From the Guidelines
Lidocaine with epinephrine can be safely used for finger lacerations, contrary to the traditional teaching of "no epinephrine in fingers, toes, penis, nose, or ears." Modern evidence, as seen in the 2016 guidelines for the use of local anesthesia in office-based dermatologic surgery 1, has debunked this old medical myth. The standard concentration (typically 1% or 2% lidocaine with 1:100,000 epinephrine) is appropriate for digital blocks or local infiltration.
The benefits of using lidocaine with epinephrine for finger lacerations include:
- Reduced bleeding at the surgical site
- Longer duration of anesthesia (typically 4-6 hours versus 1-2 hours with plain lidocaine)
- The ability to use less lidocaine overall The epinephrine causes temporary vasoconstriction, which keeps the anesthetic localized longer and reduces systemic absorption.
However, caution should still be exercised in patients with peripheral vascular disease, and it should be avoided in fingers with compromised circulation. Always aspirate before injecting to avoid intravascular administration, and be aware that the onset of anesthesia typically takes 5-10 minutes. The maximum safe dose is 7 mg/kg of lidocaine with epinephrine (not to exceed 500 mg) 1.
It's worth noting that the use of epinephrine in small amounts is safe for dermatologic surgery, even in patients with stable cardiovascular disease, as demonstrated by studies in the dental literature 1. However, consultation with the patient’s cardiologist is recommended if there are concerns about the patient’s ability to safely undergo the procedure.
In summary, the use of lidocaine with epinephrine for finger lacerations is supported by modern evidence and can be safely used in most patients, with appropriate caution and consideration of individual patient factors.
From the FDA Drug Label
Local anesthetic solutions containing a vasoconstrictor should be used cautiously and in carefully circumscribed quantities in areas of the body supplied by end arteries or having otherwise compromised blood supply. Patients with peripheral vascular disease and those with hypertensive vascular disease may exhibit exaggerated vasoconstrictor response. Ischemic injury or necrosis may result
The use of lidocaine with epinephrine for a finger laceration is not recommended due to the risk of ischemic injury or necrosis in areas with compromised blood supply, such as the fingers.
- Key considerations:
- Risk of ischemic injury or necrosis
- Exaggerated vasoconstrictor response in patients with peripheral vascular disease or hypertensive vascular disease
- Use of local anesthetic solutions containing a vasoconstrictor in areas supplied by end arteries 2
From the Research
Safety of Lidocaine with Epinephrine for Finger Lacerations
- The use of lidocaine with epinephrine for finger lacerations has been a topic of debate due to concerns about potential necrosis or ischemia 3, 4, 5.
- However, several studies have shown that the risk of necrosis or ischemia is low when using lidocaine with epinephrine for finger lacerations 3, 4, 6.
- A review of literature found no evidence to support the warning against using lidocaine with adrenaline in fingers and toes 3.
- Another study found that the use of lidocaine with epinephrine in hand surgery is safe and effective, and offers several advantages, including a bloodless field and reduced need for conscious sedation 4.
Anesthetic Effectiveness of Lidocaine with Epinephrine
- The anesthetic effectiveness of lidocaine-adrenaline-tetracaine gel on finger lacerations has been studied, and found to be effective in providing adequate anesthesia for repair of finger lacerations 6.
- A prospective case series found that the overall success rate of lidocaine-adrenaline-tetracaine gel was 53.7%, with no signs of digital ischemia noted in any of the cases 6.
- Another study compared the anesthetic efficacy of lidocaine, epinephrine, and tetracaine (LET) solution with that of EMLA cream, and found that LET was more effective in providing anesthesia for lacerations 7.
Precautions and Considerations
- While the use of lidocaine with epinephrine for finger lacerations is generally considered safe, there are some precautions and considerations to be taken into account 5.
- Patients with certain comorbidities, such as Raynaud's syndrome, may be at higher risk of digital ischemia, and should be monitored closely 3, 5.
- Phentolamine rescue should be available to any provider using lidocaine with epinephrine in the hands and digits, in case of epinephrine-induced vasospasm 5.