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Conclusion A literature review failed to provide evidence to support the dogma that block or infiltrative anesthesia with lidocaine and epinephrine produces digital necrosis. Proper injection technique and adequate selection of patients (absence of thrombotic, vasospastic conditions, or uncontrolled hypertension) are mandatory to minimize complications. The addition of epinephrine, in fact, reduces the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during digital procedures.
When I was young and foolish (as opposed to being old and foolish ) I once did a digital block on my index finger using, if I remember rightly, a 2% solution of lignocaine with epinephrine. I remember the injection being painful, but the finger is still attached, good as new :) .
See also -
Radovic P, Smith RG, Shumway D. J Am Podiatr Med Assoc. 2003 Mar-Apr;93(2):157-60
Anesthetics containing epinephrine have long been thought unsuitable for use in the foot and, particularly, the digits. However, research suggests that epinephrine use is beneficial in the appropriately selected patient. These benefits include a decreased local anesthetic plasma concentration; an increased duration of anesthesia, with a decreased need for additional narcotic use after surgery; decreased development of hemorrhage and postoperative hematoma, without occlusion of vessels; and a lack of complications (in millions of patients reported on in the literature). A retrospective review of more than 150 patients receiving local anesthetics containing epinephrine revealed no complications in the foot and ankle.
I have been using epinephrine in digital blocks judiciously for the last 25 years. I think you'll read the PDR to say that epinephrine is to be used cautiously in the digits. A review of JAPMA will find an article by Don Green many years ago showing the bloodflow into the digit after using epinephrine, which would demonstrate very nicely that it is no more dangerous for digital necrosis than puttint a thigh tourniquet on for 1.5-2 hours.
Every year I have to retrain residents that with a little bit of common sense, epinephrine can be safely used in many if not most patients. I would not use it on someone who already has dependent rubor and no pulses nor on someone who has vasospastic disease.
I don't think medical-legally if there was a problem you would have a good defense. Since the PDR states judicious use only, I think the lawyers with their twisted wording would find some way to convolute the truth. As for me, even though I know it is safe if administered correctly, I'll stick with the torniquet.
For me if the pacient have no historie of vascular disease why not the use of epinephrine? However, in Portugal and Spain podiatrists are not recomended to use it. We normaly use the torniquet. By the way i´m for Portugal.