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A Critical Look at the Evidence for and against Elective Epinephrine Use in the Finger

Thomson, Christopher J. M.D.; Lalonde, Donald H. M.D.; Denkler, Keith A. M.D.; Feicht, Anton J. Ph.D.

Plastic and Reconstructive Surgery: January 2007 - Volume 119 - Issue 1 - p 260-266
doi: 10.1097/01.prs.0000237039.71227.11

Background: Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery.

Methods: All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger.

Results: The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue.

Conclusions: The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.

Halifax, Nova Scotia, and Saint John, New Brunswick, Canada; and Larkspur, Calif.

From the Division of Plastic Surgery, Dalhousie University, Halifax and Saint John; Department of Plastic Surgery, University of California at San Francisco; and Department of Physical Sciences, University of New Brunswick Saint John.

Received for publication February 22, 2005; accepted May 5, 2005.

Presented at the Atlantic Society of Plastic Surgeons Annual Meeting, in Digby, Nova Scotia, September of 2004.

Donald H. Lalonde, M.D., Dalhousie University, Hilyard Place, Suite A280, 560 Main Street, Saint John, New Brunswick, E2K 1J5 Canada,

©2007American Society of Plastic Surgeons