Epinephrine-Containing Digital Nerve Block: A Case of Digital Tip Necrosis Leading to Amputation in a Patient With No Known Vascular, Rheumatologic, or Smoking History

Digital necrosis following combined liquid nitrogen and candida antigen therapy for digital warts

“…However, the most likely explanation for the observed necrosis in this situation involves the interaction between cryotherapy and lidocaine-epinephrine injection, as reported by Hong et al 6 in a patient with no underlying autoimmune disease or smoking. According to the Pfenninger Candida Protocol, lidocaine is meant to be administered without epinephrine during Candida injection.…”

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery

“…Although recent case reports of digital necrosis after lidocaine with epinephrine administration [54][55][56][57][58][59] renewed safety concerns for some, critical appraisal suggests that factors other than epinephrine contributed substantially to these untoward events. In some cases, patient-related risk factors, such as underlying Raynaud phenomenon 54,57 or atherosclerosis 56 , were unrecognized contraindications to using local anesthesia with epinephrine (Table I).…”

“…In some cases, patient-related risk factors, such as underlying Raynaud phenomenon 54,57 or atherosclerosis 56 , were unrecognized contraindications to using local anesthesia with epinephrine (Table I). In other cases, a suboptimal injection technique, including insufflation of the flexor sheath instead of the palmar fat 58 or administration of too much volume sufficient to tamponade digital blood flow 59 , resulted in an adverse outcome. Perhaps most commonly, patients may inadvertently burn their own anesthetized fingers by submerging them in hot water attempting to “get their feeling back,” an embarrassing self-inflicted adverse event which few patients are likely to admit 4,58 .…”

“…In the unlikely event of persistent ischemia for 6 hours or more after epinephrine-containing digital block, the alpha-antagonist phentolamine may be injected into the finger to reliably reverse the vasoconstriction in approximately 85 minutes 63,64 . Phentolamine rescue, which was not attempted in any case of digital necrosis previously cited [54][55][56][57][58][59] , should be available whenever the WALANT technique is used. In this context, the proposed "Stop Before You Block" initiative 65 to rule out contraindications to epinephrine due to compromised peripheral circulation and to confirm the availability, dosage, and location of phentolamine may be a useful tool for hand surgeons (Table II).…”