Phentolamine rescue for glanular ischemia in the setting of inadvertent administration of high-dose 1:1,000 epinephrine to glans in distal hypospadias surgery

Abstract

Low-dose 1:100,000 epinephrine is often injected into the glans penis during hypospadias surgery as a vasoconstrictive agent to reduce bleeding and assist with surgeon visualization. In this case, high-dose 1:1000 epinephrine was inadvertently injected into the glans, resulting in persistent tissue ischemia that did not resolve with conservative measures. Injection of phentolamine, an alpha-adrenergic antagonist, into the glans penis was successful in reversing the ischemia. In addition to demonstrating usefulness of phentolamine in this situation, this case also demonstrates the necessity for good communication in the operating room and the need for processes to ensure safe administration of high-risk medications.

Highlights

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Epinephrine injection can improve visibility during hypospadias surgery.
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Phentolamine can reverse ischemia due to epinephrine injection in the glans penis.
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Communication in the operating room is essential to prevent medication errors.

1 Introduction

The use of low-dose epinephrine injection (1:100,000, 1 g/100,000 mL, 0.01 mg/ml) in hypospadias repair has gained popularity due to its hemostatic properties. It has been demonstrated to be safe and effective to improve hemostasis and visibility during critical dissection steps.

Phentolamine, an alpha-adrenergic antagonist, has been used in emergency settings for reversal of digital ischemia secondary to accidental epinephrine pen injections. Additionally, it has been used in hand surgery as a rescue agent when epinephrine is injected into a digit and digital ischemia persists for greater than 1 h.

We present a case of inadvertent injection of high-dose (1:1,000, 1 g/1000 mL, 1 mg/mL) epinephrine into the glans penis during meatoplasty for distal hypospadias inducing glanular ischemia that was successfully reversed with phentolamine administration.

2 Case presentation

The patient was evaluated in the urology clinic for hypospadias at 8 months of age. He had a history of congenital anomalies related to an unbalanced translocation (loss in 18q22.3 and gain at 8q24.3) including cleft palate, micrognathia, and hypospadias. He had no difficulties with urination and no history of urinary tract infections. He was noted to have a coronal/glanular hypospadias with abnormal, bulky glans tissue between the meatus and distal pit. He had 30–45 degrees of ventral chordee, ventral skin deficiency, and a dorsal hooded prepuce. His penis and glans were noted to be on the smaller end of normal and thus the decision was made to give three testosterone shots each about one month apart prior to proceeding with hypospadias repair. The family also requested circumcision.

At 12 months of age, the patient was taken to the operating room for hypospadias repair versus meatoplasty, chordee repair, and circumcision. After intraoperative assessment, the distal hypospadias was deemed amenable to urethral advancement meatoplasty. There was thick, abnormal tissue between the hypospadiac meatus and the distal glanular pit which was excised prior to urethral advancement. In preparation for the excision of this bulky tissue, what was labeled as 1:100,000 epinephrine was used to infiltrate the glans. A total of 0.3 mL was used. The anesthesia team immediately noticed the onset of tachycardia, EKG waveform changes, and hypertension not typically seen with 1:100,000 epinephrine. It was discovered that 1:1000 epinephrine had inadvertently been injected, which had been incorrectly labeled as 1:100,000 epinephrine on the back table.

The systemic effects of the 1:1000 epinephrine resolved without intervention within 15 minutes. However, the glans appeared white and dusky after 20 minutes of observation and use of topical warm saline. First, injectable saline was injected into the glans to try to flush out the epinephrine. The glans remained pale. Then phentolamine was used to counteract the epinephrine. A total of 0.45 mg was injected into the glans with almost immediate improvement in glans color and bright red bleeding seen through the glans holding stitch site. Upon continued observation, 20–30 minutes later the distal aspect of the glans was improved in color but still was whiter than prior. Therefore, an additional 0.75 mg of phentolamine was injected with immediate improvement. The glans remained healthy and pink throughout the remainder of the case. The tissue was blanchable, with immediate return of pink color after pressure was released. The rest of the case was performed without complication. At the end of the case, the glans remained pink and appeared well-perfused ( Fig. 1 ). The patient was examined in the post-operative recovery area 2.5 hours after case completion and the patient was discharged. The glans appeared pink and healthy on POD 1 ( Fig. 2 ).

The patient followed up 3 months after his surgery. His surgical site had healed without any complication, and the glans appeared healthy and normal ( Fig. 3 ).