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Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal
CASE REPOSITORY
Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal Andy F. Zhu, MD,* Brandon R. Hood, MD,* Mark S. Morris, MD,* Kagan Ozer, MD*
The use of low-dose epinephrine in hand surgery has made it possible to perform a wide range of surgical procedures in the office setting. Low-dose epinephrine use is safe, and its vasoconstrictive effects are reversible with phentolamine. In this report, we present late-onset finger ischemia beginning 3 hours after an ipsilateral carpal tunnel and A1 pulley release of the middle finger anesthetized with local anesthetic and low-dose epinephrine (1:100,000). Finger ischemia lasted 14 hours until rescued with phentolamine injection. (J Hand Surg Am. 2017;-(-):1.e1-e4. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Anesthesia, carpal tunnel syndrome, digital ischemia, epinephrine, phentolamine.
T
in hand surgery has gained popularity because it provides excellent hemostasis, which eliminates the need for a tourniquet, sedation, and the risks and costs associated with sedation and general anesthesia.1 Procedures performed under low-dose epinephrine are safe, as confirmed in a large multicenter study, demonstrating no instance of digital tissue loss or infarction and no case requiring the injection of phentolamine, an a-blocking agent.2 In cases in which finger ischemia lasts more than an hour after the procedure, it is recommended to use phentolamine to reverse the vasoconstrictive effects of epinephrine. HE USE OF LOW-DOSE EPINEPHRINE
From the *Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. Received for publication November 13, 2016; accepted in revised form January 9, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kagan Ozer, MD, Department of Orthopaedic Surgery, University of Michigan, 2098 South Main St., Ann Arbor, MI 48103; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.01.006
We present a case of low-dose (1:100,000) epinephrine-induced digit ischemia that was successfully reversed with phentolamine administration. CASE REPORT A right-handed 65-year-old woman nonsmoker presented with symptoms consistent with bilateral carpal tunnel syndrome and stenosing tenosynovitis of the right middle finger. The diagnosis of carpal tunnel syndrome was confirmed with physical examination and nerve conduction studies. Her comorbidities included coronary artery disease previously requiring 4 stent placements. The patient elected to undergo an in-office surgery for both right carpal tunnel release and right A1 pulley release of the middle finger. A solution of 10 mL 1% lidocaine and 10 mL 0.25% bupivacaine with epinephrine (1:100,000) was injected between the 2 surgical sites, around the right carpal tunnel and right middle finger A1 pulley as previously described.3 In the palm, injections were given directly under the skin, above the flexor tendon sheath; in line with the third ray and distal palmar crease. The injections were given at 8:00 AM. Both surgeries were
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
EPINEPHRINE AND DIGITAL ISCHEMIA
performed 30 minutes following the injections without complications. The patient tolerated the procedure well and left the office at 10:00 AM displaying pink digits with 2 seconds of capillary refill as confirmed by the attending hand surgeon (K.O.). Reportedly around 10:30 AM, the patient began to notice the first signs of circulatory compromise in her middle finger with a slightly dusky appearance at the tip of the digit. At 8:30 PM, 10 hours after discharge, the patient contacted the hospital and forwarded a picture of her hand, demonstrating a dusky-appearing middle finger distal to the proximal interphalangeal joint (Fig. 1). She was instructed to report to the emergency department immediately. On arrival at 10:30 PM, the patient continued to have numbness in the median nerve distribution with decreased capillary refill of the middle finger (Fig. 2A). At 10:35 PM, the patient received 1.5 mg of phentolamine in 1 mL of 2% lidocaine at the base of the proximal phalanx of the right middle finger. The hand was placed in warm blankets with heat packs and a diagnostic vascular ultrasound (DVU) scan was ordered. At 11:30 PM, 1 hour after phentolamine injection, the finger demonstrated marked improvement in color (Fig. 2B). At 12:00 AM, 1.5 hours after phentolamine injection, return of circulation was complete, although residual numbness remained (Fig. 2C). Diagnostic vascular ultrasound scan demonstrated normal digital pressures and waveforms. Further inquiry revealed a history of cold intolerance during winter months with her fingers occasionally turning blue. The patient was discharged on a 5-day course of 20 mg of verapamil. At her 3-week follow-up, the patient reported complete resolution of the sensory disturbance in the median nerve distribution and requested to have surgery for her left carpal tunnel syndrome. This time, surgery was performed with a wrist tourniquet and the same local anesthetic agents (5 mL 1% lidocaine with 5 mL 0.25% bupivacaine) were used without epinephrine. The patient tolerated the procedure well with no signs of circulatory compromise.
FIGURE 1: Dusky-appearing middle finger distal to the proximal interphalangeal joint at 8:30 PM, 12.5 hours after injection.
satisfaction is high, with studies showing that over 85% of patients would prefer wide-awake surgery when undergoing another surgery in the future and 90% of patients would recommend the procedure to a friend.4,5 Benefits to the provider include active participation and assessment during the procedure along with decreased costs and increased efficiency compared with performing the same procedure in the operating room.6,7 Wide-awake hand procedures achieve hemostasis in the operative field through injection of epinephrine, thus circumventing the need for a tourniquet and either general or regional anesthesia typically required for tourniquet pain. Epinephrine is a nonselective agonist of adrenergic receptors. When injected locally, epinephrine causes vasoconstriction of blood vessels in the skin and subcutaneous tissue providing improved hemostasis and prolonged anesthetic duration. The use of epinephrine as an adjunct to control bleeding in hand surgery has become increasingly popular because its safety has been well established in large clinical studies and because historical complications previously attributed to epinephrine have been proven to be due to other factors.2,8e11 In a large, prospective multicenter trial involving over 3,100 patients
DISCUSSION Performing basic hand procedures in the wide-awake patient under local anesthesia in the office setting has become increasingly popular. This setup offers many advantages to both patients and providers. From a patient perspective, there is typically no required preoperative visit, a shorter visit time, less preoperative anxiety, decreased narcotic need, and avoidance of general anesthesia and its after effects.4 Patient J Hand Surg Am.
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Vol. -, - 2017
EPINEPHRINE AND DIGITAL ISCHEMIA
FIGURE 2: A Dusky-appearing middle finger at 10:30 PM, 14.5 hours after procedure. B Marked improvement in color at 11:30 hour after phentolamine injection. C Return of normal color at 12:00 AM, 1.5 hours after phentolamine injection.
undergoing elective hand, finger, and combined procedures with low-dose epinephrine ( 1:100,000) injections, no cases required use of a reversal agent, like phentolamine.2 Nonetheless, relative contraindications for the use of epinephrine in finger surgeries include vasoconstrictive disorders, thrombotic disorders, and previously replanted digits.10 When indicated, phentolamine is the agent of choice to reverse the vasoconstrictive effects of epinephrine. Phentolamine is an a-blocker that has been shown to effectively reverse the effects of epinephrine.8,12 A prospective, randomized study conducted by Nodwell and Lalonde8 demonstrated an average time to return to normal color of 85 minutes after phentolamine injection compared with 320 minutes after saline injection in an epinephrine-injected finger. Although there have been no reports of phentolamine rescue required in low-dose epinephrine injections, there have been multiple reports of phentolamine reversal for accidental, high-dose of epinephrine (1:1,000) injection into the finger from Epi-Pen (Dey Laboratories, Napa, CA). Review of the literature revealed 59 cases of Epi-Pen injections into the digit.12 Of the 27 cases treated, 13 patients were treated solely with phentolamine and 2 patients with phentolamine in combination with nitropaste. Phentolamine was the most commonly used treatment and appeared to have the most success in reversing the effects of epinephrine. It is important to note that no tissue loss or permanent sequelae occurred in the 32 cases without treatment. Our case is unique in that there was a delayed onset of digital ischemia following low-dose epinephrine injection. Studies evaluating the effects of low-dose epinephrine injections in the finger have all demonstrated immediate digital pallor with spontaneous J Hand Surg Am.
1.e3
PM,
1
resolution on average 6 hours after injection.8,12 In our patient, the onset of signs of ischemia was delayed until 2.5 hours after injection and persisted well over 10 hours along with associated numbness and decreased capillary refill. It is possible that her history of cold intolerance may have been consistent with a cold weathereinduced triggering of a vasospastic reaction because the temperature outside was 39 F on that day. The digit may also have been ischemic owing to the volume injected for trigger finger. Although injection was given directly under the skin, 8 mL was injected, twice the volume previously recommended.13 In conclusion, physicians using epinephrine in office procedures should be aware of late-onset digital ischemia and be prepared to offer phentolamine rescue treatment. REFERENCES 1. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011;38(4):761e769. 2. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30(5):1061e1067. 3. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am. 2013;38(10):2025e2028. 4. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47e53. 5. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective of wide-awake hand surgery—100 consecutive cases. J Hand Surg Eur Vol. 2013;38(9):992e999. 6. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010;126(3):941e945. 7. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada. Hand (N Y). 2007;2(4):173e178.
r
Vol. -, - 2017
1.e4
EPINEPHRINE AND DIGITAL ISCHEMIA
11. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010;126(6):2031e2034. 12. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated? Hand (N Y). 2007;2(1):5e11. 13. Lalonde DH. Trigger finger. In: Lalonde DH, ed. Wide Awake Hand Surgery. Boca Raton, FL: CRC Press; 2015:145e148.
8. Nodwell T, Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: The Dalhousie project experimental phase. Can J Plast Surg. 2003;11(4):187e190. 9. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001;108(1):114e124. 10. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119(1):260e266.
J Hand Surg Am.
r
Vol. -, - 2017
Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal Andy F. Zhu, MD,* Brandon R. Hood, MD,* Mark S. Morris, MD,* Kagan Ozer, MD*
The use of low-dose epinephrine in hand surgery has made it possible to perform a wide range of surgical procedures in the office setting. Low-dose epinephrine use is safe, and its vasoconstrictive effects are reversible with phentolamine. In this report, we present late-onset finger ischemia beginning 3 hours after an ipsilateral carpal tunnel and A1 pulley release of the middle finger anesthetized with local anesthetic and low-dose epinephrine (1:100,000). Finger ischemia lasted 14 hours until rescued with phentolamine injection. (J Hand Surg Am. 2017;-(-):1.e1-e4. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Anesthesia, carpal tunnel syndrome, digital ischemia, epinephrine, phentolamine.
T
in hand surgery has gained popularity because it provides excellent hemostasis, which eliminates the need for a tourniquet, sedation, and the risks and costs associated with sedation and general anesthesia.1 Procedures performed under low-dose epinephrine are safe, as confirmed in a large multicenter study, demonstrating no instance of digital tissue loss or infarction and no case requiring the injection of phentolamine, an a-blocking agent.2 In cases in which finger ischemia lasts more than an hour after the procedure, it is recommended to use phentolamine to reverse the vasoconstrictive effects of epinephrine. HE USE OF LOW-DOSE EPINEPHRINE
From the *Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. Received for publication November 13, 2016; accepted in revised form January 9, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kagan Ozer, MD, Department of Orthopaedic Surgery, University of Michigan, 2098 South Main St., Ann Arbor, MI 48103; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.01.006
We present a case of low-dose (1:100,000) epinephrine-induced digit ischemia that was successfully reversed with phentolamine administration. CASE REPORT A right-handed 65-year-old woman nonsmoker presented with symptoms consistent with bilateral carpal tunnel syndrome and stenosing tenosynovitis of the right middle finger. The diagnosis of carpal tunnel syndrome was confirmed with physical examination and nerve conduction studies. Her comorbidities included coronary artery disease previously requiring 4 stent placements. The patient elected to undergo an in-office surgery for both right carpal tunnel release and right A1 pulley release of the middle finger. A solution of 10 mL 1% lidocaine and 10 mL 0.25% bupivacaine with epinephrine (1:100,000) was injected between the 2 surgical sites, around the right carpal tunnel and right middle finger A1 pulley as previously described.3 In the palm, injections were given directly under the skin, above the flexor tendon sheath; in line with the third ray and distal palmar crease. The injections were given at 8:00 AM. Both surgeries were
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
EPINEPHRINE AND DIGITAL ISCHEMIA
performed 30 minutes following the injections without complications. The patient tolerated the procedure well and left the office at 10:00 AM displaying pink digits with 2 seconds of capillary refill as confirmed by the attending hand surgeon (K.O.). Reportedly around 10:30 AM, the patient began to notice the first signs of circulatory compromise in her middle finger with a slightly dusky appearance at the tip of the digit. At 8:30 PM, 10 hours after discharge, the patient contacted the hospital and forwarded a picture of her hand, demonstrating a dusky-appearing middle finger distal to the proximal interphalangeal joint (Fig. 1). She was instructed to report to the emergency department immediately. On arrival at 10:30 PM, the patient continued to have numbness in the median nerve distribution with decreased capillary refill of the middle finger (Fig. 2A). At 10:35 PM, the patient received 1.5 mg of phentolamine in 1 mL of 2% lidocaine at the base of the proximal phalanx of the right middle finger. The hand was placed in warm blankets with heat packs and a diagnostic vascular ultrasound (DVU) scan was ordered. At 11:30 PM, 1 hour after phentolamine injection, the finger demonstrated marked improvement in color (Fig. 2B). At 12:00 AM, 1.5 hours after phentolamine injection, return of circulation was complete, although residual numbness remained (Fig. 2C). Diagnostic vascular ultrasound scan demonstrated normal digital pressures and waveforms. Further inquiry revealed a history of cold intolerance during winter months with her fingers occasionally turning blue. The patient was discharged on a 5-day course of 20 mg of verapamil. At her 3-week follow-up, the patient reported complete resolution of the sensory disturbance in the median nerve distribution and requested to have surgery for her left carpal tunnel syndrome. This time, surgery was performed with a wrist tourniquet and the same local anesthetic agents (5 mL 1% lidocaine with 5 mL 0.25% bupivacaine) were used without epinephrine. The patient tolerated the procedure well with no signs of circulatory compromise.
FIGURE 1: Dusky-appearing middle finger distal to the proximal interphalangeal joint at 8:30 PM, 12.5 hours after injection.
satisfaction is high, with studies showing that over 85% of patients would prefer wide-awake surgery when undergoing another surgery in the future and 90% of patients would recommend the procedure to a friend.4,5 Benefits to the provider include active participation and assessment during the procedure along with decreased costs and increased efficiency compared with performing the same procedure in the operating room.6,7 Wide-awake hand procedures achieve hemostasis in the operative field through injection of epinephrine, thus circumventing the need for a tourniquet and either general or regional anesthesia typically required for tourniquet pain. Epinephrine is a nonselective agonist of adrenergic receptors. When injected locally, epinephrine causes vasoconstriction of blood vessels in the skin and subcutaneous tissue providing improved hemostasis and prolonged anesthetic duration. The use of epinephrine as an adjunct to control bleeding in hand surgery has become increasingly popular because its safety has been well established in large clinical studies and because historical complications previously attributed to epinephrine have been proven to be due to other factors.2,8e11 In a large, prospective multicenter trial involving over 3,100 patients
DISCUSSION Performing basic hand procedures in the wide-awake patient under local anesthesia in the office setting has become increasingly popular. This setup offers many advantages to both patients and providers. From a patient perspective, there is typically no required preoperative visit, a shorter visit time, less preoperative anxiety, decreased narcotic need, and avoidance of general anesthesia and its after effects.4 Patient J Hand Surg Am.
r
Vol. -, - 2017
EPINEPHRINE AND DIGITAL ISCHEMIA
FIGURE 2: A Dusky-appearing middle finger at 10:30 PM, 14.5 hours after procedure. B Marked improvement in color at 11:30 hour after phentolamine injection. C Return of normal color at 12:00 AM, 1.5 hours after phentolamine injection.
undergoing elective hand, finger, and combined procedures with low-dose epinephrine ( 1:100,000) injections, no cases required use of a reversal agent, like phentolamine.2 Nonetheless, relative contraindications for the use of epinephrine in finger surgeries include vasoconstrictive disorders, thrombotic disorders, and previously replanted digits.10 When indicated, phentolamine is the agent of choice to reverse the vasoconstrictive effects of epinephrine. Phentolamine is an a-blocker that has been shown to effectively reverse the effects of epinephrine.8,12 A prospective, randomized study conducted by Nodwell and Lalonde8 demonstrated an average time to return to normal color of 85 minutes after phentolamine injection compared with 320 minutes after saline injection in an epinephrine-injected finger. Although there have been no reports of phentolamine rescue required in low-dose epinephrine injections, there have been multiple reports of phentolamine reversal for accidental, high-dose of epinephrine (1:1,000) injection into the finger from Epi-Pen (Dey Laboratories, Napa, CA). Review of the literature revealed 59 cases of Epi-Pen injections into the digit.12 Of the 27 cases treated, 13 patients were treated solely with phentolamine and 2 patients with phentolamine in combination with nitropaste. Phentolamine was the most commonly used treatment and appeared to have the most success in reversing the effects of epinephrine. It is important to note that no tissue loss or permanent sequelae occurred in the 32 cases without treatment. Our case is unique in that there was a delayed onset of digital ischemia following low-dose epinephrine injection. Studies evaluating the effects of low-dose epinephrine injections in the finger have all demonstrated immediate digital pallor with spontaneous J Hand Surg Am.
1.e3
PM,
1
resolution on average 6 hours after injection.8,12 In our patient, the onset of signs of ischemia was delayed until 2.5 hours after injection and persisted well over 10 hours along with associated numbness and decreased capillary refill. It is possible that her history of cold intolerance may have been consistent with a cold weathereinduced triggering of a vasospastic reaction because the temperature outside was 39 F on that day. The digit may also have been ischemic owing to the volume injected for trigger finger. Although injection was given directly under the skin, 8 mL was injected, twice the volume previously recommended.13 In conclusion, physicians using epinephrine in office procedures should be aware of late-onset digital ischemia and be prepared to offer phentolamine rescue treatment. REFERENCES 1. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011;38(4):761e769. 2. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30(5):1061e1067. 3. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am. 2013;38(10):2025e2028. 4. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47e53. 5. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective of wide-awake hand surgery—100 consecutive cases. J Hand Surg Eur Vol. 2013;38(9):992e999. 6. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010;126(3):941e945. 7. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada. Hand (N Y). 2007;2(4):173e178.
r
Vol. -, - 2017
1.e4
EPINEPHRINE AND DIGITAL ISCHEMIA
11. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010;126(6):2031e2034. 12. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated? Hand (N Y). 2007;2(1):5e11. 13. Lalonde DH. Trigger finger. In: Lalonde DH, ed. Wide Awake Hand Surgery. Boca Raton, FL: CRC Press; 2015:145e148.
8. Nodwell T, Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: The Dalhousie project experimental phase. Can J Plast Surg. 2003;11(4):187e190. 9. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001;108(1):114e124. 10. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119(1):260e266.
J Hand Surg Am.
r
Vol. -, - 2017