By Will Fleischman, MD
Please refer to SMARTEM
Axiom – noun – A statement or proposition that is regarded as being established, accepted, or self-evidently true. Pseudoaxiom – A false axiom passed down as anecdote, tradition, or simple repetition from one generation of medical providers to the next.
Literature commonly cited to support epinephrine as dangerous:
- Garlock, 1931. 4 cases of gangrene following digital blocks with NO epinephrine; concludes gangrene was probably due to mechanical injury from the tourniquet used.
- Kaufman, 1941. Case report of a pt who developed gangrene following digital block of procaine/epinephrine for I&D of a felon. Buto pt soaked digit in boiling boric acid solution following the surgery.
- McLaughlin, 1942. Case similar to above, pt also soaked finger in hot boric acid solution while finger was still anesthetized and developed severe blistering.
- O’neil, 1944. 8 cases of finger gangrene following digital anesthesia; all cases that used epinephrine involved hot water soaks followed by finger blistering.
- Bradfield, 1963. Literature review, concludes that there is no significant association between epi and gangrene
Later literature showing no harm from epinephrine:
- Burnham, 1958. Case series, 93 digital blocks with epi without complications.
- Latimer & Kay, 1991. Injected own toes and fingers w/epinephrine and noted mild pallor followed by vasodilation and warmth.
- Wilhelmi, 1998. Case series, 23 digital blocks with epinephrine without complications.
- Sylaidis, 1998. Case series of 100 digital blocks with epi; dopplers showed never more than 40% reduction in flow.
- Denkler, 2001. Systematic review, concludes no evidence against using epinephrine.
- Wilhelmi, 2001. Double-blind RCT, 60 digital blocks, half with epi. Epi group had less bleeding, less re-dosing of local anesthesia, quicker procedure. No adverse effects in either group.
Keep in mind that the half life of epinephrine injected systemically is 3-5 minutes (hence the dosing in ACLS protocols), and approx. 10-15 minutes in the tissues. In contrast, BP tourniquets are accepted as safe when inflated for 2-3 hours during surgical procedures of the upper extremities. In contrast, BP tourniquets are accepted as safe when inflated for 2-3 hours during surgical procedures of the upper extremities.
Conclusion: it is safe, and in many cases beneficial, to use epinephrine in digital anesthesia.