Digital anesthesia with epinephrine

admin · Nov 3, 2004

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From latest Journal of the American Academy of Dermatology:
Digital anesthesia with epinephrine: An old myth revisited

Conclusion A literature review failed to provide evidence to support the dogma that block or infiltrative anesthesia with lidocaine and epinephrine produces digital necrosis. Proper injection technique and adequate selection of patients (absence of thrombotic, vasospastic conditions, or uncontrolled hypertension) are mandatory to minimize complications. The addition of epinephrine, in fact, reduces the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during digital procedures.
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Abstract

Comments?

davidh · Nov 4, 2004

When I was young and foolish (as opposed to being old and foolish :eek: ) I once did a digital block on my index finger using, if I remember rightly, a 2% solution of lignocaine with epinephrine. I remember the injection being painful, but the finger is still attached, good as new :) .
Regards,
David

bob · Nov 4, 2004

Good Morning,
See also -
Radovic P, Smith RG, Shumway D. J Am Podiatr Med Assoc. 2003 Mar-Apr;93(2):157-60

Anesthetics containing epinephrine have long been thought unsuitable for use in the foot and, particularly, the digits. However, research suggests that epinephrine use is beneficial in the appropriately selected patient. These benefits include a decreased local anesthetic plasma concentration; an increased duration of anesthesia, with a decreased need for additional narcotic use after surgery; decreased development of hemorrhage and postoperative hematoma, without occlusion of vessels; and a lack of complications (in millions of patients reported on in the literature). A retrospective review of more than 150 patients receiving local anesthetics containing epinephrine revealed no complications in the foot and ankle.

Robert D. Phillips DPM · Dec 20, 2004

25 years later

I have been using epinephrine in digital blocks judiciously for the last 25 years. I think you'll read the PDR to say that epinephrine is to be used cautiously in the digits. A review of JAPMA will find an article by Don Green many years ago showing the bloodflow into the digit after using epinephrine, which would demonstrate very nicely that it is no more dangerous for digital necrosis than puttint a thigh tourniquet on for 1.5-2 hours.

Every year I have to retrain residents that with a little bit of common sense, epinephrine can be safely used in many if not most patients. I would not use it on someone who already has dependent rubor and no pulses nor on someone who has vasospastic disease.

Best wishes.

summer · May 9, 2005

Epinephrine

I don't think medical-legally if there was a problem you would have a good defense. Since the PDR states judicious use only, I think the lawyers with their twisted wording would find some way to convolute the truth. As for me, even though I know it is safe if administered correctly, I'll stick with the torniquet.

André Azevedo · Nov 1, 2005

For me if the pacient have no historie of vascular disease why not the use of epinephrine? However, in Portugal and Spain podiatrists are not recomended to use it. We normaly use the torniquet. By the way i´m for Portugal.

NewsBot · Jan 22, 2015

From Latest Podiatry Today:
Why Are We So Afraid Of Local Anesthetics With Epinephrine?

NewsBot · Feb 19, 2016

Anaesthetic digital block with epinephrine vs. tourniquet in ingrown toenail surgery: a clinical trial on efficacy.
C?rdoba-Fern?ndez A, Rodr?guez-Delgado FJ.
J Eur Acad Dermatol Venereol. 2015 May;29(5):985-90

BACKGROUND:
Current evidence shows that anaesthetic digital block with epinephrine is safe in surgical selected patients. There are no controlled studies that have examined the efficacy of local anaesthesia with vasoconstrictor in chemical matricectomy without using tourniquet to control bleeding.
OBJECTIVES:
A controlled, prospective and randomized study was conducted to examine primarily the rate of recurrence after segmental phenolization matricectomy with anaesthetic digital block with epinephrine vs. tourniquet. As secondary aims, duration of anaesthetic effect, post-operative bleeding and pain were analysed in both groups.
METHODS:
Forty-four healthy subjects with ingrown hallux nails (70 toes) were enrolled. A total of 34 toes were anaesthetized with a solution of 2% mepivacaine with (1 : 100,000) epinephrine and operated without tourniquet (experimental group) vs. 36 toes anesthetized with a solution of 2% mepivacaine without epinephrine and operated with tourniquet (control group).
RESULTS:
There was no statistically significant difference in recurrence rates (P = 0.478). Post-operative bleeding was significantly higher in the group with anaesthetic digital block without vasoconstrictor and with tourniquet (P = 0.001). Anaesthetic effect was higher in the group with anaesthetic digital block with vasoconstrictor and without tourniquet (P = 0.001). No post-operative complications occurred in any of the treatment groups.
CONCLUSIONS:
The use of local anaesthetic with vasoconstrictor to perform chemical matricectomy likely to be an effective procedure to reduce the disadvantages of using digital tourniquet (post-operative bleeding and lower anaesthetic effect) without increasing the risk of recurrence. The addition of epinephrine may reduce the need for a tourniquet and produce better and longer perioperative pain control.
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NewsBot · Jun 19, 2016

Evaluation of the safety of epinephrine in digital nerve blockade
Retrospective case series analysis of 1334 toe surgeries
Henry Chapeskie et al
Canadian Family Physician June 2016 vol. 62 no. 6 e334-e339

Objective To evaluate the safety profile of lidocaine containing 1:200 000 to 1:100 000 epinephrine with concurrent tourniquet use in patients undergoing toe surgery.

Design A retrospective case series analysis of toe procedures performed under digital blockade with adjuvant vasopressor from January 25, 2009, to May 31, 2014, was conducted. Exclusion criteria were limited to procedures performed without adjuvant vasopressor use.

Setting A single clinic in Ontario.

Participants A total of 1334 toe procedures performed in 937 patients.

Main outcome measures The primary study outcome was the incidence of postoperative digital necrosis. Secondary outcomes included other postoperative complications including infection, reperfusion injury, persistent granulation, and damage to the nail matrix.

Results In total, 1334 toe procedures were included in this study, of which 45 involved patients with a pre-existing diagnosis of diabetes mellitus. The overall incidence of postoperative complications was low (4.6%). No cases of digital ischemia or gangrenous necrosis were observed. Subgroup analysis of patients with and without diabetes showed no statistically significant difference in the rate of complications.

Conclusion This study demonstrates the safety of adjuvant vasopressor use in digital nerve blockade of the toes within a large, diverse population. This study adds to a growing base of evidence on the safety of lidocaine with 1:200 000 to 1:100 000 epinephrine for digital anesthesia.
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NewsBot · Jun 28, 2019

Is Epinephrine Safe for Infant Digit Excision? A Retrospective Review of 402 Polydactyly Excisions in Patients Younger than 6 Months.
Mantilla-Rivas E, Tan P, Zajac J, Tilt A, Rogers GF, Oh AK.
Plast Reconstr Surg. 2019 Jul;144(1):149-154

BACKGROUND:
Conventional dogma suggests that the use of local anesthetic with epinephrine is contraindicated in the digits because of fear of ischemia and necrosis. Although several reports have refuted this notion, the precept is still propagated in many clinical forums. For many years, the authors have used lidocaine with epinephrine to perform removal of postaxial polydactyly in infants and have observed few complications and no cases of digital ischemia or necrosis. This investigation details the authors' outcomes with this anesthetic modality in neonates and supports the growing body of literature documenting the safety of using lidocaine with epinephrine in the digits.

METHODS:
A retrospective review of all infants younger than 6 months who underwent preaxial and postaxial polydactyly excision and removal of their sequelae of the hand or foot under local anesthesia, from 2011 to 2017, was completed. All demographic characteristics, frequency of complications, and descriptive statistics of the sample clinical group were documented.

RESULTS:
In the 215 patients who met inclusion criteria, a total of 402 procedures were performed. Mean follow-up was 19.9 months for 140 patients, or 264 procedures (65.7 percent). The total complication rate was 2.6 percent. There were two cases of minor bleeding, one wound dehiscence, and four surgical-site infections.

CONCLUSIONS:
In 402 procedures of surgical excision of polydactyly in infants, there were few short-term complications, none of which were necrosis or any vascular complication related to the use of epinephrine. The authors believe that, with the use of a low-dose epinephrine injection (1:200,000), the risk for digital infarction is low in this population.
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NewsBot · May 3, 2022

The Dogma of Tissue Ischemia with Local Anesthetic and Epinephrine Use
Laura Morrissey
Source

Epinephrine is often combined with Lidocaine for local anesthetic use as it
improves the duration and quality of Lidocaine and promotes wound
hemostasis.1-2 Despite these benefits, epinephrine has been historically
contraindicated from being injected into fingers, toes, ears and the nose
due to concern over the vasoconstrictive properties of epinephrine leading
to ischemia in these end-arterial areas.3-7 However, there is very little
documented evidence of this happening with epinephrine use.5-13 An
exhaustive review done by Denkler in 20015 reviewed 21 cases between
1889-2001 that involve epinephrine local injection prior to digit ischemia.
However, none of these cases used the current pre-mixed lidocaine and
epinephrine concentrations and none showed evidence of epinephrine as
the sole cause of ischemia. In fact, during the same time period, Denkler
revealed 5 separate studies that involve between 23-200,000 patients per
study that all fail to document ischemia secondary to local epinephrine
injection.5 A review of the literature since 2001 demonstrates similar
results; Numerous studies fail to show ischemia secondary to epinephrine
injection.9-13 Furthermore, in rare cases where ischemia did occur,
Phentolamine or other vasodilatory agents were readily available and
given to reverse the effects of epinephrine, resulting in full resolution of
symptoms without permanent damage.13-14 From this evidence, it is
concluded that the dogma of tissue ischemia secondary to epinephrine
injection should be abandoned as local anesthetic with epinephrine is
likely safe to use in areas such as the fingers, toes ears and nose in most
patients prior to both laceration repairs and surgeries.
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