Low-dose epinephrine shows no digital infarction

Surgeons found no need for phentolamine rescue in more than 3000 consecutive cases.

Injecting low-dose epinephrine into fingers and hands may not prove as dangerous as previously believed, new Canadian research suggests.

A study of 3110 consecutive cases injected with a small dose of adrenaline (1:100,000 or less) found no cases of tissue death from lack of oxygen. “We did not find a single case with digital infarction and, just as importantly, not one patient required phentolamine rescue,” said Donald H. Lalonde, MD, who presented the results at the Joint Annual American Society for Surgery of the Hand/American Society for Hand Therapists Meeting.

The results dispute 21 cases that occurred before 1950, which linked epinephrine with digital infarction. The previous studies proved invalid because patients were also injected with phentolamine, “which killed more fingers without epinephrine than with epinephrine before 1950,” said Lalonde, a plastic surgeon at St. John Regional Hospital in Canada. The surgeons also used outdated phentolamine, which had a pH level of 1, he noted.

The new research gathered two-year data from nine surgeons in six cities. The surgeons had injected epinephrine in elective hand and finger procedures, including tendon transfers, basal joint arthroplasties and 99 flexor tendon repairs. They were prepared to reverse vasoconstriction using phentolamine if necessary.

Watching intraoperative movement

In addition to demonstrating no digital infarction, epinephrine allowed patients to remain alert during surgery. “Dupuytren's patients do not have to suffer general anesthesia problems,” Lalonde said. “They just sit up at the end of the case and then go home like they're going to the dentist.”

This allows surgeons to watch patients move after a repair, but before skin closure. The benefit: finding flaws and adjusting repairs without additional visits. For example, Lalonde's flexor tendon repair showed no gap at rest, “until we asked the patient to move. Then the gap appeared,” he said.

“In complicated reconstructions, I've been able to watch active movement rupture extension tendon sutures, which has guided me to reposition them in the right place,” Lalonde said. Additionally, surgeons can compare ranges of motion between operated and non-operated limbs. “You can also compare active flexion in both thumbs to make sure that the tendon transfer isn't too tight,” he said.

For more information:
Lalonde DH, Bell MS, Denkler K, et al. A multicenter prospective study of 3110 consecutive cases of elective Epinephrine use in the fingers and hand. #PSA07. Presented at the Joint Annual ASSH/ASHT Meeting. Sept. 22-24, 2005. San Antonio, Texas.