In a patient undergoing Nexplanon removal who is tachycardic (initial heart rate 130 bpm, repeat 111–116 bpm), should I use lidocaine without epinephrine instead of lidocaine with epinephrine to avoid further increasing heart rate?

Use Lidocaine WITH Epinephrine for Nexplanon Removal in This Tachycardic Patient

The small dose of epinephrine in local anesthetic (typically 1-2 mL of 1% lidocaine with 1:100,000 or 1:200,000 epinephrine) for Nexplanon removal poses minimal cardiovascular risk and is safe to use even in this tachycardic patient. 1, 2

Why Epinephrine is Safe in This Clinical Scenario

Minimal Systemic Absorption from Small Volume Infiltration

• For a simple Nexplanon removal, you'll use approximately 1-3 mL of local anesthetic, which contains only 10-30 mcg of epinephrine (with 1:100,000 concentration) 1, 2
• This tiny dose produces negligible systemic cardiovascular effects compared to the body's endogenous epinephrine release from anxiety or pain 3
• The maximum safe dose of lidocaine with epinephrine is 7.0 mg/kg in adults, so even 3 mL of 1% solution (30 mg lidocaine) is far below toxic thresholds for any adult patient 1, 4

Evidence from Cardiovascular Disease Patients

• A study of 27 patients with established cardiovascular disease (including NYHA class I-III heart failure) showed that 1.8 mL of 2% lidocaine with 1:80,000 epinephrine caused only minimal hemodynamic changes: heart rate increased by just 5.1% and systolic blood pressure by 4.1% 3
• No patients experienced cardiac symptoms or adverse events despite having compromised cardiac function 3
• If epinephrine is safe in patients with documented heart disease, it is certainly safe in your patient whose tachycardia may simply reflect anxiety about the procedure 3

The Real Concern: What's Causing the Tachycardia?

Evaluate Before Proceeding

Before focusing on the anesthetic choice, address the underlying cause of tachycardia:

• Anxiety/pain anticipation: Most likely cause in a young patient presenting for a minor procedure 3
• Hyperthyroidism: Check for tremor, heat intolerance, weight loss
• Dehydration/hypovolemia: Check orthostatic vital signs
• Fever/infection: Check temperature
• Medications: Stimulants, decongestants, bronchodilators
• Substance use: Caffeine, energy drinks, other stimulants

When to Defer the Procedure

• If heart rate remains >120 bpm after reassurance and rest
• If patient has chest pain, dyspnea, or other concerning cardiac symptoms
• If you identify an acute medical condition requiring treatment 5

Benefits of Using Epinephrine That Outweigh Theoretical Risks

Hemostasis and Visualization

• Epinephrine provides superior hemostasis, making the Nexplanon easier to visualize and remove 2, 6
• Reduced bleeding decreases procedure time and patient discomfort 2

Prolonged Anesthesia Duration

• Epinephrine extends lidocaine's duration from approximately 30-60 minutes to 90-200 minutes 2
• This provides better post-procedure analgesia 2

Lower Systemic Lidocaine Levels

• Vasoconstriction from epinephrine slows systemic absorption of lidocaine, reducing the risk of local anesthetic systemic toxicity (LAST) 2, 4
• This is the primary reason maximum doses are higher with epinephrine (7.0 mg/kg vs 4.5 mg/kg) 1, 4

Critical Safety Measures During the Procedure

Proper Injection Technique

• Always aspirate before injecting to confirm you're not in a blood vessel, as intravascular injection dramatically increases systemic effects 4, 5
• Inject slowly to allow time to detect early toxicity symptoms 4
• Use the smallest effective volume (typically 1-2 mL for Nexplanon removal) 1

Monitor for Local Anesthetic Toxicity

Early warning signs include 4:

• Circumoral numbness or facial tingling
• Metallic taste
• Tinnitus or auditory changes
• Lightheadedness or dizziness
• Slurred speech

Have Resuscitation Equipment Available

• The FDA label mandates that "resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use" when administering any local anesthetic 5
• For office-based procedures, this means having oxygen, suction, and emergency medications accessible 5

Common Pitfalls to Avoid

Don't Confuse Anxiety-Induced Tachycardia with a Contraindication

• Baseline tachycardia from anxiety is extremely common before minor procedures 3
• The 10-30 mcg of epinephrine in your local anesthetic is far less than what the patient's adrenal glands are already releasing from procedure-related stress 3

Don't Use Plain Lidocaine When Epinephrine Would Be Safer

• Without epinephrine, you have worse hemostasis, shorter anesthesia duration, and paradoxically higher risk of systemic lidocaine toxicity due to faster absorption 1, 2
• The theoretical concern about epinephrine raising heart rate is not supported by clinical evidence at the doses used for local infiltration 3

Don't Inject Near Blood Vessels

• The upper arm has relatively few major vessels in the subcutaneous space where Nexplanon sits, but always aspirate before injecting 4, 5
• Inadvertent intravascular injection can cause immediate cardiovascular effects including arrhythmias, though this is rare with proper technique 7, 8

Specific Contraindications to Epinephrine (None Apply Here)

The FDA label states epinephrine-containing solutions "should be used cautiously and in carefully circumscribed quantities in areas of the body supplied by end arteries" 5. However:

• The upper arm is not an end-artery territory 2
• Historical concerns about epinephrine in digits have been thoroughly debunked by modern evidence 2
• True contraindications are limited to patients taking nonselective beta-blockers or tricyclic antidepressants (due to drug interactions), or those with severe uncontrolled hypertension 6

Practical Approach for This Patient

1. Reassure the patient and allow 5-10 minutes of rest to see if heart rate decreases
2. Recheck vital signs after reassurance
3. Proceed with lidocaine 1% with epinephrine 1:100,000 or 1:200,000 using 1-2 mL for infiltration 1, 2
4. Aspirate before injecting and inject slowly 4, 5
5. Monitor the patient during and after the procedure for any signs of toxicity 4

The evidence overwhelmingly supports using lidocaine with epinephrine for this procedure, as the cardiovascular effects from the tiny dose of epinephrine are clinically insignificant compared to the procedural benefits. 1, 2, 3