Epinephrine in Digital Foot Surgery DeKalb Medical Carl A. Kihm, DPM Allison J.A. Menke, DPM THE PODIATRY INSTITUTE BACKGROUND INFORMATION EVIDENCE BASED MEDICINE Local anesthetics (LA) cause vasodialation.1 Epinephrine causes vasoconstriction.1 When mixed with LA, epinephrine serves as a “chemical tourniquet.” 2 Advantages of Epinephrine (Vasoconstriction)1-5 Aids in surgical hemostais Decreases the rate of LA systemic absorption Longer lasting LA block Larger toxic limit of LA Less amount of LA needed for effective block Less IV sedation needed Contraindications of Epinephrine Use6 Severe HTN, CAD, PVD, Vasospastic Conditions (Raynaud’s), Hyperthyroidism, Infection Historical literature highlights risk of digital ischemia and gangrenous necrosis as a result of epinephrine use.8-9 Apprehension of epinephrine use in digital surgery persists because a historical dogma is propagated.10 Allegations stem from literature published before 1953. Prior to this time, epinephrine concentrations were manually prepared using hand droppers – an imprecise and archaic preparation method.11 In commercially-packaged, known and precise quantities, is epinephrine use safe in digital surgery? Anecdotally, epinephrine has been safely used in digital surgery at our large training institution over the past 40 years. Retrospective review of over 78,000 podiatric procedures (84% were digital surgeries) with 1% lidocaine with epinephrine – no complications from epinephrine use.12 Epinephrine shown to temporarily restrict digital perfusion but not to completely occlude it. 31 toes injected with 1% lidocaine with epinephrine – no complication from epinephrine use.13 Questionnaire assessment of over 2,000,000 digital LA injections with epinephrine (839 practitioners) – Loss of toe reported in 1:132,000 cases. Loss of limb in 1:2,109,555 cases. Other risk factors not reported. Final conclusion that epinephrine use is well within acceptable therapeutic limits of safety for digital toe injections.14 Prospective study assessing LA digital hand blocks; lidocaine plain in 29 subjects and lidocaine with epinephrine in 31 subjects – no complications from epinephrine use.15 Prospective review of 21 digital blocks of fingers or toes using 2% lidocaine with epinephrine – no complication from epinephrine use; faster onset, fewer reinforcement injections needed, decreased need for tourniquet use.16 Prospective review of 1,340 digital hand blocks with lidocaine with epinephrine – no complications from epinephrine use.17 Extensive literature review from 1880-2000 revealed 48 documented cases of digital necrosis secondary to LA use. Epinephrine was used in only 21 of these 48 cases. No case of digital necrosis caused by epinephrine use has been reported since LA with epinephrine has been commercially prepared.18-19 A large, double-blinded, prospective study comparing outcomes of digital foot surgery performed using (1) plain LA , or (2) LA with epinephrine FDA Black Box Warning7 “Local anesthetic solutions containing a vasoconstrictor should be used cautiously and in careful circumscribed quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply.” FUTURE STUDY NEEDED (1)Local Anesthetics. In: Miller’s Anesthesia, Volume 1, 7th Edition. Philadelphia, Churchill Livingstone, 2009. (2)Berger RA, Arnold-Peter CW. Hand Surgery, Volume 1. Philadelphia. Lippincott Williams and Wilkins. 2004; 70. (3)Gaiser RR: Pharmacology of local anesthetics in: Longnecker DE, et al. Introduction to Anesthesia, 9th Edition. 1997, 201-15. (4)Reilley TE, Gerhardt MA. Anesthesia for foot and ankle surgery. Clinics in Podiatric Medicine and Surgery 2002; 19:125-47. (5)Kihm C. Local anesthetic considerations in podiatric surgery. The Podiatry Institute Update 2011, 231-35. (6)Ravenell R, Powell DR, Ryan JD. Vasospastic disorders, ischemic digits, and the use of epinephrine in digital surgery. The Podiatry Institute Update 2009, 187-92. (7)Lidocaine with epinephrine (package insert), Hospira Inc, Lake Forest, 2010. (8)Wylie WD, Ed: A Practice of Anesthesia, Ed 3, p 1166, Year Book Medical Publishers, Chicago, 1972. (9)Steinberg MV and Block P. The use and abuse of epinephrine in local anesthetics. JAPA 1978; 68: 329. (10)Radovic P, Smith RG, and Shumway D: Revisiting epinephrine in foot surgery. JAPMA 2003; 93: 157-60. (11)McGlamry MC. Epinephrine in forefoot and digital surgery. The Podiatry Institute Update 1994; 189-91. (12)Kaplan EG, Kashuk: Disclaiming the myth of use of epinephrine local anesthesia in feet. JAPA 1971; 61: 336-340. (13)Scarlet JJ, Walter JH Jr, Bachmann RJ: Digital blood perfusion following injections of plain lidocaine and lidocaine with epinephrine. JAPA 1978; 68: 339. (14)Roth RD: Utilization of epinephrine-containing anesthetic solutions in the toes. JAPA 1981; 71: 189-199. (15)Wilhelmi BJ, Blackwell SJ, et al. Do not use epinephrine in digital blocks: myth or true? Plast Reconstr Surg. 2001; 107: 393-97. (16)Andrades P, Olguin F, Calderon W. Digital blocks with and without epinephrine. Plast Reconstr Surg. 2003; 111:1769-70. (17)Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg (AM). 2005; 30: 1061-67. (18)Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstru Surg. 2001; 108: 114-24. (19)Krunic AL, Wang LC, Soltani K, Weitzul S, and Taylor RS: Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol 2004; 51: 755-759.