Home Medizin Bigfoot, Bermudadreieck, „Kein Lido mit Epi“?

Bigfoot, Bermudadreieck, „Kein Lido mit Epi“?

von NFI Redaktion

According to Thomas Ehlers, DPM, in Podologie Heute, „Fingers, toes, ears, and nose are places where adrenaline never reaches.“ He mentioned hearing this during his podiatry training and various visits throughout his education.

However, Ehlers added that adrenaline has a bad reputation. The catchy saying has proven to be a myth over time.

Why do many doctors believe that the combination of adrenaline and lidocaine is taboo for surgical procedures on fingers and other poorly perfused areas? Despite medical students being taught to fear this practice and warn of the risk of gangrene, the evidence does not support its harmful reputation.

Lack of Sensation Does Not Care About Your Facts

The debate resurfaced in response to a recent column in Medical News from Medscape by Kenny Lin, MD, MPH, a family physician and assistant director at Lancaster General Hospital Family Medicine Residency in Pennsylvania, on the rather mundane topic of why he no longer performs nail surgery. Lin’s admission that he used to use a combination of adrenaline and lidocaine for the procedure sparked a lot of comments, many of which were sharply critical of the practice:

Kenneth Lin
Kenny Lin, MD

„Adrenaline is not a suitable drug for podiatry or use in marginal areas. Gangrene?“ one commentator posted.

„Avoid using Epi with lidocaine on fingers, toes, nose, and earlobes,“ wrote another.

„No Lido with Epi, whether contraindicated or not, because if there is a negative outcome, a lawyer will find plenty of indications that it was contraindicated,“ chimed in a reader.

Other commentators disagreed, saying, „Please, people, don’t show that you trained 50 years ago and haven’t changed since…“

For Lin, the reaction was surprising as he believes there is no evidence of the alleged dangers.

„When I think about it, it’s something that was taught to me during my residency – that they should not be used in certain areas,“ said Lin. „But since then, studies have been conducted looking at thousands of cases of people using adrenaline together with lidocaine, and no cases of necrosis have been reported.“

Many doctors, like Lin, say they were cautioned about it during their training. Others can’t recall exactly where they heard it, but acknowledge that the idea has had an unclear impact on practice.

The combination of adrenaline with lidocaine helps prolong anesthesia, stop bleeding, and reduce the required use of lidocaine, ultimately improving the chances of an effective and comfortable procedure for the patient, said Lin. The approach also reduces the use of tourniquets, which are associated with risks such as nerve injuries.

However, in poorly perfused areas, this vasoconstrictive effect may be more pronounced, potentially leading to complications in patients with complicating factors.

Doctors who regularly use the combination of adrenaline and lidocaine for surgical procedures acknowledge that it may pose certain dangers and concerns in poorly perfused areas.

However, the literature largely points to its safety.

In 2001, California-based plastic and reconstructive surgeon Keith Denkler, MD, conducted a comprehensive review dating back to the 19th century, including a review of the Index Medicus from 1880 to 1966, a computer review of the National Library of Medicine database from 1966 to 2000, and key textbooks from 1900 to 2000.

He found a total of 48 cases of finger necrosis – most of which were attributable to the consumption of cocaine or procaine. Of the 48 cases, 21 involved the use of adrenaline, and 17 used an unknown concentration based on manual dilution.

„These case reports involved several concurrent conditions (hot soaks, tight tourniquets, and infections), making it difficult to determine the exact cause of tissue damage,“ Denkler wrote.

In a retrospective review in 2010 in the Journal of the American Society of Plastic Surgeons, the authors examined 1111 cases involving finger and hand surgery. None of the 611 patients who received injections of 1% lidocaine with adrenaline experienced digital necrosis.

In another review in 2003, the safety of the combination was emphasized in hopes of dispelling the myth that adrenaline has no place in podiatric anesthesia. However, the authors pointed out application restrictions, including „known hypersensitivity, thyrotoxicosis, and the use of tricyclic antidepressants or monoamine oxidase inhibitors.“

James Christina, DPM, executive director and CEO of the American Podiatric Medical Association, echoed this sentiment. He said he had regularly used the combination in his 20-year practice for correcting bunions, hammer toes, and ingrown toenails, but acknowledged that the technique may not be suitable for all patients.

„Caution has always been necessary when using adrenaline together with a local anesthetic,“ Christina told Medicine News from Medscape. „You need a healthy patient with normal circulation and no other complications; someone without vascular impairment.“

Marie Hanna, MD, MEHP, head of the Regional Anesthesia and Acute Pain Management department at Johns Hopkins University in Baltimore, Maryland, considers herself cautious. Citing Principles of Practice Anesthesia: Part I. Infiltrative Anesthesia, Hanna stated that adrenaline should never be used in finger and penile blocks or in skin flaps with marginal viability.

„In certain areas, like the wrist or arm, it’s perfectly fine,“ Hanna said. „But specifically for use in end organs like the nose, fingers, ears, and toes – all of which are poorly perfused – this is not good practice.“

The divide among doctors is more due to theoretical concerns than empirical evidence, said Rebecca Johnson, MD, chair of the Regional Anesthesia and Acute Pain Medicine Committee of the American Society of Anesthesiologists and a faculty member at the Mayo Clinic in Rochester, Minnesota.

„This is just one of those myths we have in practice,“ she said.

From a legal perspective, Johnson said, the mere existence of a myth can be deterrent enough for physicians: „When trying to do the right thing, you don’t want a jury of your peers to bring up that myth if a complication were to arise from another cause.“

The sources in this story reported no relevant financial conflicts of interest.

Lindsay Kalter is a freelance health journalist based in Ann Arbor, Michigan, and regularly contributes to Medscape Medical News.

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