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Hammert Epinephrine in Hand Surgery

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Hammert Epinephrine in Hand Surgery EVIDENCE-BASED MEDICINE Evidence-Based Medicine Epinephrine and Hand Surgery Tobias Mann, MD, Warren C. Hammert, MD THE PATIENT Denkler1 did not identify a single reported case of A 45-year-old man injured his dominant hand at work, digital gangrene from lidocaine and epinephrine in a with zone II flexor tendon injuries to the index and search of Index Medicus from 1880 to 1966, the Na- middle fingers. He states he has severe nausea after tional Library of Medicine database from 1966 to 2000, general anesthesia and would prefer local anesthesia for and selected textbooks from 1900 to 2000. Among 48 repair of the injuries. cases of digital gangrene, all but 6 occurred over 50 years ago; the anesthetics used were procaine and co- THE QUESTION caine with epinephrine and only 44% (21 cases) had Is lidocaine with epinephrine safe for use in digits of the epinephrine mixed with the local anesthetic. In 17 of upper extremity, potentially allowing surgery with no those cases, the anesthetic was manually diluted, creat- sedation or tourniquet? ing an unknown concentration of epinephrine. In the remaining 4 cases, epinephrine concentrations ranged CURRENT OPINION from 1:160,000 to 1:400,000. There were several Traditional concern regarding the use of epinephrine in complicating factors such as presence of infection, the fingers is based on 21 reported cases of digital tourniquets, and use of hot soaks. Thomson et al2 necrosis after being injected with a local anesthetic with reviewed evidence showing that as procaine ages it epinephrine.1 Most occurred before 1950 and all used becomes more acidic. Given that expiration dates procaine, which may have been expired and thus may on injectable medications were not mandated until have had a toxically low pH.2 The effects of epineph- 1978, the authors argued that aged procaine, rather rine can be easily and expediently reversed with the use than epinephrine, was the likely culprit in the of phentolamine.3–5 reported cases of digital necrosis.7 Krunic et al8 found 2 additional cases of finger THE EVIDENCE necrosis after digital blocks with plain lidocaine. One In the world literature, no cases of finger necrosis have case involved laser ablation of warts on an index finger been reported after the use of lidocaine with epineph- that developed postprocedure swelling and an infection rine.2 Furthermore, as epinephrine auto-injectors are necessitating surgical debridement; necrosis developed becoming commonplace, there have been several case after the debridement. The second case involved surgi- reports and case series of patients who accidentally cal debridement of a finger infection in a patient with injected their fingers with epinephrine 100 times more scleroderma and Raynaud phenomenon and the authors concentrated than what is found in the commercially concluded that the necrosis was likely caused by the available lidocaine and epinephrine mixtures. In some infection, pre-existing microvascular damage, or exces- of these cases, the patients went untreated, and still sive necrosis caused by the laser ablation rather than the there were no reports of digital necrosis or other per- lidocaine. manent harmful sequelae from these cases.3,4,6 Several case reports have been published on acci- dental injection of high-concentration (1:1,000) epi- FromtheDepartmentofOrthopaedicSurgery,UniversityofRochesterMedicalCenter,Rochester,NY. nephrine into the hand and fingers.9–19 In most of these TheauthorsacknowledgeDr.DonLalondeforworkonthistopicandeffortstomakehandsurgeons aware of the safety regarding epinephrine in the hand and fingers. cases, the effect of epinephrine was reversed using phentolamine. All of these patients made a full recov- Received for publication November 7, 2011; accepted in revised form November 21, 2011. ery. In 2007, Fitzcharles-Bowe et al3 published a re- No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. view of the documented cases of high-dose finger epi- Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, Univer- nephrine injections. They searched the literature from sity of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642; e-mail: 1900 to 2005 and found 59 cases that matched their [email protected]. inclusion criteria. Of these 59 cases, 32 received no 0363-5023/12/37A06-0029$36.00/0 treatment. The remaining 27 were treated with phentol- doi:10.1016/j.jhsa.2011.11.022 amine reversal, transdermal nitroglycerin ointment, 1254 ᭜ © ASSH ᭜ Published by Elsevier, Inc. All rights reserved. EPINEPHRINE AND HAND SURGERY 1255 heat, terbutaline, nifedipine, iloprost, or some combina- nephrine for hand and finger blocks. This resulted in tion of these; no cases of finger necrosis were reported. over 1,300 cases of digital blocks reported in the Jour- The most notable adverse effects noted were reperfu- nal of Hand Surgery in 2005.6 The authors reported no sion pain that lasted up to 4 hours and neurapraxia that incidence of digital necrosis. There was no need for lasted up to 10 weeks. phentolamine rescue and no long-term ill effects were Simons et al20 published another literature review of noted. Chowdhry et al21 reported 1,111 cases of finger unintentional injections of high-dose epinephrine in surgery in which over half received digital blocks with 2009. They identified 69 epinephrine. As in the prior cases over the past 20 years, EDUCATIONAL OBJECTIVES studies discussed here, there 63 of which involved injec- ● State when expiration dates on injectable medications were mandated. were no cases of digital gan- tion into a finger. No treat- ● Discuss what happens to procaine as it ages. grene or other permanent Evidence-Based Medicine ment was undertaken in 13% ● Discuss the treatment measures following accidental injection of high- deleterious sequelae. 22 of these 69 cases; the remain- concentration (1:1,000) epinephrine into the hand and finger. Sönmez et al published a ing patients were treated randomized, controlled study ● Statetheroleofphentolamineinjectionstoreversetheeffectsofepineph- pharmacologically or with rine in the digits. comparing fingertip blood gas heat, or with a combination parameters in patients receiv- ● Listthebenefitsofepinephrineinhandsurgerywithrespecttotourniquet of both. There were no per- use, sedation, and cost. ing digital anesthesia with or manent sequelae reported. without epinephrine augmen- A retrospective cohort Earn up to 2 hours of CME credit per JHS issue when you read the related tation. The authors measured study by Muck et al4 pub- articles and take the online test. To pay the $20 fee and take this month’s capillary blood gas parameters lished in the Annals of Emer- test, visit http://www.jhandsurg.org/CME/home. before performing the digital gency Medicine lends further block, and again 15 minutes credence to the notion that high-dose epinephrine injec- after the block. They also recorded the time to return of tions into the digits do not cause digital necrosis. They sensation in the blocked digit in the 2 groups. In the plain found 365 cases of accidental epinephrine injections lidocaine group, they saw an increase in the partial pres- from auto-injectors over a 4-year period. Of those, 127 sure of oxygen and pulse oximeter oxygen saturation after involved injections into the fingers and had follow-up. the block. Return of sensation in this group occurred after Only 29 patients received pharmacologic treatment in an average of almost 5 hours. In the lidocaine with epi- the form of transdermal nitroglycerin ointment, phen- nephrine group, there was no statistically significant tolamine, or terbutaline. Again, no cases of digital ne- change in the blood gas partial pressures after the block. crosis were reported. Furthermore, no patients required The effects of the block wore off at an average of 8 hours hospitalization or involvement of a hand surgeon, and in this group. 23 all had complete resolution of symptoms. Wilhelmi et al published a double-blinded, ran- Phentolamine injections have been successfully used to domized, controlled trial examining the effect of digital reverse the effects of epinephrine in the digits.3,4,9–20 To block with or without epinephrine. They performed a document the timeline of phentolamine reversal, Nodwell total of 60 digital blocks, 29 without and 31 with et al5 designed a randomized, blinded study in which they epinephrine. There were no complications reported in injected volunteers with a lidocaine-epinephrine mixture. the lidocaine with epinephrine group. Denkler retro- A total of 18 board-certified hand surgeons, 2 residents, 1 spectively compared patients with Dupuytren surgery hand therapist, and 1 nurse underwent a digital block on treated with palmar and digital fasciectomies. One co- each hand using lidocaine with 1:100,000 epinephrine. hort consisted of 42 digits treated in the hospital with an After 1 hour, the block on 1 hand was reversed with upper arm tourniquet. The second cohort consisted of phentolamine and the other received a sham reversal. On 60 digits treated in the office with local anesthetic with average, phentolamine reversed the clinically apparent ef- epinephrine without a tourniquet. Complications were fects of epinephrine after 85 minutes, whereas it took an similar in each group. There were no cases of digital necrosis, but there was one arterial transection in the average of 320 minutes for the effects of epinephrine to 24 wear off on the sham reversal side. All subjects retained local anesthesia group. capillary refill in the nail beds during the period when the epinephrine was in effect. No subjects experienced perma- SHORTCOMINGS OF THE EVIDENCE nent sequelae as a result of this experiment. Several large cohorts and a few randomized trials sup- Between 2002 and 2004, 9 hand surgeons in 6 cities port the safety of using epinephrine to augment local prospectively recorded the use of lidocaine with epi- anesthetic in digital blocks. On the other hand, to date JHS ᭜ Vol A, June 1256 EPINEPHRINE AND HAND SURGERY 6.
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