Safe and Unsafe Locations for Epinephrine with Lidocaine
Epinephrine with lidocaine is safe and recommended for use on the ear, nose, hands, feet, and digits, with no absolute contraindications based on anatomic location—the historical dogma about "end arteries" causing necrosis has been thoroughly refuted by extensive research. 1
Safe Anatomic Locations (Level A Evidence)
The following locations are explicitly safe and recommended:
Ear, nose, hands, feet, and digits - The American Academy of Dermatology gives this an "A" strength recommendation based on Level I and II evidence, with multiple systematic reviews and randomized controlled trials demonstrating no cases of necrosis 1
Penis - May be considered safe for penile skin surgery, though evidence is more limited (Level B recommendation based on retrospective studies) 1
Over 10,000 surgical procedures on ears and nose using epinephrine-supplemented anesthesia showed zero complications related to tissue necrosis 2
A comprehensive literature review of 50 cases of digital gangrene found that none were causally related to commercial lidocaine-epinephrine mixtures—all cases involved other factors like cocaine, procaine, non-standardized mixing, tourniquets, hot soaks, or infection 3
Unsafe Injection Techniques (Not Locations)
The FDA explicitly warns against these injection methods:
Do NOT inject into buttock - Associated with Clostridial infections (gas gangrene) and may not provide effective treatment; alcohol cleansing does not kill bacterial spores 4
Do NOT inject into digits, hands, or feet via accidental intravascular injection - The FDA warning refers to accidental injection into blood vessels, not subcutaneous/intradermal infiltration which is safe 4
Do NOT give repeated injections at the same site - Resulting vasoconstriction may cause tissue necrosis 4
Patient-Specific Considerations
Stable Cardiac Disease (Safe with Precautions)
Patients with stable, controlled cardiovascular conditions can safely receive lidocaine with epinephrine:
This includes hypertension, ischemic heart disease, arrhythmia, chronic coronary disease, and heart transplantation (Level B recommendation) 1
Studies in dental surgery using 1.8-3.6 mL of lidocaine 2% with epinephrine 1:80,000 to 1:200,000 showed only minimal hemodynamic changes: 4.1% increase in systolic BP, 5.1% increase in heart rate, with no cardiac symptoms 5
A study of 32 patients with ischemic heart disease receiving 10 mL of 2% lidocaine with 1:100,000 epinephrine showed hemodynamic stability with no myocardial ischemic changes 6
If uncertain about cardiac stability, consult the patient's cardiologist before proceeding 1, 7
Uncontrolled Hypertension (Defer if Possible)
Defer elective procedures if systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg until hypertension is optimized 7
For urgent procedures, have intravenous antihypertensive agents immediately available (nicardipine, labetalol, or esmolol) 7
Have alpha-blockers (phentolamine) available for severe hypertension from epinephrine, NOT beta-blockers alone 7
Pregnancy (Use with Caution)
Small amounts of lidocaine with epinephrine may be used in pregnant women, but with specific precautions:
Postpone elective procedures until after delivery 1
Delay urgent procedures until the second trimester when possible 1
Epinephrine is FDA Pregnancy Category C, but in small amounts for local infiltration, the benefits of limiting systemic lidocaine absorption outweigh risks 1
Consult with the patient's obstetrician if uncertain 1
Other Medical Conditions (Use with Caution)
The FDA advises caution (but not contraindication) in:
Hyperthyroidism - May precipitate cardiac arrhythmias 4
Parkinson's disease - May cause psychomotor agitation or temporary worsening of symptoms 4
Diabetes mellitus - May cause transient increases in blood sugar 4
Pheochromocytoma - Risk of hypertensive crisis 4
Sulfite Allergy (Not a Contraindication)
Lidocaine with epinephrine contains sodium bisulfite, which may cause allergic reactions in susceptible individuals 4
However, sulfite sensitivity does not preclude its use in life-threatening or urgent situations, as alternatives may not be satisfactory 4
Optimal Dosing and Concentrations
Use the lowest effective concentration to minimize side effects:
Most commonly used concentrations: 1:100,000 and 1:200,000 1, 8, 9
Concentrations of 1:50,000,1:100,000, and 1:200,000 all provide similar vasoconstriction and prolong anesthetic duration by approximately 200% 1, 8, 9
Maximum safe dose for adults: 7.0 mg/kg of lidocaine with epinephrine (up to 490 mg or 49 mL of 1% solution for a 70 kg adult) 8, 7
Lower concentrations (1:800,000 to 1:3,200,000) prolong duration by only 100% and may offer less effective vasoconstriction 1
Critical Safety Precautions
Always follow these safety measures:
Aspirate before each injection to avoid intravascular administration 8, 10
Inject slowly in incremental doses while continuously monitoring for early signs of toxicity 8, 7, 10
Buffer with sodium bicarbonate (1:9 or 1:10 ratio) to reduce injection pain—this is a Level A recommendation 1, 8, 7
Avoid using within 4 hours of other local anesthetic interventions to prevent cumulative toxicity 8, 7
Have 20% intravenous lipid emulsion immediately available as the primary antidote for local anesthetic systemic toxicity 7
Common Pitfalls to Avoid
Do not withhold epinephrine based on outdated dogma about "end arteries"—extensive research has refuted concerns about necrosis in digits, ears, nose, hands, and feet 7, 3, 11
Do not use bupivacaine in cardiac patients—it is most frequently implicated in cardiovascular collapse and cardiac arrest 7
Do not exceed maximum dosing limits—always calculate total dose before injection based on patient weight 8, 7
Do not use isolated beta-blockade for epinephrine-induced hypertension—this can precipitate pulmonary edema and cardiac arrest; use alpha-blockade first or combined alpha-beta blockade (labetalol) 7