a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
"Adrenaline should never be injected into the finger, becauseof the gangrene that frequently results." This affirmation,which appears in Bunnel's textbook Surgery of the hand (1956),serves to demonstrate the extent to which adrenaline in asso-ciation with a local anesthetic has been rejected for handsurgery.1Despite studies showing that the true cause of digi-tal gangrene is not adrenaline, such as the work by Thomson,2the myth revolving around the causal relationship betweenadrenaline and necrosis persists until today.It is important to break down this dogma, because themethod most used for maintaining the operative field freefrom blood (pneumatic tourniquets) may cause difficulties,given that patients can only tolerate this for short periods, ofless than 30 min on average.3Thus, greater sedation is neededand the pneumatic tourniquet has to be deflated, with a waitbefore inflating it again so as to avoid complications such asischemia and muscle dysfunction, along with other possiblecomplications.
Use of adrenaline provides the advantages of a faster startand longer duration of anesthesia, a longer-lasting surgicalfield without blood, without interruptions, and a lower con-centration of anesthesia for achieving pain control.5Thismakes it possible to perform the surgery with a lower dosageof sedatives and also facilitates certain surgical procedures,such as tenolysis and tenorrhaphy, thus demonstrating theintraoperative efficacy of adrenaline.
6With the aim of demonstrating the various advantages ofusing lidocaine with adrenaline in hand surgery, given the lackof evidence of occurrences of digital necrosis in the literature,and also because of the impressive strength of this dogmain our setting and the scarcity of this subject in the Brazil-ian literature, we decided to conduct this study in order todemonstrate the safety and efficacy of this method in handsurgery.
We chose to always have an anesthetist present duringour surgical procedures, which were all performed in a sur-gical center. Thus, our study differed from those conducted in other countries, without an anesthetist and with proceduresdone in an outpatient environment, which we judged not tobe applicable to our country, because of the legislation and thebehavior of our patients in the light of the situation of tensionthat the procedures involve.
Methods
Starting on July 6, 2012, patients at our institution and in pri-vate hospitals underwent the method.
Patients undergoing surgery as a result of complications(for example, recurrence of carpal tunnel syndrome or syno-vial cysts), or who presented poor peripheral perfusion beforethe surgery, histories of vascular diseases or contraindicationsto anesthetics, were excluded.
The solution used was 1% lidocaine with adrenalineat 1:100,000. The standard was the solutions described byLalonde,6who used them in cases in which less than 50 mLwas necessary. We used flasks of 20 mL of 1% lidocaine andadded 0.2 mL of adrenaline to obtain the solution. If a greatervolume is necessary, Lalonde recommends that the concentra-tions should be more diluted (Table 1), with a view to maintaina safety limit for lidocaine with adrenaline of less than 7 mg/kgof weight.
Initially, we infiltrated the desired area after putting thefields into place, although in a few cases we did the infiltra-tion before placing the fields, in order to make the processmore dynamic. We observed that the ideal time for startingto make the incision was at least 15 min later, when the skinhad already undergone a change in coloration in the area ofthe incision, becoming lighter in tone (more whitish), therebyleaving the field exsanguinated and anesthetized in order toperform the planned surgical procedure. At the time of infil-tration, all the patients were under sedation and were beingmonitored by the anesthetist. We had the substance phen-tolamine available, in case it was necessary to reverse anysituation of severe ischemia that might develop. The dose tobe used would be 1 mg in 1 mL of 0.9% physiological serum.
We developed a standardized evaluation form to cover allthe cases and broach a variety of parameters, as described inAnnex 1.
The form began with the date and type of surgery and thepatient's identification. Following this, preoperative data wereevaluated.
Bleeding during the operation was addressed in accordancewith a scale created by our group, graded thus: 3 - excessivebleeding (halting progress in the operation unless a tourniquetwas used); 2 - moderate (making it difficult but not impossibleto continue without using a tourniquet); and 1 - minimal(bleeding similar to that of surgery with a tourniquet).
Use of bipolar tweezers: yes or no; if positive, this wasgraded as 1 - minimal, 2 - normal or 3 - excessive.
Use of a tourniquet was assessed in terms of situations inwhich the tourniquet had to be inflated during the surgery.
Intraoperative pain was assessed according to the patient,the anesthetist (in terms of alterations of vital signs, for exam-ple) and the surgeon (in terms of the patient's reactions), andgraded as intense, moderate, minimal or absent.
Systemic alterations were evaluated by the anesthetist bydescribing alterations to vital signs, neurological signs or anyclinical intercurrences.
The other parameters, which were self-explanatory, can beseen in Annex 1.
Regarding the infiltration technique in cases of carpal tun-nel syndrome, we first infiltrated about 10 mL, at around 4 cmproximal to the wrist flexion crease, in parallel with the ulnarborder of the long palmar tendon, when present, under thefascia of the forearm, in order to bathe the space betweenthe median and ulnar nerves (Fig. 1A). Around another 10 mLof the solution was injected into the incision site, advancingslowly without letting the needle go beyond 3-4 mm of thewhite tumescent subcutaneous tissue (Fig. 1B and C).
In cases of trigger finger, around 4 mL of the solution wasinjected into the fat under the center of the incision. The A1pulley was released and the patient was able to view activefinger movements that were made intraoperatively (Fig. 1D).
In the operations on fingers, anesthesia was applied at thebase, on the midline and in the digital palmar crease, whichcould be complemented distally (Fig. 2A-C).
In cases of Quervain's tendinopathy, 10 mL of the solu-tion was injected proximally and also into the tendon sheath(Fig. 2D and E).
In cases of Dupuytren's contracture, a greater volume(10 mL) was injected into the most proximal locality of theincision that was to be made, and then the remainder wasinjected into the incision site in the hand and fingers.
In the other cases, the locality of the incision was infiltratedproximally to distally. According to Lalonde,6if the locality ofthe incision does not undergo infiltration, it will bleed morethan the area infiltrated with adrenaline.
Results
We operated on 41 patients (18 men and 23 women). Of these,18 underwent surgical treatment for carpal tunnel syndrome.In two of these cases, this was done in association with surgical treatment for trigger finger. Six patients underwentsurgical treatment for trigger finger (seven fingers). The othercases can be seen in Table 2.
There was one case that we have described separately,in which we performed an additional application of thetechnique. This consisted of raising a lateral microsurgicalfasciocutaneous flap from the arm, with accompanying skinof dimensions 9 cm × 6 cm, which was transferred to cover anarea of tumor resection on the contralateral hemiface, with-out using a pneumatic cuff. The patient was under generalanesthetic and it was possible to raise the flap and dissect the6 cm length of the posterior collateral radial vascular pediclewithout additional difficulty and within the usual length oftime for obtaining a flap. We have not placed the data on thispatient with the data on the other patients because this woulddistort the data, given that the other surgical procedures wereof much smaller proportions.
The patients' mean age was 52 years (range: 15-81); themean waiting time between the infiltration and the incisionwas 15 min (range: 2-30); the mean duration of the surgerywas 40 min (range: 10-150); and the mean volume of solu-tion infiltrated was 14.6 mL (range: 4-20) for the conventionalprocedures and 80 mL into the lateral flap of the arm. Bipo-lar tweezers were not used in 12 patients, minimally usedin 16, normally used in 10 and excessively used in three.
The bleeding was minimal in 32 cases, moderate in six andexcessive in three. Two of these cases of excessive bleedingcomprised patients with chronic kidney failure, in surgicaltreatments for carpal tunnel syndrome ipsilateral to the fis-tula.
In none of the cases was the procedure interrupted due tobleeding.
In all of the cases, the skin color had altered at the time ofinjecting the solution.
In none of the cases were there any signs of arterial deficit,intraoperative pain or significant systemic alterations. Norwas it necessary to introduce ischemia using a pneumatictourniquet.
In two cases, there was a need for infiltration during thesurgical procedure, at a deep level or in a cutaneous area thathad not been envisaged in the initial infiltration.
As a complication, there was one case of injury to adigital nerve during fasciectomy, in surgical treatment forDupuytren's contracture. This was treated by means ofmicroneurorrhaphy during the same surgical procedure.
There were no cases of necrosis, hematoma or any otherpostoperative complication.
The data are described individually in Table 3.
Discussion
Prohibition of use of local anesthetics together withadrenaline for digital blocks is a surgical tradition.7Most text-books refer to the theory that the vasoconstriction induced byadrenaline leads to ischemia and necrosis.8In the book Green'sOperative Hand Surgery - 5th edition,9in relation to use ofadrenaline for digital blocks, the authors write: "to avoid com-promising the blood supply to the fingers, adrenaline shouldnot be used for digital blocks". However, in the 6th edition,10the authors of the chapter "Anesthesia for Hand Surgery" citethe prospective randomized controlled trial by Wilhelmi, on 60patients, in which there were no complications in any patientin either of the groups, prolonged pain control was achievedand there was lower bleeding and lower need for tourniquet use during the procedure in the group with adrenaline (withlidocaine at 1:200,000).
Fitzcharles-Boweet et al.11reported that 59 cases of acci-dental injection of adrenaline at 1:1000 into fingers inautoinjectors had been described in the worldwide literatureand that there had not been a single case of finger necro-sis. The authors also injected solutions of 1:1000, 1:10,000 and1:100,000 into their own fingers and there were no complica-tions. One case of accidental injection of adrenaline at 1:1000was reversed efficiently using phentolamine.12
There are descriptions in the literature of 48 cases ofdigital gangrene associated with adrenaline use with localanesthetic, and a study analyzing each of these cases wasconducted.2Among the 21 patients in whom adrenaline wasused, procaine was used in 18, cocaine in two and an unknowndrug in one. In the cases without adrenaline, procaine was alsoused most frequently (13 out of 27), while an unknown drugwas used in eight cases (probably procaine, because of the dateof publication), cocaine was used in four cases, screen in onecase and water in one case.
Denkler7also analyzed all these cases and showed thatmuch of the information was incomplete, regarding the useand concentrations of adrenaline, use of hot immersion baths(which caused burns in 14 cases), tourniquets, tight dress-ings, infections (11 cases) or preexisting medical conditions.In only four of the 21 cases that involved adrenaline was theconcentration of the solution described.
Lalonde et al.13conducted a prospective multicenter studyin which nine hand surgeons in six cities prospectivelyreported their consecutive cases of injection of lidocaine andadrenaline at concentrations of 1:100,000 or lower, into handsand fingers. This resulted in 3110 patients without any typeof finger tissue loss. In none of these cases was phento-lamine necessary for reversing the vasoconstriction of thefingers.
The study by Nodwell and Lalonde14demonstrated thatphentolamine reliably reversed the vasoconstriction in the fin-gers caused by adrenaline, in an average time of one hour and25 min.
Chowdhry et al.8reported a retrospective study consist-ing of 1111 cases of hand and finger surgery, among which611 cases received blocks of 1% lidocaine with adrenaline(1:100,000), without any complications of necrosis.
Sönmez et al.15published a randomized controlled study inwhich blood gas parameters at the fingertips were comparedwith and without use of adrenaline, and found that there wasno statistically significant difference.
Manne and Hammert16reported that they routinely usedlidocaine with adrenaline because of its safety, given thatit decreased the need to use tourniquets and sedation andreduced the costs, as well as making it possible to evaluate therange of motion in tenorrhaphy and tenolysis procedures. Italso increased the duration of the analgesic effect and dimin-ished the need for opioids after the operation.
We did not find any studies that reported the use ofadrenaline and lidocaine in hand surgery in the Brazilian liter-ature, after investigating in the Revista Brasileira de Ortopedia(www.rbo.org.br), SciELO Brazil (www.scielo.br) and BIREME(www.bireme.br), which further motivated us towards con-ducting this study and future studies on this technique.
In our study, there were no cases of postoperative necrosisor hematoma among the 41 procedures. In no case did we haveto use phentolamine to reverse the effects of the ischemia.
In the first three cases, we waited only two minutesbetween the anesthesia and the incision. Although excellentischemia was obtained in the first two of these cases, abun-dant bleeding occurred in the third case, which stopped atthe end of the procedure. Following this case, we then estab-lished a minimum of 10 min and subsequently 15 min. As away of maintaining a minimum waiting time so as to allow theeffect of the adrenaline to begin, we started to apply the anes-thetic before placing the surgical fields. Through this action,we started to achieve a better ischemic effect. The interval of15 min was sufficient in the majority of the situations. In mostcases (28), bipolar tweezers were either not used or minimallyused.
One possible complication resulting from this bleed-ing, even if diminished, has been inadvertent sectioning ofthe finger nerve when performing fasciectomy in cases ofDupuytren's contracture. According to Lalonde, this surgeryis one of the most difficult procedures to perform using thismethod, because of the close proximity of the finger's vessels.6
6In the two cases of patients with chronic kidney failure whounderwent surgical treatment for carpal tunnel syndromeipsilateral to the fistula, there was excessive bleeding, whichmade the procedure difficult to perform.
Our study had some limitations. There was no controlgroup; we still only have a small number of cases avail-able; and no statistical analysis was performed on the data.Nonetheless, we conducted an initial prospective study andobtained good results from this series, with good ischemiaand anesthesia, without any complications relating tonecrosis.
Another noteworthy point was that the solution was suc-cessfully used to raise a lateral flap on one patient's armin the absence of blood, without using a pneumatic cuff. In original technique, a sterile cuff is installed high on thearm, but this was not possible here because the hospital hadtechnical difficulty in sterilizing the tourniquet. The patientunderwent general anesthesia so that a malignant tumoron the opposite hemiface could be resected by a head andneck surgeon. The microsurgical anastomoses of the poste-rior collateral pedicle were performed on branches of the facialvessels, with a lumen of 2.5 mm, using 10.0 mononylon thread.The surgery was performed taking the normal time and usingnormal methods, without harm to the vascular pedicle afterinjection of the solution, which was distributed at deep levelsaround the humerus and in the subcutaneous tissue, in thearea of the cutaneous and subfascial incision.the
A bibliographic survey was conducted through theCAPES periodicals website (www.periodicoscapes.gov.br) andPubMed (www.pubmed.com), and we did not find any sci-entific studies that made specific use of adrenaline orlidocaine-adrenaline solution for replacing the pneumaticcuff in surgery of the extremities that would enable discussion.
Conclusions
Use of lidocaine with adrenaline in hand surgery, at a concen-tration of 1:100,000 or less, was shown to be a safe techniquefor local anesthesia, without complications relating to necro-sis or systemic absorption. Moreover, it provided a surgicalfield that was efficiently exsanguinated, thereby making itpossible to perform the surgical procedures without using apneumatic tourniquet, which avoided the potential risks oftourniquets and provided the benefit to patients of less seda-tion.
Conflicts of interest
The authors declare no conflicts of interest.
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