Sir:
Chowdhry et al. have presented another 1111 cases of digital anesthetic procedures performed successfully using lidocaine with epinephrine.1 In addition to these cases, Lalonde et al. have prospectively studied 3110 cases of lidocaine with epinephrine in the hand without digital infarction.2 Together, these 4221 cases are a large number that should negate the traditional dogma against using epinephrine in the digits. Green's Operative Hand Surgery, published in 2011,3 considers the use of lidocaine with epinephrine in the digits “debatable,” so it appears that further effort is necessary to convince skeptics that the myth should be dead. The effort by Chowdhry et al. is to be commended. However, it is important to call attention to certain details in the article, so future readers do not echo them.
Hall and Halstead in 1884 are credited by many as the first to report nerve blocks with cocaine,4–6 though Burke reported his successful digital block 1 week before Hall.7 Between 1884 and 1891, there were 13 deaths reported with cocaine as a local anesthetic but not in the digit.8 Strauss9 in 1889 was the first to report gangrene as a complication of digital blocks with cocaine, although the Strauss article is known only as a secondary reference source by means of the 1933 article by Lambert and Snyers.10
Braun introduced epinephrine, not ephedrine, in 1903 by the addition of suprarenin extracts to solutions of cocaine.11 Braun described this mixture as a “chemical tourniquet,” retarding absorption of the local anesthetic and prolonging its effect, a feature much appreciated by surgeons. Thank you, Dr. Chowdhry and colleagues, for continuing the fight for the use of epinephrine, a very useful adjunct to wide-awake hand surgery that uses a chemical tourniquet rather than a mechanical tourniquet.
Keith A. Denkler, M.D.
Department of Surgery
University of California, San Francisco
275 Magnolia Avenue
Larkspur, Calif. 94939-2067
[email protected]
REFERENCES
1. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: Myth or truth? Part II. A retrospective review of 1111 cases.
Plast Reconstr Surg. 2010;126:2031–2034.
2. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: The Dalhousie Project clinical phase.
J Hand Surg Am. 2005;30:1061–1067.
3. Fisher L, Gordon M. Anesthesia for hand surgery. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds.
Green's Operative Hand Surgery, 2-Volume Set Expert Consult: Online and Print. 6th ed. Philadelphia: Elsevier/Churchill Livingstone; 2011:25–40.
4. Hall RJ. Hydrochlorate of cocaine.
NY Med J. 1884;40:643–644.
5. Olch PD. William S. Halsted and local anesthesia: Contributions and complications.
Anesthesiology 1975;42:479–486.
6. Calatayud J, González A. History of the development and evolution of local anesthesia since the coca leaf.
Anesthesiology 2003;98:1503–1508.
7. Burke WCJ. Hydrochlorate of cocaine in minor surgery.
NY Med J. 1884;28:616–617.
8. Dillane D, Finucane BT. Local anesthetic systemic toxicity.
Can J Anaesth. 2010;57:368–380.
9. Strauss L.
Ueber locale Gangran nach Cokaininjectionen. 1889.
10. Lambert G, Snyers J. Gangrene des doigts consécutive à l'anesthesie loco-régionale.
Rev Chir. 1933;52:741–760.
11. Braun H. Ueber den Einfluss der Vitalitat der Gewebe auf die ortlichen und allgemeinen Giftwirkungen localanasthesirender Mittel und uber die Bedeutung des Adrenalins fur die Localanasthesie.
Arch Klin Chir. 1903;69:541–591.
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