Digital anesthesia with epinephrine: An old myth revisited

doi:10.1016/j.jaad.2004.05.028

Journal of the American Academy of Dermatology

Volume 51, Issue 5, November 2004, Pages 755-759

https://doi.org/10.1016/j.jaad.2004.05.028 Get rights and content

Background

The prohibition against the use epinephrine with local anesthetics for digital blocks or infiltrative anesthesia is an established dogma in dermatologic surgery. Major textbooks reinforce this teaching suggesting that there is substantial risk of digital gangrene caused by local anesthesia containing epinephrine.

Objective

To provide a comprehensive literature review of the cases of digital necrosis associated with the use of local anesthesia containing epinephrine.

Methods

A PubMed search of the National Library of Medicine database using the terms “lidocaine” and “epinephrine” and “finger” with no specified limits was performed.

Results

A total of 16 papers were referenced and only 6 papers dealt with digital anesthesia. A total of 50 cases of digital gangrene were reported, mostly in the early part of the 20^th century. In 21 cases digital gangrene was associated with anesthetic mixed with epinephrine. Actual concentration of epinephrine was known in only 4 cases. Careful analysis of all cases of necrosis did not support epinephrine itself as a cause. Other contributing factors including older compounds (cocaine, eukaine, and procaine), non-standardized inaccurate methods of mixing epinephrine with lidocaine, inappropriate use of a tourniquet, postoperative hot soaks, infection, or large anesthetic volume were also present. None of the reported cases were associated with the use of a commercial lidocaine-epinephrine mixture.

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.

Section snippets

Material and methods

We performed a PubMed search of the National Library of Medicine database (MEDLINE) using the following headings: “lidocaine,” “epinephrine,” and “finger.” A total of 16 papers were generated without specific limits. Ten reports were excluded from the discussion: 2 addressed accidental injection of epinephrine from an autoinjector device, 3 concentrated on non-digital nerve blocks (2 brachial plexus, 1 sternocleidomastoid block), 1 described phentolamine reversal of epinephrine-induced digital

Literature review (Table I)

In 1998, Sylaidis and Logan¹⁷ did a prospective study on digital arterial perfusion after performing digital blocks with 2% lidocaine with 1:80,000 concentration of epinephrine. Although transient reduction in digital blood flow was noticed, finger perfusion was maintained without the development of digital ischemia or gangrene in any of 100 consecutive cases.

In 1998, Wilhelmi et al¹⁸ reported no apparent complications in 23 cases where 1% lidocaine with epinephrine was used to repair various

Discussion

Our literature review revealed 50 cases of digital gangrene after local anesthesia. Twenty-one of these cases involved the use of epinephrine, and in only 4 the concentration was reported. Careful analysis of these 21 reports fails to show that epinephrine by itself was the cause of the necrosis. Other factors were also present and included: the use of older compounds (cocaine, Eukain, procaine, water), infiltration of excessive volumes producing increases of the extravascular pressure and

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Conflicts of interest: None identified.

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TherapyDigital anesthesia with epinephrine: An old myth revisited