Anatomical Locations Where Lidocaine with Epinephrine Should Be Avoided for Incision and Drainage
Based on current evidence, there are essentially NO anatomical locations where lidocaine with epinephrine must be avoided for incision and drainage procedures—the historical prohibition against using epinephrine in digits, ears, nose, and penis has been thoroughly refuted by modern research. 1, 2, 3, 4
The Outdated "End-Artery" Myth
The traditional teaching that epinephrine causes necrosis in areas with "end arteries" (fingers, toes, nose, ears, penis) is not supported by evidence and should be abandoned. 1, 2, 3
A comprehensive literature review examining over 15,000 patients found zero cases of necrosis when using commercial lidocaine with epinephrine in digits, toes, noses, and ears since its introduction in 1948. 3, 4
The American Academy of Dermatology provides Level A (strongest) evidence supporting the use of epinephrine with lidocaine on digits, with benefits including prolonged anesthesia (200% longer duration), reduced bleeding, and elimination of tourniquet need. 1, 2, 5
True Contraindications Based on FDA Labeling
The only absolute contraindication from FDA labeling is avoiding injection into the buttock, as this has been associated with Clostridial infections (gas gangrene) and may not provide effective treatment. 6
Specific High-Risk Injection Sites to Avoid:
Buttock: Risk of gas gangrene from Clostridial spores; alcohol cleansing does not kill spores. 6
Avoid repeated injections at the same site: Resulting vasoconstriction may cause tissue necrosis from cumulative effect. 6
Important Safety Precautions (Not Contraindications)
Technique-Related Warnings:
Prevent extravasation during IV administration: If blanching occurs along the vein, change infusion sites to prevent superficial slough and tissue necrosis. 6
Aspirate before injection: Always aspirate to ensure you're not in a blood vessel, particularly in highly vascular areas. 7, 2
Use lower doses in vascular tissues: When injecting into highly vascular areas, reduce the standard dose. 7
Maximum Safe Dosing:
Adults: Maximum 7.0 mg/kg of lidocaine with epinephrine (up to 490 mg or 49 mL of 1% solution for a 70 kg adult). 7, 1, 2
Children: Maximum 3.0-4.5 mg/kg; for infants under 6 months, decrease amide doses by 30%. 7, 1
Avoid cumulative toxicity: Do not use lidocaine with epinephrine within 4 hours of other local anesthetic interventions. 1, 2
Clinical Advantages for Incision and Drainage
Epinephrine provides superior hemostasis, which improves visualization of the surgical field and reduces procedure time. 1, 2
The vasoconstriction slows systemic absorption, reducing peak blood levels and toxicity risk while extending anesthesia duration from 90-200 minutes. 7, 1
Use concentrations of 1:100,000 or 1:200,000 epinephrine for optimal balance of vasoconstriction and safety. 1, 2
Common Pitfalls to Avoid
Don't withhold epinephrine from digits based on outdated teaching—this deprives patients of better hemostasis and longer anesthesia. 1, 4
Monitor for early toxicity signs: Circumoral numbness, facial tingling, metallic taste, tinnitus, slurred speech. 1, 2
Have phentolamine available: Though extremely rare, epinephrine-induced vasospasm can be reversed with 5-10 mg phentolamine infiltrated into the affected area within 12 hours. 6, 8
Buffer with sodium bicarbonate (1:9 or 1:10 ratio) to reduce injection pain without compromising effectiveness. 1, 2