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Emerg Med J. 2007 November; 24(11): 789–790.
PMCID: PMC2658331

Epinephrine in digital nerve block

Epinephrine in digital nerve block

Report by P P Mohan, Research Fellow, Gastrointestinal Surgery

Checked by P T Cherian, Specialist Registrar, Hepatobiliary Surgery

Good Hope Hospital NHS Trust, Sutton Coldfield, University Hospital Birmingham, UK.

Abstract

A short cut review was carried out to establish whether epinephrine (adrenaline) is safe to use in digital nerve blocks. A total of 16 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are presented in table 22.. The clinical bottom line is that epinephrine (1:200 000 to 1:100 000) is safe to use in digital blocks.

Table thumbnail
Table 2

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 “Anesthesia”[MeSH] OR “Anesthesia, Local”[MeSH]) OR “Nerve Block”[MeSH] AND “Epinephrine”[MeSH] AND “Fingers”[MeSH].

Outcome

Sixteen papers were retrieved, of which seven were found to be relevant, including two randomised control trials, three observational studies and two reviews (table 22).

Comments

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.

Clinical 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

  • Sylaidis P, Logan A. Digital blocks with adrenaline. An old dogma refuted. J Hand Surg (Br) 1998;23:17-19. [PubMed]
  • Wilhelmi B J, Blackwell S J, Miller J. et al. Epinephrine in digital blocks: revisited. Ann Plast Surg 1998;41:410-4. [PubMed]
  • Wilhelmi B J, Blackwell S J, Miller J H. et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg 2001;107:393-7. [PubMed]
  • Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001;108:114-24. [PubMed]
  • Altinyazar H C, Ozdemir H, Koca R. et al. Epinephrine in digital block: color Doppler flow imaging. Dermatol Surg 2004;30(4 Pt 1):508-11. [PubMed]
  • Krunic A L, Wang L C, Soltani K. et al. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol 2004;51:755-9. [PubMed]
  • Andrades P R, Olguin F A, Calderon W. Digital blocks with or without epinephrine. Plast Reconstr Surg 2003;111:1769-70. [PubMed]

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