A systematic review of the uses and contraindications of epinephrine in local anesthesia in the dermatologic setting

Transcription

1 A systematic review of the uses and contraindications of epinephrine in local anesthesia in the dermatologic setting Syril Keena Que, MD; James Whalen, MD University of Connecticut Health Center Department of Dermatology March 23, 2015

2 Background Epinephrine is a hormone and neurotransmitter that non-selectively binds to the alpha and beta adrenergic receptors. Epinephrine can be added to a local anesthetic to decrease the amount of bleeding and prolong the duration of local anesthesia by vasoconstricting blood vessels To our knowledge, there is no comprehensive review on the uses and relative contraindications of epinephrine in dermatologic surgery.

3 Methods A PubMed search of the National Library of Medicine database ( pubmed) was performed using the following search terms: epinephrine, lidocaine, dermatologic surgery, complications, pregnancy, digital anesthesia, grafts, flaps. Studies from the dermatologic, dental, and plastic surgery literature were used.

4 Results 14 papers detailing the use of epinephrine in digital or penile anesthesia 20 papers relating to epinephrine in flaps and grafts 7 papers about medical conditions in which epinephrine is contraindicated 2 papers about epinephrine in the pregnant patient 2 papers about patients with catecholamine hypersensitivity.

5 Epinephrine use on the digits or penis 0.5% lidocaine with 1:200,000 epinephrine is safe for digital or penile anesthesia and unlikely to cause necrosis (Firoz et al., 2009; Krunic et al., 2004). One exception is in patients with vasospastic or peripheral vascular disease (Ravindran et al., 2012).

6 Epinephrine use in flaps and grafts Epinephrine is generally safe to use for flaps and grafts but has resulted in lower survival when used in delayed flaps (Eley et al., 2012; Wu et al., 1978; Fazio et al., 1995; Wolfort et al., 1990). Epinephrine has been reported to cause flap necrosis if too high a volume of local anesthesia is injected.

7 Epinephrine in pregnant patients Generally the doses of epinephrine used in dermatologic surgery are safe in pregnant patients. Theoretically, higher doses of epinephrine can cause vasoconstriction of the uterine artery and decrease placental perfusion (Richards et al, 2002).

8 Epinephrine use in medical disease Caution recommended when using epinephrine in patients with severe cardiac disease, hyperthyroidism, or pheochromocytoma (Kaufman et al., 2002). Patients with autonomic neuropathy or severe spinal cord injury may require lower doses because of catecholamine hypersensitivity, a phenomenon known as denervation hypersensitivity (Frisbie et al., 2009; Bickel et al., 2002).

9 Medications that interact with epinephrine The following medications may also increase sensitivity to epinephrine by interacting with or potentiating the effects of epinephrine: Nonselective beta blockers MAO inhibitors Tricyclic antidepressants Phenothiazines

10 Conclusion In the scenarios mentioned above, epinephrine at a lower concentration (1:400,000 to 1:1,000,000) can still achieve effective vasoconstriction and may be safer for use in dermatologic surgery.

11 References Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine, dobutamine, and dopexamine effects on free flap skin blood flow. Plast Reconstr Surg Sep;130(3): Firoz B, Davis N, Fazio MJ, Zitelli JA. Full-thickness skin grafts. Clinical observations on the impact of using epinephrine in local anesthesia of the donor site. Arch Dermatol Jun;131(6): Goldberg LH. 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 Oct;61(4): Kaufman E, Garfunkel A, Findler M, Elad S, Zusman SP, Malamed SF, Galili D. [Emergencies evolving from local anesthesia]. Refuat Hapeh Vehashinayim Jan;19(1):13-8, 98. Hebrew. Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol Nov;51(5): Ravindran V, Rajendran S. Digital gangrene in a patient with primary Raynaud's phenomenon. J R Coll Physicians Edinb Mar;42(1):24-6. Richards KA, Stasko T. Dermatologic surgery and the pregnant patient. Dermatol Surg Mar; 28(3): Wolfort S, Rohrich RJ, Handren J, May JW Jr. The effect of epinephrine in local anesthesia on the survival of full- and split-thickness skin grafts: an experimental study. Plast Reconstr Surg Sep;86(3): Wu G, Calamel PM, Shedd DP. The hazards of injecting local anesthetic solutions with epinephrine into flaps: experimental study. Plast Reconstr Surg Sep;62(3):