What procedures should lidocaine with epinephrine (adrenaline) be used for?

Lidocaine with Epinephrine: Recommended Procedures

Lidocaine with epinephrine is safe and recommended for a wide variety of office-based dermatologic procedures, including skin biopsies, excisions, wound closures, tissue rearrangements, skin grafting, cauterization, nonablative laser procedures, and ablative skin resurfacing. 1

Recommended Procedures and Applications

• Skin biopsies, excisions, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing can all be successfully performed using lidocaine with epinephrine 1
• Full-face ablative laser resurfacing (combined with topical and nerve block anesthesia) 1
• Follicular unit hair transplantation (combined with tumescent local anesthesia) 1
• Procedures on digits, hands, and feet (contrary to historical concerns about terminal vessel vasoconstriction) 1, 2
• Procedures on the ear and nose 1, 3
• Procedures on the penis (with appropriate caution) 1

Anatomical Considerations

• Digits (fingers and toes): Multiple systematic reviews and randomized controlled trials have demonstrated that adding epinephrine to local infiltrative anesthesia is safe for use in digits 1, 4

  • No cases of necrosis were reported in studies, and epinephrine use resulted in less need for tourniquets 1
  • Buffered 0.5% lidocaine with 1:200,000 epinephrine has been used safely in digits even in patients with circulatory disorders, diabetes, hypertension, or those on anticoagulation 2

• Ear and nose: Safe for use in these areas with no reported complications in over 10,000 surgical procedures 3

  • Results in a relatively bloodless operating field and longer effectiveness of local anesthesia 3
  • Decreases operative time and need for electrocautery hemostasis 1

• Penis: May be considered for penile procedures, with a single retrospective study showing no anesthetic-related complications 1

Dosing Recommendations

• For adults: Maximum 7.0 mg/kg of lidocaine with epinephrine in a single treatment 1
• For children: Maximum 3.0-4.5 mg/kg of lidocaine with epinephrine in a single treatment 1
• For multistage procedures (e.g., Mohs micrographic surgery): Maximum 50 mL of 1% lidocaine solution (500 mg) delivered over several hours 1

Optimal Epinephrine Concentration

• Concentrations of 1:50,000,1:100,000, and 1:200,000 all have similar effects on vasoconstriction 1, 5
• These concentrations prolong anesthetic duration by approximately 200% 1
• Use the lowest effective concentration to minimize potential side effects like palpitations and anxiety 1, 5
• For facial injections, no significant differences were found between 1:100,000 and 1:200,000 epinephrine combined with lidocaine 6

Special Populations

• Patients with stable cardiac disease: Local infiltrative anesthesia with epinephrine may be administered to patients with stable cardiac disease 1

  • If uncertain about a patient's ability to tolerate epinephrine, consult with the patient's cardiologist 1

• Pregnant women: Small amounts appear safe, but elective procedures should be postponed until after delivery 1

  • Urgent procedures should be delayed until the second trimester when possible 1
  • For large amounts of anesthesia, consultation with the patient's obstetrician is recommended 1

Safety Precautions

• Use the lowest effective dose of local anesthetic 1
• Aspirate the needle/catheter prior to each injection to avoid intravascular injection 1
• Use incremental injections of anesthetic 1
• Continually assess and communicate with the patient to monitor for signs of early toxicity 1
• For patients with multiple comorbidities that may predispose them to epinephrine-induced vasospasm, consider having phentolamine available as a rescue medication 7

Timing Considerations

• For optimal hemostatic effect, incisions should be delayed for approximately 8 minutes in the face and 10 minutes in the forearm following lidocaine with epinephrine injection 6

Alternatives for Lidocaine-Allergic Patients

• Ester-type local anesthetics (cross-reaction between amide and ester types is rare) 1
• Bacteriostatic normal saline (0.9% benzyl alcohol in normal saline) 1
• 1% diphenhydramine (longer onset of action and limited efficacy) 1