Skip to main content

Advertisement

Log in

The safety and efficacy of epinephrine in hand surgery: a systematic review of the literature and international survey

  • Review
  • Published:
European Journal of Plastic Surgery Aims and scope Submit manuscript

Abstract

The concept that epinephrine-based local anesthetics cannot be injected in terminal appendages has been perpetuated for decades. The hypothesis that the vasoconstrictive effect of epinephrine will result in finger necrosis has been accepted as fact, often preventing its use in hand surgery. To scientifically challenge this hypothesis, a systematic review of the literature was performed, and a survey of ASPS members reported to highlight the lack of evidence-based opinions. A systematic literature review performed using Medline, Embase, PubMed, and Cochrane databases identified all published studies evaluating use of epinephrine/adrenaline in hand, finger or digit surgery. Each study was independently evaluated by three reviewers for inclusion or exclusion from the systematic review. Additionally, a survey (E-survey link) was distributed to all ASPS members and data were collected over a 5-month period through SurveyMonkey®. A total of 568 articles published prior to December 2012 were identified. After elimination of 151 duplicates, 417 articles remained. Fifty-five articles were selected and full examination of the texts was performed. Forty-five studies matched the selection criteria and were included in the analysis. The ASPS member survey demonstrated a 13 % overall questionnaire response rate (5,299 questionnaires/687 responses). Of all respondents, 37.4 % felt it was unsafe to inject local anesthesia mixed with epinephrine into the fingers/thumb, respectively. Critical literature review validated the safety and efficacy of utilizing epinephrine-based local anesthetics. The author’s survey elucidates the pervasive concern of employing epinephrine in hand surgery.

Level of Evidence: Not ratable

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Bunnell S (1944) Surgery of the hand. J B Lippincott Co, Philadelphia

    Google Scholar 

  2. Christopher F (1955) Minor surgery, 7th edn. Saunders, Philadelphia

    Google Scholar 

  3. Schwartz SI (1999) Principles of surgery, 7th edn. McGraw-Hill Health Professions Division, New York

    Google Scholar 

  4. Campbell WC, Speed JS (1956) Campbell’s operative orthopedics, 3rd edn. Mosby, St. Louis

    Google Scholar 

  5. Green DP, Hotchkiss RN, Pederson WC (1999) Green’s operative hand surgery, 4th edn. Churchill Livingstone, New York

    Google Scholar 

  6. Physicians’ Desk Reference. 28 ed. Medical Economics Company, Montvale, NJ; 1974

  7. Auletta MJ, Grekin RC (1991) Local anesthesia for dermatologic surgery. Churchill Livingstone, New York

    Google Scholar 

  8. Flatt AE (1963) The care of minor hand injuries. Mosby, St. Louis

    Google Scholar 

  9. Green DP (1993) Operative hand surgery. Churchill Livingstone, New York

    Google Scholar 

  10. Kleinert HE (1959) Finger tip injuries and their management. Am Surg 25:41–51

    CAS  PubMed  Google Scholar 

  11. McCarthy JG (1990) Plastic surgery. Saunders, Philadelphia

    Google Scholar 

  12. Raj PP (1985) Handbook of regional anesthesia. Churchill Livingstone, New York

    Google Scholar 

  13. Sandzen SC Jr (1974) Treating acute hand and finger injuries. Am Fam Physician 9:100–17

    PubMed  Google Scholar 

  14. Scott DB, Jebson PJ, Braid DP, Ortengren B, Frisch P (1972) Factors affecting plasma levels of lignocaine and prilocaine. Br J Anaesth 44:1040–9

    Article  CAS  PubMed  Google Scholar 

  15. Weckesser EC (1974) Treatment of Hand Injuries; Preservation and Restoration of Function. Press of Case Western Reserve University, Cleveland, Distributed by Yearbook Medical Publishers

    Google Scholar 

  16. Thomson CJ, Lalonde DH (2006) Randomized double-blind comparison of duration of anesthesia among three commonly used agents in digital nerve block. Plast Reconstr Surg 118:429–432

    Article  CAS  PubMed  Google Scholar 

  17. Sonmez A, Yaman M, Ersoy B, Numanodlu A (2008) Digital blocks with and without adrenalin: a randomized-controlled study of capillary blood parameters. J Hand Surg Eur 33:515–518

    Article  Google Scholar 

  18. Lalonde DH, Martin AL (2013) Wide-awake flexor tendon repair and early tendon mobilization in zones 1 and 2. Hand Clin 29(2):207–213

    Article  PubMed  Google Scholar 

  19. Fomon S (1960) Cosmetic surgery: principles and practice. Lippincott, Philadelphia

    Google Scholar 

  20. Rittinghausen RE, Moulds RF (1980) The use of isolated digital arteries to study factors influencing adrenergic-transmitter release in man. Clin Sci (Lond) 58:373–8

    CAS  Google Scholar 

  21. Stevens MJ, Moulds RF (1982) Pharmacological comparison of human isolated digital arteries and metacarpal veins. Clin Exp Pharmacol Physiol 9:129–38

    Article  CAS  PubMed  Google Scholar 

  22. Stevens MJ, Moulds RF (1986) Antagonism by nifedipine of alpha-1 and alpha-2 adrenoceptor-mediated responses of human digital arteries. J Pharmacol Exp Ther 236:764–9

    CAS  PubMed  Google Scholar 

  23. Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG (1998) Epinephrine in digital blocks: revisited. Ann Plast Surg 41:410–4

    Article  CAS  PubMed  Google Scholar 

  24. Geddes IC (1954) A review of local anesthetics. Br J Anaesth 26:208–24

    Article  CAS  PubMed  Google Scholar 

  25. DeJong RH (1977) Local anesthetics. Thomas, Springfield

    Google Scholar 

  26. Salo M, Kanto J, Jalonen J, Laurikainen E (1979) Plasma lidocaine concentrations after different methods of releasing the tourniquet during intravenous regional anesthesia. Ann Clin Res 11:164–8

    CAS  PubMed  Google Scholar 

  27. Wilhelmi BJ, Blackwell SJ, Miller JH et al (2001) Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg 107:393–7

    Article  CAS  PubMed  Google Scholar 

  28. Burnham PJ (1958) Regional block anesthesia for surgery of the fingers and thumb. Ind Med Surg 27:67–9

    CAS  PubMed  Google Scholar 

  29. Garlock JH (1931) Gangrene of the finger following digital nerve block anesthesia. Ann Surg 94:1103–7

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  30. Hixson FP, Shafiroff BB, Werner FW, Palmer AK (1986) Digital tourniquets: a pressure study with clinical relevance. J Hand Surg 11:865–8

    Article  CAS  Google Scholar 

  31. Bradfield WJ (1963) Digital block anesthesia and its complications. Br J Surg 50:495–8

    Article  CAS  PubMed  Google Scholar 

  32. Wilhelmi BJ, Blackwell SJ (2002) Epinephrine in the finger. Plast Reconstr Surg 110:999, author reply -1000

    Article  PubMed  Google Scholar 

  33. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P (2005) 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 30:1061–7

    Article  Google Scholar 

  34. Covino BG (1987) Pharmacology of local anesthetic agents. Ration Drug Ther 21:1–9

    CAS  PubMed  Google Scholar 

  35. Albert J, Lofstrom B (1965) Effects of epinephrine in solutions of local anesthetic agents. Acta Anaesthesiol Scand Suppl 16:71–7

    Article  CAS  PubMed  Google Scholar 

  36. Karev A (1979) A simple finger tourniquet. Br J Plast Surg 32:136

    Article  CAS  PubMed  Google Scholar 

  37. Rougemont J, Carcassonne F (1933) L’anesthesie regionale dans la pratique journaliere des interventions au niveau des doigts. Presse Med 66:218

    Google Scholar 

  38. Moulongeuet P (1928) Sphacele d’un doigt apres anesthesie en bague a la novocaine sans adrenaline. Bull Mem Soc Chir 54:782

    Google Scholar 

  39. Halla F (1928) Gangran nach oberstscherer anesthesie. Med Klin 41:15–22

    Google Scholar 

  40. Johnson HA (1967) Infiltration with epinephrine and local anesthetic mixture in the hand. JAMA: J Am Med Assoc 200:990–1

    Article  CAS  Google Scholar 

  41. Sylaidis P, Logan A (1998) Digital blocks with adrenaline. An old dogma refuted. J Hand Surg (Br) 23:17–9

    Article  CAS  Google Scholar 

  42. Denkler K (2005) Dupuytren’s fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg 115:802–10

    Article  CAS  PubMed  Google Scholar 

  43. Firoz B, Davis N, Goldberg LH (2009) Local anesthesia using buffered 0.5 % lidocaine with 1:200,000 epinephrine for tumors of the digits treated with Mohs micrographic surgery. J Am Acad Dermatol 61:639–43

    Article  CAS  PubMed  Google Scholar 

  44. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ (2010) Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1,111 cases. Plast Reconstr Surg 126:2031–4

    Article  CAS  PubMed  Google Scholar 

  45. Altman AJ, Albert DM, Fournier GA (1985) Cocaine’s use in ophthalmology: our 100-year heritage. Surv Ophthal 29:300–6

    Article  CAS  Google Scholar 

  46. Barnett A, Pearl RM (1983) Readily available, inexpensive finger tourniquet. Plast Reconstr Surg 71:134–5

    CAS  PubMed  Google Scholar 

  47. Klenerman L, Biswas M, Hulands GH, Rhodes AM (1980) Systemic and local effects of the application of a tourniquet. J Bone Joint Surg Br 62:385–8

    CAS  PubMed  Google Scholar 

Download references

Disclosures

The following authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this submitted manuscript (such associations include consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing a study described in the manuscript): Shridharani, Manson, Magarakis, Broyles, Whitaker, Rodriguez

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sachin M. Shridharani.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Shridharani, S.M., Manson, P.N., Magarakis, M. et al. The safety and efficacy of epinephrine in hand surgery: a systematic review of the literature and international survey. Eur J Plast Surg 37, 183–188 (2014). https://doi.org/10.1007/s00238-013-0925-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00238-013-0925-1

Keywords

Navigation