CAT bespreking

N. van der Meij, 08-04-2010

Casus Een 34-jarige patiënte zal een nagelextractie ondergaan onder lokale anaesthesie.

VraagMag bij een chirurgische ingreep aan de vinger lidocaïne met adrenaline gebruikt worden?Op onze poli gebruiken wij: Ultracain D-S forte: 0.01mg epinefrine per ml: dit komt overeen met 1 : 100.000. In bijsluiter: injectie in eind-arteriële gebieden staat NIET genoemd bij de contra-indicaties.

PICOP patiënten die verdoving nodig hebben van de vinger I lokale anaesthesie met lidocaïne + adrenaline C lokale anaesthesie met lidocaïneO complicaties bij het gebruik van adrenaline

LiteratuursearchBovenste gedeelte pyramide begonnen met zoeken: gezocht met termen:

anesthesia OR local anesthesia OR nerve block AND epinephrine AND fingers Evidence Based Richtlijnen

CBO: Richtlijnen National Guideline Clearinghouse National Library of Guidelines NHG standaarden Oncoline: Oncologische Richtlijnen (VIKC)

Syntheses en Synopsissen Best Practice (BMJ) incl. Clinical Evidence

Systematische Reviews Cochrane Library

Geaggregeerde Evidence Evidence-Based Medicine Guidelines Trip Database

Oorspronkelijke Studies

CINAHL EMBASE Google Scholar Medline (via Ovid) PsycINFO PubMed (Medline) PubReMiner

Web of Science

1 e trede : evidence based richtlijnenCBO: geen richtlijn,National Guideline Clearinghouse: geen richtlijnNational Library of Guidelines: 0 hitsNHG standaarden: 0 hitsOncoline: 0 hits

2e trede: synthesissen/synopsissenBest Medical Practice: 0 hits

3 e trede : systematische reviewsCochrane Library: 1 hit!!

Title Changes in acral blood flux under local application of ropivacaine and lidocaine with and without an adrenaline additive: a double-blind, randomized, placebo-controlled study. Links      Export Central Citation  

Author(s) Häfner HM, Schmid U, Moehrle M, Strölin A, Breuninger HSource Clinical hemorheology and microcirculationDate of Publication 2008Volume 38Issue 4Pages 279-88Abstract Vascular effects of local anesthetics are especially important in

dermatological surgery. In particular, adequate perfusion must be ensured in order to offset surgical manipulations during surgical interventions at the acra. However, the use of adrenaline additives appears fraught with problems when anesthesia affects the terminal vascular system, particularly during interventions at the fingers, toes, penis, outer ears, and tip of the nose. We studied skin blood flux at the fingerpads via laser Doppler flowmetry over the course of 24 hours in a prospective, double-blind, randomized, placebo-controlled study with 20 vascularly healthy test persons following Oberst's-method anesthetic blocks. In each case, 6 ml ropivacaine (7.5 mg/ml) (A), lidocaine 1% without an additive (B), and lidocaine 1% with an adrenaline additive (1:200,000) (C) was used respectively as a verum. Isotonic saline solution was injected as a placebo (D). Measurements were carried out with the aid of a computer simultaneously at D II and D IV on both hands. Administration of (A) led to increased blood flux (+155.2%); of (B) initially to a decrease of 27%; of (C) to a reduction of 55% which was reversible after 40 minutes and of (D) to no change.(A) resulted in sustained vasodilatation which was still demonstrable after 24 h. (B) had notably less vasodilative effect, although comparison with (D) clearly showed that (B) is indeed vasodilative. (C) resulted in only a passing decrease in perfusion; this was no longer measurable when checked after 6 and 24 h. This transient inadequacy of blood flux also appeared after administration of (D). These tests show that adrenaline additive in local anesthesia does not decrease blood flow more than 55% for a period of 16 min. Following these results an adrenaline additive can be safely used for anesthetic blocks at the acra in healthy persons.

Medical Subject Headings (MeSH)

Amides [therapeutic use]; Anesthetics, Local [therapeutic use]; Double-Blind Method; Drug Combinations; Epinephrine [*pharmacology]; Fingers [*blood supply]; Hemorheology; Laser-Doppler Flowmetry; Lidocaine [therapeutic use]; Microcirculation [*drug effects]; Vasoconstrictor Agents [*pharmacology]

MeSH check wordsAdult; Female; Humans; Male

Correspondence Address Department of Dermatology, University of Tübingen, Germany. hans-martin.haefner@med.uni-tuebingen.de

Accession Number PUBMED 18334782Publication Type Journal Article; Randomized Controlled Trial

Schuine trede: Geaggregeerde evidenceEvidence-Based Medicine Guidelines: 0 hitsTRIP database: 0 hits

4e trede: oorspronkelijke studiesEmbase:anesthesia OR local anesthesia OR nerve block AND epinephrine AND fingers: 16 hits, waarvan bruikbaar: 3 artikelen:

1A critical look at the evidence for and against elective epinephrine use in the finger.

Thomson C.J., Lalonde D.H., Denkler K.A., Feicht A.J.

Plastic and Reconstructive Surgery. 119(1)(pp 260-266), 2007. Date of Publication: Jan

2007. The evidence that created the dogma that adrenaline should notbe injected into the fingers is clearly not valid. However, there is considerablevalid evidence in the literature that supports the tenet that properly usedadrenaline in the fingers is safe, and that it removes the need for a tourniquetand therefore removes the need for sedation and general anesthesia for many

hand operations. (Plast. Reconstr. Surg. 119: 260, 2007.)

2A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: The dalhousie project clinical phase. Lalonde D., Bell M., Benoit P., Sparkes G., Denkler K., Chang P. Journal of Hand Surgery. 30(5)(pp 1061-1067), 2005. Date of Publication: Sep 2005. [Journal: Article] There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. Conclusions: The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.3

Authors Denkler K.

Institution(Denkler) Department of Plastic Surgery, Univ. of California, San Francisco, San Francisco, CA, United States.(Denkler) 275 Magnolia Avenue, Larkspur, CA 94939, United States.

Title Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet.

Source Plastic and Reconstructive Surgery. 115(3)(pp 802-810), 2005. Date of Publication: Mar 2005.

Abstract

Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomy, is an outpatient operation performed with the patient under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephrine in the digits. This study is a retrospective review of operations performed by the same surgeon in the hospital (43 digits) versus the office using local anesthetics with epinephrine and no tourniquet (60 digits). Results and complications were compared and tabulated. The hospital and epinephrine groups were comparable regarding preoperative measurements. Postoperative improvement in extension at the metacarpophalangeal and proximal interphalangeal joints was similar in both the hospital and epinephrine groups. Complications, including digital nerve and artery injuries, infections, and hematomas, were similar between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of a digital artery at the proximal interphalangeal joint. Because of the similarities in results and complications, there does not seem to be an advantage to performing Dupuytren's excisions with full arm tourniquet and outpatient admission in many cases. Local anesthetics with epinephrine are safe in the treatment of Dupuytren's contracture, although both the use of digital epinephrine and the use of mechanical tourniquets carry the potential for complications. Visibility is similar to that for facial or head and neck surgery and is aided by the use of loupe magnification. The old dogma against its use in the fingers is refuted, as seen by the results in these 60 consecutive Dupuytren's fasciectomies and the results of other authors.

Pubmed:Zoektermen: ("Anesthesia"[MeSH] OR "Anesthesia, Local"[MeSH]) OR "Nerve Block"[MeSH] AND "Epinephrine"[MeSH] AND "Fingers"[MeSH] Daarbij: alleen de reviewsZoekresultaat: 6 hits, waarvan 4 bruikbaar

1 Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Epinephrine in digital nerve block.

Mohan PP.

Emerg Med J. 2007 Nov;24(11):789-90. Review.PMID: 17954841 [PubMed - indexed for MEDLINE]Related articles

A short cut review was carried out to establish whether epinephrine (adrenaline) is safe to use in digital nerve blocks. A total of 16 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are presented in table 2. The clinical bottom line is that epinephrine (1:200 000 to 1:100 000) is safe to use in digital blocks.

2 Digital anesthesia with epinephrine: an old myth revisited.

Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS.

J Am Acad Dermatol. 2004 Nov;51(5):755-9. Review.PMID: 15523354 [PubMed - indexed for MEDLINE]Related articles

BACKGROUND: The prohibition against the use epinephrine with local anesthetics for digital blocks or infiltrative anesthesia is an established dogma in dermatologic surgery. Major textbooks reinforce this teaching suggesting that there is substantial risk of digital gangrene caused by local anesthesia containing epinephrine. OBJECTIVE: To provide a comprehensive literature review of the cases of digital necrosis associated with the use of local anesthesia containing epinephrine. METHODS: A PubMed search of the National Library of Medicine database using the terms "lidocaine" and "epinephrine" and "finger" with no specified limits was performed. RESULTS: A total of 16 papers were referenced and only 6 papers dealt with digital anesthesia. A total of 50 cases of digital gangrene were reported, mostly in the early part of the 20th century. In 21 cases digital gangrene was associated with anesthetic mixed with epinephrine. Actual concentration of epinephrine was known in only 4 cases. Careful analysis of all cases of necrosis did not support epinephrine itself as a cause. Other contributing factors including older compounds (cocaine, eukaine, and procaine), non-standardized inaccurate methods of mixing epinephrine with lidocaine, inappropriate use of a tourniquet, postoperative hot soaks, infection, or large anesthetic volume were also present. None of the reported cases were associated with the use of a commercial lidocaine-epinephrine mixture. CONCLUSION: A literature review failed to provide evidence to support the dogma that block or infiltrative anesthesia with lidocaine and epinephrine produces digital necrosis. Proper injection technique and adequate selection of patients (absence of thrombotic, vasospastic conditions, or uncontrolled hypertension) are mandatory to minimize complications. The addition of epinephrine, in fact, reduces the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during digital procedures.

3 A comprehensive review of epinephrine in the finger: to do or not to do.

Denkler K.

Plast Reconstr Surg. 2001 Jul;108(1):114-24. Review.PMID: 11420511 [PubMed - indexed for MEDLINE]Related articles

The prohibition against the use of local anesthetics with epinephrine for digital blocks or infiltration is an established surgical tradition. The present article provides a comprehensive review of all reported digital necrotic and ischemic complications with epinephrine in the digits in an effort to understand whether the current prohibition is based on documented reports. A comprehensive review of articles showing the successful use of local anesthetic with epinephrine in the digits is presented.A review of Index Medicus from 1880 to 1966 and a computer review of the National Library of Medicine database from 1966 to 2000 were performed using multiple keywords. Selected major textbooks from 1900 to 2000 were also reviewed.A total of 48 cases of digital gangrene after anesthetic blocks (mostly using cocaine or procaine) have been reported in the world literature. Only 21 cases involved the use of epinephrine; 17 involved an unknown concentration based on manual dilution. Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult. There have been no case reports of digital gangrene using commercial lidocaine with epinephrine (introduced in 1948). Multiple studies involving thousands of patients support the premise that the use of lidocaine with epinephrine is safe in the digits. An extensive literature review failed to provide consistent evidence that our current preparations of local anesthesia with epinephrine cause digital necrosis, although not all complications are necessarily reported. However, as with all techniques, caution is necessary to balance the risks of this technique with the dangers of mechanical tourniquets and upper extremity block anesthesia.

4 Epinephrine in digital blocks: revisited.

Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG.

Ann Plast Surg. 1998 Oct;41(4):410-4. Review.PMID: 9788222 [PubMed - indexed for MEDLINE]Related articles

Digital block anesthesia with epinephrine, ring technique, and digital tourniquet have been implicated in causing finger gangrene. An extensive review of the literature provided no case of finger gangrene attributed solely to the adjunctive use of epinephrine with lidocaine for digital block. By causing vasoconstriction, epinephrine complements the local analgesic by prolonging the duration of action and providing a temporary hemostatic effect. Epinephrine augmentation of digital block anesthesia was used in the treatment of 23 finger injuries without a complication.

Antwoord op de vraag:Ja, bij een chirurgische ingreep aan de vinger mag lidocaïne met adrenaline gebuikt worden! Waarbij 1 studie het volgende opmerkt: “mits patiënten nauwkeurig geselecteerd worden (geen trombose, vasospastische aandoeningen of ongecontrolleerde hypertensie)”.

Lokale opvattingen (plastische chirurgie AMC):ANESTHESIE

Boek: HandletselsCopyright © 2006Tweede druk, oktober 2006Eerste druk, oktober 2005Exemplaren van dit boek zijn te bestellen via het secretariaat vande Nederlandse Vereniging voor Handchirurgie ende Nederlandse Vereniging van Spoedeisende Hulp Artsen.www.algemene-handchirurgie.nlwww.nvsha.nl

www.medirisk.nlDeze uitgave is tot stand gekomen door fi nanciële ondersteuningvan MediRisk.Druk: Van de Ridder, Nijkerk.AlgemeenEerst onderzoeken, dan pas verdoven!Kleine procedures kunnen onder lokaalanesthesie worden uitgevoerd.In andere gevallen wordt regionale anesthesie toegepast.Lidocaïne met adrenaline kan veilig in de hand van gezonde patiëntenworden gebruikt. Dit is in tegenstelling tot de algemeen gangbare opvattingwaarbij de vrees bestond dat door een spasme van de eindarterieënnecrose zou kunnen ontstaan. Een zogenaamd Bier’s blockis minder geschikt voor de handchirurgie. De werkingsduur is kort,niet langer dan één uur. Bij het opheffen van de bloedstilstand bestaatgeen mogelijkheid meer voor controle van hemostase.Het meest gebruikte lokaalanestheticum is lidocaïne. De maximaledosis lidocaïne met adrenaline (1:100.000) is 25 ml 2% oplossing, of50 ml 1% oplossing. Opwarmen en toevoegen van natriumbicarbonaat8,4% (in een verhouding 4:1) maakt de injectie minder pijnlijk.

Protocollenboek Afd. Plastische, Reconstructieve en Handchirurgie AMC Handchirurgie AlgemeenJanuari 2006 1Inhoudsopgave deel 5.1Handchirurgie algemeenTechniekgeef liefst zelf een plexus anesthesie; dit kan ook op de POK (poliklinisch behandel centrum)Zo nodig lokaal extra anesthesie (zonder adrenaline in de vingers!)

Protocollenboek Afdeling Plastische, Reconstructieve en Handchirurgie AMC Poliklinische operatiesMaart 2005 1Inhoudsopgave deel 3Poliklinische operaties3.2 Lokaal-anestheticaMeestal lidocaïne (= xylocaine) (werkingsduur 1-3 uur)dosis: maximaal 3 mg/kg (zonder adrenaline)7 mg/kg met adrenaline (1:100 000)1% lidocaïne = 10 mg/l (dus 70 kg = 21 ml zonder adrenaline en 49 ml met adrenaline)gelaat/romp meestal 1% lidocaine + adrenalinegeen adrenaline bij endarteriën (oor/penis/vingers) + ontstoken weefsel(onbetrouwbare absorbtie)