterization for suspected coronary artery disease (CAD). After rest imaging, a 2 mg Atropine (AT) bolus followed by 400 mcg of REG was given. Standard stress imaging views were obtained and interpreted in blinded fashion. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated using cardiac catheterization >70 % stenosis as gold standard. Additional endpoints included major adverse cardiac events (MACE) and patient questionnaire responses. The mean duration of REGAT was 18 ± 7.2 min. There were no MACE, with only transient side-effects of dry mouth, shortness of breath, and headache. The incidence of significant CAD was 51.1 %. The sensitivity and specificity for significant stenosis was 60.9 and 86.4 %, with a PPV and NPV of 82.4 and 67.9 %. By coronary territories, the sensitivity, specificity, PPV, and NPV were: left anterior descending artery 58.8, 92.9, 83.3, and 78.8 %; left circumflex artery 6.7, 93.3, 33.3, and 67.7 %; and right coronary artery 16.7, 93.9, 50, and 75.6 %. Over 90 % of subjects reported feeling comfortable, with 83 % preferring REGAT as a future stress modality. The REGAT protocol is fast, safe, and well-tolerated with good specificity for CAD detection, but its low sensitivity and NPV precludes it from being an imaging modality for routine use.

Ecocardiografia sob estresse farmacológico com dobutamina em baixa dose associada a exercício isométrico e atropina precoce: relato da experiência com novo protocolo / Low-dose dobutamine stress echocardiography associated to isometric exercise (Hand Grip) and early atropine: a new protocol experience

Introdução: A ecocardiografia com estresse farmacológico com dobutamina (EEF-Db) oferece perfil de segurança satisfatório; contudo, eventos adversos sérios podem ocorrer, predominantemente, derivados da condição clínica. EEF-Db apresenta maior incidência de complicações do que o estresse físico, o que leva a supor que quanto menor a dose de dobutamina utilizada menor o risco. Objetivo: Relatar a experiência em EEDbt com novo protocolo. Método: Exames de EEDbt foram realizados com protocolo diferenciado pela administração de dobutamina, em baixa dose, associada, precocemente a exercício isométrico continuo e atropina. Foram selecionados 156 pacientes (pac) referidos para avaliação de isquemia, com visibilidade miocárdica adequada, que não apresentavam, em condições basais, alterações da contratilidade nem valvopatias significativas e divididos em 2 grupos. GrFem, 76 pac do sexo feminino, com idade media de 59 (+-14) anos e GrMasc, 80 pac do sexo masculino, com idade de 54(+ -13)anos. Resultados: No total de pacientes, a dose máxima de dobutamina utilizada foi 5mcg/Kg/minuto em 5pac(3,2%); 10mcg/Kg/minuto em 83pac(53,2%); 15mcg/Kg/minuto em 62 pac (3 9.7%) e 20mcg/Kg/minuto em 6 pac (3,9%). Não foi necessária a utilização das doses de 30 e 40mcg/kg/minuto, sendo que 96,1% dos pac atingiram os critérios de interrupção com dose igual ou inferior a 15mcg/kg/min. Não foi adicionada atropina em 30 pac (39,5%) do GrFem; e em 8 pac (10%) do GrMasc. Em 2 pac, o teste foi ineficaz por resposta cronotrópica, acentuadamente baixa pelo uso de betabloqueador. Conclusões: A realização do EEDbt com novo protocolo, permitiu atingir os objetivos do exame, com baixa dose de dobutamina e com complicações pouco expressivas.

Introduction: The pharmacological stress echocardiography with dobutamine(PSE-Db) provides satisfactory safety profile, however serious adverse events may occur predominantly derived from clinical condition. PSE-Db has a higher incidence of complications than physical stress, which leads to the supposition that the lower the dose of dobutamine used the lower the risk. Objective: To report our experience with PSE-Db new protocol using low-dose dobutamine, associated with isometric exercise and atropine early. Methods: We selected 156 patients referred for evaluation of ischemia, which showed no changes in basal contractility or significant valvular heart disease, divided into two groups, GrFem, 76 females patients with a mean age of 59 (+ -14) and GrMasc, 80 males patients aged 54 (+ -13) years. Results: In all patients, the maximum dose of dobutamine was used 5mcg/Kg/minutein 5 patients (3.2%); 10mcg/Kg/minute in 83 patients (53.2%); 15mcg/Kg/minute in 62 patients (39.7%) and 20mcg/Kg/minute in 6 patients (3.9%). It was not necessary to use doses of 30 and 40mcg/kg/minute, and 96.1% of patients met the criteria interrupt dose 15mcg/kg/min or less. Atropine was not used in 30 patients (39.5%) ofGrFem; and 8 patients (10%) of GrMasc. In 2 patients using beta-blockers, the test was ineffective due to very low increase of cardiac frequency. Conclusions: The implementation of the PSE-Db associated with early isometric exercise and simultaneous administration of atropine, achieved the objectives of the exam, with reduction in the dose of dobutamine compared to the usual protocols, and with no significant complications.

La homatropina en colirio: Estudio de caso por drogadicción / Homatropine in eye drops: study of a case by drug addiction

El delirio atropínico es un síndrome confusional agudo caracterizado por excitación del sistema nervioso central dado por alucinaciones visuales. En casos de intoxicación con drogas atropínicas y afines como la homatropina en colirio oftálmico y el alcohol, los efectos sobre el sistema nervioso central son mixtos, se observa una estimulación al comienzo seguida de una profunda depresión posterior. Este síndrome es un proceso de origen multifactorial; cuando es reversible, las causas más frecuentes son la deprivación de drogas y los efectos de algunos fármacos, como los agentes parasimpaticolíticos. En oftalmología, estos fármacos se emplean para provocar midriasis y parálisis de la acomodación en distintas circunstancias, como tratamiento de queratitis o en el examen del fondo de ojo. Debe recordarse que su uso como gotas o pomadas también puede provocar efectos sistémicos. Muchos de ellos son dependientes de la dosis, y deben ser conocidos por los profesionales que los emplean. El trabajo expone la presentación de caso de un adolescente de 14 años que combinaba el uso de la homatropina en colirio con el alcohol, se considera que este caso puede ser de interés para todos los profesionales de la salud.

Central anti-cholinergic syndrome induced by single therapeutic dose of atropine.

A 55 years old male patient, who is planned for bronchoscopy developed central anti-cholinergic syndrome due to therapeutic dose of atropine. Withdrawal of atropine has improved the symptoms. Thereafter, instillation of atropine as eye drops leads to reappearance of symptoms. The reaction was definite according to Naranjo's algorithm. It was severe and definitely preventable according to Modified Hartwig and Siegel's scale and Modified Schumock and Thornton scale respectively. Central anti-cholinergic syndrome may be due to variation in the genetic susceptibility (Idiosyncrasy) to atropine. Idiosyncratic reaction on administration of atropine as a pre-anesthetic medication or eye drops should be kept in mind while prescribing.

The management of drooling in adults with neurological conditions.

PURPOSE OF REVIEW: Drooling is a distressing symptom for adults with neurological conditions and can be challenging for health professionals. This review will consider the physical and psychosocial impact of drooling and will discuss the current management options including behavioural, pharmacological and surgical approaches. RECENT FINDINGS: A number of studies describe the use of botulinum toxin injections and irradiation of the salivary glands but no conclusive guidelines exist to recommend the most efficient dose or technique. The majority of saliva management studies focus on children with physical and/or cognitive disabilities and this evidence cannot be generalized to adults. There are relatively few studies that focus on saliva management in the adult neurological population. SUMMARY: Drooling is distressing for patients and their families. Ideally an individual would have easy access to the most efficient treatment with the fewest side effects. More evidence is now available but a lack of consensus on management approach, treatment dose and administration technique still exists. The symptom of drooling is best managed by a multidisciplinary team, starting with a conservative approach and then leading to more invasive procedures as appropriate.