Is Epinephrine Safe for Infant Digit Excision? A Retrospective Review of 402 Polydactyly Excisions in Patients Younger than 6 Months

Abstract

Background: Conventional dogma suggests that the use of local anesthetic with epinephrine is contraindicated in the digits because of fear of ischemia and necrosis. Although several reports have refuted this notion, the precept is still propagated in many clinical forums. For many years, the authors have used lidocaine with epinephrine to perform removal of postaxial polydactyly in infants and have observed few complications and no cases of digital ischemia or necrosis. This investigation details the authors’ outcomes with this anesthetic modality in neonates and supports the growing body of literature documenting the safety of using lidocaine with epinephrine in the digits. Methods: A retrospective review of all infants younger than 6 months who underwent preaxial and postaxial polydactyly excision and removal of their sequelae of the hand or foot under local anesthesia, from 2011 to 2017, was completed. All demographic characteristics, frequency of complications, and descriptive statistics of the sample clinical group were documented. Results: In the 215 patients who met inclusion criteria, a total of 402 procedures were performed. Mean follow-up was 19.9 months for 140 patients, or 264 procedures (65.7 percent). The total complication rate was 2.6 percent. There were two cases of minor bleeding, one wound dehiscence, and four surgical-site infections. Conclusions: In 402 procedures of surgical excision of polydactyly in infants, there were few short-term complications, none of which were necrosis or any vascular complication related to the use of epinephrine. The authors believe that, with the use of a low-dose epinephrine injection (1:200,000), the risk for digital infarction is low in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Local Anesthetics With Dilute Epinephrine in Extremity Surgery, Including New Evidence for Pediatric Population

“…Although there is substantial evidence in the literature supporting the safe use of epinephrine with local anesthetics in the extremities of adult patients, there has not been a similar amount of research published related to the pediatric patient population. The results of a recent pediatric study documenting the safe use of lidocaine with epinephrine for extremity surgery in infants—a vulnerable population at a higher risk for adverse drug events—correlate with the adult patient research study results …”

“…The surgeons reviewed 402 surgeries in 215 patients who were less than six months old in which 0.5% lidocaine with dilute epinephrine (1:200,000) was used for a digital nerve block on the ulnar side of the hand before removing the extra digit(s). The researchers found no adverse effects related to ischemia after use of lidocaine with dilute epinephrine . Anecdotally, pediatric surgeons have reported safe use of local anesthetics with epinephrine on extremities with no adverse ischemic effects (Gary F. Rogers, MD JD, LLM, MBA, MPH; verbal communication; November 23, 2018).…”

“…The results of a recent pediatric study documenting the safe use of lidocaine with epinephrine for extremity surgery in infants-a vulnerable population at a higher risk for adverse drug events-correlate with the adult patient research study results. 17 A group of pediatric plastic and reconstructive surgeons at an urban pediatric teaching hospital completed a retrospective review of outcomes after a local anesthetic with epinephrine was used in infants undergoing surgery for polydactyly between December 2011 and August 2017. 17 The surgeons reviewed 402 surgeries in 215 patients who were less than six months old in which 0.5% lidocaine with dilute epinephrine (1:200,000) was used for a digital nerve block on the ulnar side of the hand before removing the extra digit(s).…”

“…17 A group of pediatric plastic and reconstructive surgeons at an urban pediatric teaching hospital completed a retrospective review of outcomes after a local anesthetic with epinephrine was used in infants undergoing surgery for polydactyly between December 2011 and August 2017. 17 The surgeons reviewed 402 surgeries in 215 patients who were less than six months old in which 0.5% lidocaine with dilute epinephrine (1:200,000) was used for a digital nerve block on the ulnar side of the hand before removing the extra digit(s). The researchers found no adverse effects related to ischemia after use of lidocaine with dilute epinephrine.…”

“…The researchers found no adverse effects related to ischemia after use of lidocaine with dilute epinephrine. 17 Anecdotally, pediatric surgeons have reported safe use of local anesthetics with epinephrine on extremities with no adverse ischemic effects (Gary F. Rogers, MD JD, LLM, MBA, MPH; verbal communication; November 23, 2018).…”