Epinephrine in digital nerve block
Date First Published:
June 22, 2006
Last Updated:
October 24, 2007
Report by:
P P Mohan, Research Fellow, Gastrointestinal Surgery (Good Hope Hospital NHS Trust, Sutton Coldfield, University Hospital Birmingham, UK.)
Search checked by:
PT Cherian, Good Hope Hospital NHS Trust, Sutton Coldfield, University Hospital Birmingham, UK.
Three-Part Question:
In [adult patients with no underlying vascular compromise undergoing digital block] is [local anaesthetic with low dose epinephrine as safe as local anesthetic alone] at [achieving analgesia without causing ischaemic complications]?
Clinical Scenario:
A 25-year-old man presents to the emergency department with a traumatic laceration to his left index finger. The wound needs a thorough clean and will require suturing and you decide to do this using a digital nerve block technique. A colleague who has recently worked in plastic surgery suggests you use epinephrine (1:100 000) to help with haemostasis, but you have always been told that this can cause finger necrosis and that it should never be done. You wonder whether in fact this is true and decide to look at the evidence for yourself.
Search Strategy:
Medline search using Pubmed
Search Details:
("Anesthesia"[MeSH] OR "Anesthesia, Local"[MeSH]) OR "Nerve Block"[MeSH] AND "Epinephrine"[MeSH] AND "Fingers"[MeSH]
Outcome:
16 papers retrieved of which 7 were found to be relevant. There were 2 randomised control trials, 3 observational cohort studies and 2 review articles.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Digital blocks with or without epinephrine. Andrades PR, Olguin FA, Calderon W. Apr-03 USA | Study group (n = 21) received 2% lignocaine with 1:100 000 epinephrine and control group (n = 22) received 2% lignocaine | Randomised control trial | Pain score at 1 hour | Study group = 1.4, control group = 4.1 (p<0.05) | Small study |
| Need for further anaesthetic dose | Study group = 4%, control group = 24% (p<0.05) | ||||
| Duration of analgesia | Study group = 4.6 h, control group = 2.4 h (p<0.05) | ||||
| Ischaemic damage | |||||
| Digital anesthesia with epinephrine: an old myth revisited. Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. 2004 November USA | Review of all reported cases of digital gangrene associated with the use of epinephrine from National Library of Medicine | Review article | Presence of confounding factors in the reported cases | 21 reported cases of digital gangrene involved the use of epinephrine. Factors such as inappropriate mixing of epinephrine, use of older agents, inappropriate use of tourniquet, use of hot soaks, infection, and large volume of injection were associated with the reported cases. No case reported epinephrine as the sole cause of gangrene | Historical Review |
| Epinephrine in digital blocks: revisited. Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG. 1998 October USA | 23 procedures with digital ring bock using lignocaine 1% with adrenaline 1:100,000 (n=11) or 1:200,000 (n=12). | Observational cohort study | Ischaemic damage | Small case series, use of two different strengths of epinephrine | |
| Digital blocks with adrenaline. An old dogma refuted. Sylaidis P, Logan A. 1998 February UK | 100 consecutive patients underwent digital ring block using lignocaine 2% with adrenaline 1:80,000. | Observational Cohort Study | Digital–brachial pressure index (ratio of digital to brachial artery systolic blood pressures) | Mean fall of 19% in digital–brachial pressure index following the block (SD 14.6%). | The digital blood pressures were not measured at the end of procedure |
| Finger tip temperature | Mean increase of 0.8 (SD 2.3)°C following block | ||||
| Digital artery blood flow (10 patients, duplex scanner) | Blood flow returned to normal by 1 h in all cases | ||||
| Ischaemic damage | |||||
| Epinephrine in digital block: color Doppler flow imaging. Altinyazar HC, Ozdemir H, Koca R, Hosnuter M, Demirel CB, Gundogdu S. 2004 April Turkey | 24 adults undergoing blocks in fingers or toes with 2% lignocaine and 1:100 000 epinephrine | Observational cohort study | Digital artery blood flow at 10 min | Fall in peak systolic velocity by 60% and end diastolic velocity by 90% | |
| Digital artery blood flow at 60 min (n=21) | Blood flow returned to pre-block measurement | ||||
| Digital artery blood flow at 90 min (n=3) | Blood flow returned to pre-block measurement | ||||
| A comprehensive review of epinephrine in the finger: to do or not to do. Denkler K. 2001 July USA | Review of all reported cases of ischaemic digital necrosis associated with the use of epinephrine from 1880 to 2000 | Review article | Presence of confounding factors in reported cases of ischaemic damage | 21 out of 48 reported cases of digital gangrene involved the use of epinephrine. Confounding factors such as inappropriate concentration of epinephrine, use of older local anaesthetics, excessive volume of injection, prolonged use of tourniquet, use of hot soaks and infection were identified with all reported cases of gangrene | |
| Do not use epinephrine in digital blocks: myth or truth? Wilhelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Dardano T, Tran A, 2001 February USA | Study group (n = 31) had digital block using 1% lignocaine with 1:200 000 epinephrine. Control group (n = 29) had 1% lignocaine plain | Randomised control trial | Need for tourniquet | Study group = 9/31, control group = 20/29, (p<0.002) | |
| Need for further anaesthetic dose | Study group = 1/31, control group = 5/29 (p = 0.098) | ||||
| Ischaemic complications |
Author Commentary:
Two review articles carefully examined the previously reported cases and found that no case had epinephrine as the sole cause of ischaemic complication. Two studies examined the digital perfusion using Doppler flow, and concluded that the blood flow returned to normal by 1 h after epinephrine injection. Other randomised and observational studies showed longer duration of anaesthesia, better analgesia, less need for tourniquets and no ischaemic damage with the use of epinephrine.
This is clearly a controversial topic as it has been emergency medicine dogma that vasoconstrictive agents should not be used in digits. However, the evidence does not support this assertion for all patients. Clinicians may decide to use low concentration epinephrine when they feel this may help the procedure and where there is no underlying reason not to do so.
This is clearly a controversial topic as it has been emergency medicine dogma that vasoconstrictive agents should not be used in digits. However, the evidence does not support this assertion for all patients. Clinicians may decide to use low concentration epinephrine when they feel this may help the procedure and where there is no underlying reason not to do so.
Bottom Line:
In the absence of underlying vascular compromise, epinephrine (1:200 000 to 1:100 000) is safe to use in digital blocks along with local anaesthetics.
References:
- Andrades PR, Olguin FA, Calderon W.. Digital blocks with or without epinephrine.
- Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS.. Digital anesthesia with epinephrine: an old myth revisited.
- Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG.. Epinephrine in digital blocks: revisited.
- Sylaidis P, Logan A.. Digital blocks with adrenaline. An old dogma refuted.
- Altinyazar HC, Ozdemir H, Koca R, Hosnuter M, Demirel CB, Gundogdu S.. Epinephrine in digital block: color Doppler flow imaging.
- Denkler K.. A comprehensive review of epinephrine in the finger: to do or not to do.
- Wilhelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Dardano T, Tran A,. Do not use epinephrine in digital blocks: myth or truth?