Lidocaine with Epinephrine CAN and SHOULD Be Used on Fingers and Toes
The traditional teaching that lidocaine with epinephrine should not be used on digits is an outdated myth that has been thoroughly debunked by modern evidence. The American Academy of Dermatology gives a Level A (strongest) recommendation for the addition of epinephrine to local anesthesia on digits, including fingers and toes, based on high-quality evidence 1.
Why the Old Teaching Was Wrong
The historical concern was that epinephrine would cause vasospasm in "end arteries" leading to digital necrosis 2. However, this fear was based on:
- Case reports from the early 1900s that did not involve lidocaine - a review of 48 reported cases of finger necrosis from 1880-2000 found most were from the first half of the 20th century, and none actually involved lidocaine 2
- Theoretical concerns rather than actual clinical evidence 2
- Confounding factors such as excessive injection volume, infected fingers, or poor baseline circulation 2
Current Evidence Supporting Safety
Multiple systematic reviews and randomized controlled trials have conclusively demonstrated safety with NO cases of necrosis reported 1, 3:
- Over 250,000 procedures on feet, hands, fingers, and toes using lidocaine with epinephrine without resulting necrosis 2
- More than 10,000 surgical procedures on ears and nose (also considered "end artery" sites) without complications 4
- Doppler studies show that while epinephrine causes temporary vasoconstriction, blood flow returns to normal within 60-90 minutes and is never completely blocked 5, 4
Clinical Benefits of Using Epinephrine in Digits
Adding epinephrine provides significant advantages 1, 3, 6:
- Prolongs anesthetic duration by approximately 200% 3, 7
- Reduces bleeding during surgery (risk ratio 0.35, meaning 65% reduction in bleeding) 6
- Eliminates need for tourniquets 1, 3
- Provides a bloodless operating field, reducing operative time and need for electrocautery 1, 4
- Reduces peak blood levels of lidocaine, decreasing systemic toxicity risk 1, 3
Recommended Technique
- Use the lowest effective concentration of epinephrine: typically 1:100,000 or 1:200,000 1, 7
- Buffer with sodium bicarbonate to reduce injection pain 1
- Aspirate before injection to avoid intravascular administration 7
Important Caveats
While epinephrine is safe for digits in general, exercise caution in specific situations 2:
- Infected fingers or toes - infection may compromise already marginal circulation 2
- Pre-existing poor circulation (e.g., severe peripheral vascular disease, Raynaud's syndrome) - one case of gangrene was reported in a patient with Raynaud's syndrome 2
- Patients on nonselective beta-blockers or tricyclic antidepressants - potential drug interactions with epinephrine 8
The bottom line: Lidocaine with epinephrine is not only safe but actually preferred for digital blocks in most patients, offering superior anesthesia duration and surgical conditions compared to plain lidocaine.