Bilateral dilated nonreactive pupils secondary to rocuronium infusion in an ARDS patient treated with ECMO therapy: A case report

RATIONALE: Pupil monitoring for neurologic examination has become a regular clinical practice during extracorporeal membrane oxygenation (ECMO) therapy. Sudden dilation of pupils always indicates a severe cerebrovascular event. However, bilateral dilated nonreactive pupils secondary to neuromuscular blockade are uncommon and widely ignored in adult acute respiratory distress syndrome (ARDS) patients. This is the first case report of bilateral dilated nonreactive pupils caused by rocuronium in an ARDS patient receiving ECMO treatment. PATIENT CONCERNS: Bilateral dilated nonreactive pupils were found in an ARDS patient who received V-V ECMO therapy. However, CT angiography did not indicate the occurrence of a cerebrovascular event. Drugs that could potentially result in dilated nonreactive pupils were checked. DIAGNOSIS: Bilateral dilated nonreactive pupils were caused by rocuronium infusion. INTERVENTIONS: Rocuronium infusion was stopped. OUTCOMES: Bilateral dilated nonreactive pupils were resolved 20 h after rocuronium infusion was stopped. LESSONS: Neuromuscular blockade should be taken into consideration when bilateral dilated nonreactive pupils are found in ARDS patients treated with ECMO therapy.