эрекция во время анестезии

[almazey]

Коллеги! Имеем проблему. Второй раз подряд во время операции по коррекции гипоспадии (наркоз севоран + закись+ фентанил + каудально - наропин 0,2 % 1,0 на кг веса) имеем эрекцию, хирурги недовольны. В премедикации - транквилизатор перорально, затем В\В атропин.
Как считаете, коллеги, в чем причина и что делать?

[derbi]

Причина в регионарной анестезии наверное? довольно частое явление )

[Dr.Vad]

Похоже, все дело в фентаниле - фрагментец публикации по теме:

We would like to communicate our clinical experience regarding an unusual side effect during remifentanil infusion. Remifentanil has been used routinely in our pediatric anesthesia practice (more than 4000 children) since 2002. During this period, we have witnessed intraoperative penile erection more frequently, although we had no reported penile endoscopic or surgical procedure which was delayed because of penile erection before 2002.

With remifentanil infusion (regardless of the accompanying agents), penile erection was usually observed after manipulation (sometimes spontaneously) at the beginning of the procedure and had short duration. In most cases, it was harmless but when penile erection occurred during urological procedures, surgeons complained of abnormal bleeding or difficulty in performing endoscopy. For detumescence, we found deepening anesthesia by inhalational agents and decreasing or stopping the remifentanil infusion for a time to be effective because neither pharmacological treatment nor regional blocks needed to be used in any of the cases.

To determine the incidence of penile erection during remifentanil infusion, we reviewed the anesthesia records of boys undergoing cystoscopy in 2003–2005. Patients with epispadias and penile agenesis were excluded. In 252 cystoscopies, after midazolam premedication, anesthesia was induced with thiopental, propofol, or sevoflurane. Before tracheal intubation or laryngeal mask 0.5 μg·kg−1·min−1, remifentanil infusion was started. Anesthesia was maintained with 0.5−0.1 μg·kg−1·min−1 remifentanil infusion and 0.5–1 MAC inhalational agent. Children were 5.6 ± 4.5 years old (range 15 days–18 years). Propofol induction was used in 76 and in six caudal epidural block (CEB) was performed for subsequent surgery. Chi-squared and Fisher's exact tests were used for discriminating the effects of propofol induction and CEB, respectively.

In 14 cases (5.5%) aged 8.3 ± 5.7 years (range 2 months–17 years), surgeons complained about sustained penile erection. Detumescence occurred by decreasing remifentanil infusion below 0.1 μg·kg−1·min−1 and in four cases it had to be stopped. In three propofol, induction was used and in another two CEB was performed. The correlation between penile erection and CEB was significant (P < 0.05), while propofol induction was not related (P > 0.05).

Erection is basically a spinal reflex, mediated primarily by the parasympathetic nervous system that can be initiated by penile afferents, visual, and imaginary stimuli with nitric oxide (NO), an important factor in this mechanism (1). Sildenafil was first used in the treatment of pulmonary hypertension with this NO effect.

During consciousness, the cortical centers normally inhibit penile erection, and depression of this sympathetic control of flaccidity and activation of parasympathetic pathways by manipulation during general anesthesia may cause penile erection (2).

Regional anesthesia may precipitate or prevent erection depending on which fibers are predominantly blocked. An autonomic imbalance with the parasympathetic innervation remaining intact may cause penile erection. When epidural anesthesia blocks both parasympathetic and sympathetic fibers, detumescence occurs (3).

The incidence of sustained penile erection during penile procedures was reported to be similar for general (propofol induction was used in 18 of 19 cases) or epidural anesthesia, 3.5% and 3.8%, respectively, in adult patients (2), but has never been reported in a pediatric population.

In our cases, penile erection during remifentanil infusion seemed to be facilitated by CEB. In addition to this, we have experienced four other intraoperative penile erections with relatively longer duration in circumcision or hypospadias surgery under remifentanil anesthesia and CEB.

Unlugenc et al. (4) reported that remifentanil vasodilates isolated rat thoracic aorta strips by a mechanism involving NO release from the endothelium. This is the single report, which supported our thoughts for blaming remifentanil in the development of penile erection in our cases, but further investigations are required.

We believe that there is an increased incidence of penile erection during penile endoscopic or surgical procedures under remifentanil-based anesthesia in children. Decreasing or cessation of remifentanil infusion and/or deepening the level of anesthesia with inhalational agents is the solution.
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Paediatr Anaesth. 2006 Dec;16(12):1294-5.
Penile erection during remifentanil anesthesia in children.