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Why Are We So Afraid Of Local Anesthetics With Epinephrine?
Imagine if you could transport Socrates, Aristotle, Jobs, Einstein, Feynman, Hawking and Halstead, just to mention a few, through time to the present and combine their wisdom and knowledge into a congealed supergenius. Put this new “machine” into present day context and boy oh boy, do we have a toy — digitally speaking of course in the form of the new Bari Tass 2015 version 2.1 Mega Cortex. This interactive hybrid computer is secreted away in the high Himalayas and has extremely limited access. Go to StubHub or Ticketmaster if you don’t believe me.
Now you ask me, “How did you get access to it?” I cannot say. I had to do some unspeakable things (there were some yak milk and Sherpa traditions involved though). Since they are unspeakable, they also cannot be written. However, I can tell you that I have only very limited access (12 times in fact) to this omniscient power and I am going to use it this year to cut away at some myths and dogma that have haunted the medical profession for decades. Do you want to come along?
The room is cold. It should be. We are in a Tibetan cave for God’s sake. The “figure” in front of me is mechanically imposing but at the same time sleek, beautiful and strange. There is a slight din of nearly white noise that oddly sounds like the background sound of fluorescent lights. Maybe that is the effect of the fermented yak milk. There is no light in the room, except the glow from the Bari Tass itself.
“What is your allotted question, sir?” the mega machine bellowed in an intimidating, mechanized voice. It put that smug little Siri to complete and utter shame.
“Well,” I said, completely infatuated with this “genius” pulling my scarf up around my cold neck. “There is this great fear of the use of local anesthetics with epinephrine for digital and foot neural blockades, and people have asked me many times about it. Most recently, when I was in Spain teaching, I heard that the use of such agents is strictly forbidden. Can you give me the truth about this?”
I took a couple of steps back as the “genius” started to whir. The machine became more illuminated just as it started to answer. “Here are the facts:
First, the use of commercially available local anesthetics with epinephrine is completely safe for digital blockade, and there is abundant scientific, peer-reviewed evidence to support this fact,” stated Bari flatly. “This dogma began in the early part of the 20th century when 50 cases of digital gangrene were reported. However, in only 21 of those cases was epinephrine mixed into the anesthetic.”1
Bari continued. “The actual concentration of epinephrine in these 21 cases was only known in four cases. Please note, sir, that after careful analysis, researchers determined there was nothing to support the charge of necrosis with epinephrine and there were other contributing factors such as hot soaks, infection, inappropriate tourniquet use, etc. Sadly, when things like this start to get reported, people repeat them and then publish them — especially in the dermatology textbooks — and voila, it is ‘fact.’
“One more thing. When Einy and I were running around in Vienna drinking and writing formulas, we heard about seven cases of digital gangrene just from the injection of water,” Bari started to laugh.
I didn’t know these things had senses of humor. Too real.
“Sir,” Bari continued. “Would you like more? You still have time.”
“Hell yeah,” I politely retorted. “I love this stuff.”
“It is my universally factual opinion that once I tell you more, it will completely dispel all of this misinformation,” Bari continued. “Sylaidis and Logan reported in the British Journal of Hand Surgery in 1998 a study that completely refuted this academic fallacy. They measured the arterial blood flow in 200 consecutive patients receiving digital blocks with epinephrine and found that digital perfusion was only slightly and temporarily reduced, and that reperfusion occurred in every case.”2
The “genius” burped. “I should add one thing,” Bari continued. “That was with a 1:80,000 concentration. What do you use now?”
I quickly answered, “1:200,000 at least.”
“Precisely, sir. What are you all scared of?”
“Fear, I suppose, which has been ingrained over decades and decades.”
“The best way to overcome fear is to wipe it out with fact,” the “genius” responded.
“Give me just one more?” I implored.
“Firoz, Davis, and Goldberg used a 1:200,000 mixture in 63 patients and reported no complications in digital blocks, even in smokers and patients with diabetes.”3
“Whoa, cowboy!”
“I do not understand ‘cowboy,’ sir.”
“Just an expression of awe, my genius friend.”
“I understand. Your session is finished. Goodbye.” Just like that, the cave went black and the yak hide was drawn to the side of the opening, letting in the sunlight and more cold.
Walking down the mountain and trying to avoid breaking my ankles on the rocky terrain, I had a little time to reflect on this first session with my new “genius” friend. The first question that came to mind was what to ask him at the next session. The second thing that came to mind was how can we convey this information and dispel this ridiculous myth once and for all?
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