From the Guidelines
Lidocaine with epinephrine should be used when prolonged anesthesia and reduced bleeding are desired, such as in longer surgical procedures, dental work, or when operating in highly vascular areas, but avoided in end-arterial areas and patients with severe cardiovascular disease. The use of lidocaine with epinephrine is recommended for dermatologic procedures, including those on the ear, nose, hands, feet, and digits, as it provides prolonged anesthesia and reduced bleeding without increasing the risk of skin necrosis 1. However, its use in end-arterial areas, such as fingers, toes, nose, ears, and penis, is generally contraindicated due to the risk of ischemia and tissue necrosis. In patients with stable cardiac disease, the use of lidocaine with epinephrine is considered safe, but consultation with a cardiologist is recommended if there is uncertainty about the patient's ability to tolerate epinephrine 1. Pregnant women can receive lidocaine with epinephrine in small amounts, but elective procedures should be postponed until after delivery, and urgent procedures should be delayed until the second trimester whenever possible 1. The maximum safe dose of lidocaine with epinephrine is 7 mg/kg, which is higher than that of plain lidocaine (4.5 mg/kg), due to the slower systemic absorption and reduced toxicity risk provided by epinephrine 1. Some key points to consider when using lidocaine with epinephrine include:
- Typical concentrations: 1% or 2% lidocaine with epinephrine 1:100,000 or 1:200,000
- Contraindications: end-arterial areas, severe cardiovascular disease, uncontrolled hypertension, hyperthyroidism, and patients taking MAOIs or tricyclic antidepressants
- Precautions: pregnant women, patients with stable cardiac disease, and those with a history of bee venom allergy if hyaluronidase is used as an additive
- Maximum safe dose: 7 mg/kg for lidocaine with epinephrine, and 4.5 mg/kg for plain lidocaine.
From the Research
Use of Lido with Epi
- The use of lidocaine with epinephrine (lido with epi) is a common practice in local anesthesia, particularly in dental and surgical procedures 2, 3, 4, 5, 6.
- The addition of epinephrine to lidocaine can help to prolong the duration of anesthesia and reduce bleeding at the surgical site 2, 5.
When to Use Lido with Epi
- Lido with epi can be used for surgical extraction of impacted mandibular third molars, as it has been shown to be effective and safe in this context 2.
- It can also be used for other surgical procedures, such as eyelid surgery, although the pain scores may be higher compared to lidocaine alone 6.
- In patients with controlled hypertension, lido with epi can be used, but with careful monitoring and aspiration, and not exceeding the maximum epinephrine dose of 0.04mg 4.
When Not to Use Lido with Epi
- In hemodynamically unstable patients, 2% lidocaine with 1:200,000 epinephrine may be preferred over 2% lidocaine with 1:80,000 epinephrine due to better safety with regard to hemodynamic parameters 2.
- The use of epinephrine may increase subjective pain scores, so it may not be suitable for patients who are sensitive to pain or have a history of anxiety or fear of needles 6.
Considerations
- The concentration of epinephrine can affect the efficacy and safety of lido with epi, with higher concentrations potentially causing more significant hemodynamic changes 2, 4.
- The pH value of the anesthetic solution can also affect the pain scores, with more acidic solutions potentially causing more pain 6.
- The addition of other agents, such as bupivacaine, to lido with epi can affect the onset and duration of anesthesia, as well as the pain scores 6.