Digital ischemia after lidocaine with epinephrine injection in a patient with primary Raynaud’s phenomena

Abstract

Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature supports the overall safety of this, significant physiologic changes accompanying epinephrine can disproportionately affect vascularly compromised patients, such as in Raynaud’s phenomenon. The literature is reviewed and a case presented regarding the dangers of epinephrine injection in this population.

Full text

CASE REPORT
Digital ischemia after lidocaine with epinephrine injection in a patient with
primary Raynaud’s phenomena
Colin T. McNamara and Mark Greyson
Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA
ABSTRACT
Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature sup-
ports the overall safety of this, significant physiologic changes accompanying epinephrine can
disproportionately affect vascularly compromised patients, such as in Raynaud’s phenomenon.
The literature is reviewed and a case presented regarding the dangers of epinephrine injection
in this population.
ARTICLE HISTORY
Received 28 June 2022
Accepted 21 August 2022
KEYWORDS
Epinephrine; digital block;
Raynaud’s; epidermolysis;
necrosis; finger
Introduction
Injection of lidocaine for analgesia has become com-
mon-place in surgery for the hand. The use of epi-
nephrine concomitantly has been of continued debate
since its inception due to the theoretic concern of
vasoconstriction leading to necrosis. Raynaud’s phe-
nomenon is a vasospastic condition affecting approxi-
mately 3–5% of the population [1] and divided into
primary Raynaud’s, which is idiopathic, and secondary,
which has an underlying cause. Both have decreased
arterial inflow in specific areas related to thermoregu-
lation and heightened sympathetic response [2]. Either
of these may exacerbate the effect of epinephrine in
the finger and leading to significant injury.
Here we present a case highlighting this potential
and review the existing literature on the use of epi-
nephrine for digital blocks, particularly in
this population.
Case
A 72 year-old, non-smoking female with a history of
hyperlipidemia, hypertension, heterozygous for Factor
V Leiden, deep venous thrombosis not on anticoagula-
tion, and a transient ischemic attack 10 years prior to
exam presented for triggering of her bilateral ring fin-
gers. No specific information regarding a history of
Raynaud’s phenomena was elicited prior to presenta-
tion for surgery. She was treated with corticosteroid
injections however seven months later she noted
recurrence and was diagnosed with Green’s grade 2
trigger finger of her right long finger. She desired sur-
gical intervention in wide-awake clinic. Analgesia was
obtained via 3 mL of 1% lidocaine with 1:100,000 epi-
nephrine injected directly over the A1 pulley. Five mL
of 0.25% Marcaine without epinephrine was injected
at the conclusion of the case in the same location.
Dressings were confirmed to be wrapped loosely at
the end of the procedure.
Patient called in that evening with swelling and
stating it had been white for the rest of the day. She
was advised to apply heat and noted temporary
improvement; however by the next morning she had
developed a large bulla at the tip of the finger. She
was promptly assessed in the clinic (Figure 1). The fin-
ger was warm and well perfused and the decision was
made not to inject phentolamine. The bullae were
fenestrated and daily dressing changes were per-
formed. After additional questioning she reported
vasospastic changes to her fingers after cold exposure
consistent with primary Raynaud’s phenomena. Over
the next 2 weeks her epidermolysis evolved and
sloughed (Figure 2). By 4 weeks the wounds were
healed however she had persistent stiffness and
CONTACT Mark Greyson Mark.Greyson@CUAnschutz.edu Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical
Center, 12631 E. 17th Ave, C309 (Room 6414), Aurora, 80045, CO, USA
This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government.
In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.
This is an Open Access article that has been identified as being free of known restrictions under copyright law, including all related and neighbouring rights (https://
creativecommons.org/publicdomain/mark/1.0/). You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY
2022, VOL. 9, NO. 1, 193–196
https://doi.org/10.1080/23320885.2022.2117702

difficulty with range of motion at her distal interpha-
langeal joint (Figure 3).
Discussion
Henrich Braun added epinephrine to cocaine in 1903
in order to create a ‘chemical tourniquet’and prolong
the anesthesia effect [3]. However he had persistent
concerns regarding the possibility of the vasoconstric-
tion leading to gangrene [4,5]. Initial case reports
seemed to validate this concern but on retrospective
review, of the 48 cases found before 1948, many used
procaine or cocaine (which can cause digital infarc-
tion) versus lidocaine, only 21 used epinephrine and
typically in unknown concentrations, and many had
concurrent risks including using hot soaks, infection
and tight tourniquets [4,6]. Since 1948 and the cre-
ation of commercially available combination lidocaine
and epinephrine products, there have been very few
reported complications and numerous retro- and pro-
spective studies that emphasize the safety of epineph-
rine use in the digits of the hand and foot [6]. Even in
the cases of high dose (1:1000) epi-pen accidental
injection to the digits, many of whom were not
treated with phentolamine, none developed perman-
ent sequaele [7–9].
A number of physiologic studies have also been
performed that indicate the epinephrine creates only
transient vasoconstriction that returns to baseline
within several hours and typically within 1 h [10–13].
When examined closely however, these studies still
present findings that may be concerning when
applied to at-risk populations. Several articles have
found that after epinephrine injection there are
changes in distal oxygen saturation [13,14].
Moog et al. utilized an injection of 5–7mL of 1%
lidocaine with 1:200,000 epinephrine and continuously
monitored oxygenation. They showed significant
reductions of >30% in venous saturation occurred in
Figure 1. Bullous blisters on ring finger POD 1 from trigger
finger release.
Figure 2. POD 7 following fenestration of bullae and evolu-
tion of superficial wounds.
Figure 3. Healed wounds with persistent stiffness.
194 C. T. MCNAMARA AND M. GREYSON

7 of their 17 patients and critical levels (<10% sO
2
)in
4/17. All levels returned to normal within 30 min but
each decline had an average length of 132.5 s for a
total average length of 463 s per patient. The longest
patient had a total critical ischemia time of 684 s [14].
Alitinyazar et al. also showed in 4 out of their 24
patients that though vasoconstriction resolved in
60–90 min, 4 patients had no measurable flow by
Doppler at 10 min [12].
The majority of these prospective, retrospective and
physiologic studies exclude patients with vascular dis-
ease or compromise, which includes Raynaud’s phe-
nomenon. Given Raynaud’s phenomena patients have
been shown to have increased response to alpha
agonism [15] and an increased density of alpha recep-
tor levels [16], the alpha-agnosim of epinephrine may
result in longer critical ischemia and secondary injury.
Several case reports have been published that
emphasize this potential. Four cases of ischemic injury
are reported in the literature; in all of these, as with
ours, the diagnosis of primary Raynaud’s phenomenon
was discovered after the injury [17–20]. Two other
cases in the literature demonstrate digital ischemia
with a similar symptom sequence after epinephrine
injection although they do not explicitly state there
was a history of Raynaud’s or that there was specific
questioning regarding previous signs or symp-
toms [21,22].
All of the cases demonstrate that the ischemic
change happens remarkably quickly, with duskiness
proceeding to bullae or necrosis within hours. This
supports the hypothesis that although these ischemic
injuries may be brief, given their increased susceptibil-
ity it does not take significant injury to push them
into necrotic territory. Recovery in these cases was
mixed; some young, healthy patients required amputa-
tion and older, arteriosclerotic patients were able to
heal. Half of the patients, including our patient, were
older with hypertension, dyslipidemia and some level
of diagnosed arteriosclerosis. This may represent a
confounder or potentially a second hit hypothesis in
which risk is additive for vascular occlusion. In add-
ition, our patient was heterozygous for Factor V which
has been found to be a risk for large vein thrombosis
[23] but remains more unclear in the setting of micro-
vascular circulation or repair [24].
Anecdotally in this series patients improved with
vasodilatory therapy [18]. Only one patient was given
phentolamine but was noted to have marked improve-
ment afterward [19]. Phentolamine, a competitive
alpha-receptor antagonist, has been shown to reduce
the duration of epinephrine-induced vasoconstriction in
fingers [25] and its use is encouraged in cases of
extended vasoconstriction secondary to epinephrine.
Overall despite the evidence that epinephrine is
safe there are clear physiologic changes that accom-
pany injection, even in the vascularly normal patients
studied. This transient but potentially significant ische-
mic time combined with the pathophysiology of
Raynaud’s may increase the responsiveness to epi-
nephrine and lead to injury. We therefore encourage
excellent history and physical exam for signs or symp-
toms of Raynaud’s phenomenon in all patients under-
going digital blocks. We strongly caution against the
use of epinephrine in digital blocks for these patients
and the use of non-epinephrine analgesia such as
wide-awake anesthesia with a tourniquet if any con-
cern exists.
Disclosure statement
The authors did not receive any funding for this study. The
authors have no financial interests in any of the products or
techniques mentioned and have received no external sup-
port related to this study. The views expressed in this paper
are those of the authors and do not reflect the official policy
or position of the Department of the Navy, Department of
Defense, or the U.S. Government.
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