Epi in local solution for nerve blocks

[Sonny Crocket]

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Anyone not routinely using epinephrine in their local anesthetic solution for ultrasound guided nerve blocks?

 

[Consigliere]

You really shouldn't be. If you look at the ASA Closed Claims data, epinephrine is implicated as the culprit in most cases of nerve damage.

 

[cchoukal]

I stopped using it a couple years ago.

 

[periopdoc]

Not me.

-pod

 

[heronmd]

You really shouldn't be. If you look at the ASA Closed Claims data, epinephrine is implicated as the culprit in most cases of nerve damage.

please quote the data that supports this opinion. provide a link. thanks.

 

[sevoflurane]

Why use epi when I can use decadron?

 

[Consigliere]

please quote the data that supports this opinion. provide a link. thanks.

It's not an opinion, medical student. Do your own research you lazy slob.

 

[Mman]

You really shouldn't be. If you look at the ASA Closed Claims data, epinephrine is implicated as the culprit in most cases of nerve damage.

The culprit? As opposed to the needle hitting the nerve or local anesthetic toxicity? I find that a bit hard to believe. I'd wager a guess that the vast majority of nerve blocks in this country are performed with epinephrine as an additive. That would mean that the vast majority of complications should happen in blocks that included epinephrine as an additive. Doesn't mean the epinephrine caused the complication, though.

I also wonder what percentage of cases of systemic local anesthetic toxicity were in blocks that included epi versus those that didn't as one of the main uses is to detect intravascular injection.

Personally I use 1:400K epi routinely.

 

[Planktonmd]

The culprit? As opposed to the needle hitting the nerve or local anesthetic toxicity? I find that a bit hard to believe. I'd wager a guess that the vast majority of nerve blocks in this country are performed with epinephrine as an additive. That would mean that the vast majority of complications should happen in blocks that included epinephrine as an additive. Doesn't mean the epinephrine caused the complication, though.

I also wonder what percentage of cases of systemic local anesthetic toxicity were in blocks that included epi versus those that didn't as one of the main uses is to detect intravascular injection.

Personally I use 1:400K epi routinely.

I use epi on all blocks except sciatic since it's a thick nerve with increased likelihoods of ischemia.

 

[leaverus]

I also wonder what percentage of cases of systemic local anesthetic toxicity were in blocks that included epi versus those that didn't as one of the main uses is to detect intravascular injection.

Personally I use 1:400K epi routinely.

yeah, same here. its main use for me is detection of IV injection, and not really for block prolongation.

 

[pgg]

I do not. I don't think its nerve-stim era benefit as an intravascular marker applies now that I do all my blocks under u/s. There are better additives for increasing duration.

I first quit using it in diabetics out of concern for higher risk of ischemic nerve injury. Then I asked myself what benefit I was getting in all the other patients, and I couldn't convince myself it was useful enough to be worth the trouble.

 

[Mman]

I do not. I don't think its nerve-stim era benefit as an intravascular marker applies now that I do all my blocks under u/s. There are better additives for increasing duration.

I first quit using it in diabetics out of concern for higher risk of ischemic nerve injury. Then I asked myself what benefit I was getting in all the other patients, and I couldn't convince myself it was useful enough to be worth the trouble.

I use it because I'm afraid of lawyers and if I had an intravascular injection with serious complication, I'd have a difficult time explaining why I didn't add epinephrine to the solution. I think the added risk to the procedure from it is essentially zero.

 

[Sonny Crocket]

The main reason I used to use it was for detecting intravascular injection which I have not had ever. I stopped for no reason at all and have not gone back. I just feel, as written above, with ultrasound and aspirating I don't need it.

 

[Mman]

The main reason I used to use it was for detecting intravascular injection which I have not had ever. I stopped for no reason at all and have not gone back. I just feel, as written above, with ultrasound and aspirating I don't need it.

I, too, am batting about 0 out of somewhere between 5K and 7K, but haven't given up my documentation of using it.

 

[BLADEMDA]

The main reason for using Epi with U/S guided blocks is because the epi decreases the blood level of the local. This may be significant in bilaterat Oblique Subcostal Tap blocks where I use 60-65 mls or FICB where an Anesthesiologist uses 150 mg of Bup diluted with NS for a 50 kg patient.

I do not use Epi as a marker for intravascular injection or to prolong my blocks. That said, it is still common practice to utilize Epi when performing a Peripheral nerve block. There is some theoretical concern the Epi may increase the risk of toxicity to the nerve but that supposedly increased risk has never been proven in humans.


http://books.google.com/books?id=S0...nepage&q=epinephrine and nerve injury&f=false

(read page 899)

 

[BLADEMDA]

While the data are again variable on the ability of customary concentrations of perineural epinephrine to vasoconstrict vascular supply to peripheral nerves, 11,13,30 the combination of epinephrine and local anesthetics clearly has vasoconstrictive effects.13,30 The addition of epinephrine has been shown to increase the neurotoxicity of bisulfite-containing chloroprocaine solutions31 and to increase the axonal degeneration that follows intrafascicular bupivacaine injection.15,16. However, a contribution of vasoconstriction to peripheral nerve injury has not been proved, and clinical observations suggest that this aspect of toxicity generally plays a minor role.32 For instance, peripheral nerves are tolerant to full ischemia from the use of an occlusive tourniquet for hours (see below). Nonetheless, in the context of predisposing factors such as diabetes or peripheral vascular disease, it is prudent to add epinephrine to local anesthetic solutions only if prolongation of the block cannot be achieved by use of a different local anesthetic, or if maximal doses are used and systemic toxicity is possible.

 

[BLADEMDA]

Epinephrine

While epinephrine certainly has analgesic benefit when used with short- and intermediate-acting local anesthetics, there are limited data regarding the efficacy of epinephrine for prolonging the analgesic duration of long-acting local anesthetics (ropivacaine, bupivacaine, levobupivacaine). Some studies with long-acting local anesthetics (e.g., ropivacaine) failed to show an increased duration of analgesia with co-administration of epinephrine.1 The limited available data make it impossible to assess the potential analgesic benefits for the addition of epinephrine.

Epinephrine remains the most widely used adjunct for local anesthetics in peripheral nerve blockade; however, the increased use of ultrasound and potential concerns about neurotoxicity may temper the enthusiasm of its use for some anesthesiologists. A review by Neal (2003) notes the differential blood flow of the extrinsic and intrinsic systems in the peripheral nerve and questions whether epinephrine has any true impact on neurotoxicity.2 Decreases in blood flow2, 3 and the increased duration of analgesia4 are due to the ∝1-adrenoceptor agonist effect of epinephrine.4 Some local anesthetics, including lidocaine and ropivacaine, will also cause vasoconstriction and are synergistic with epinephrine. Whether the effect of epinephrine is simply due to decreased systemic uptake leading to a greater effect of the local anesthetic on the peripheral nerve is still not completely understood;2, 5 however, perineural epinephrine alone does not cause sensory or motor blockade.4

The controversy surrounding widespread use of epinephrine in combination with local anesthetics is the argument as to whether it is protective or harmful. There is no question that epinephrine can be a valuable marker for the detection of intravascular injection, and some experts believe that the early detection of intravascular injection greatly outweighs the potential neurotoxic or myotoxic effects. The increased use of ultrasound worldwide allows for visualization of the needle tip and real-time assessment of local anesthetic spread; however, unintentional intravascular injection of local anesthetic with subsequent cardiovascular collapse using ultrasound has still been reported and remains a legitimate concern. Along with other experts, however, we believe that the addition of epinephrine to local anesthetics may increase the potential neurotoxicity, which may be especially concerning in those patients at higher risk for nerve injury (i.e., patients with diabetes mellitus, hypertension, and/or a history of smoking).6 We still recommend the use of epinephrine as an additive for test dose purposes in out-of-plane ultrasound blocks or nerve stimulator blocks. Beta blockade may limit the use of epinephrine as a marker of intravascular injection. Avoidance of high volume blocks, use of in-plane ultrasound guidance, slow injections, and limited sedation with constant assessment of central nervous system excitatory effects are likely equally or more important for limiting potential cardiotoxicity. The authors only recommend the use of epinephrine for nerve blocks done without ultrasound guidance, or blocks in which the needle tip and local anesthetic spread is not adequately visualized, as a safety measure to detect intravascular injection.


http://europepmc.org/articles/PMC3427651/reload=0;jsessionid=MYjTACmVhIW54L2NnjYQ.8

 

[leaverus]

The main reason I used to use it was for detecting intravascular injection which I have not had ever. I stopped for no reason at all and have not gone back. I just feel, as written above, with ultrasound and aspirating I don't need it.

I had one in residency while doing a sciatic block on a old sick dude. He started seizing almost immediately - I was holding the needle and attending was injecting; never aspirated blood.

 

[BLADEMDA]

I had one in residency while doing a sciatic block on a old sick dude. He started seizing almost immediately - I was holding the needle and attending was injecting; never aspirated blood.

I've had one in my career. Negative aspiration. The Epi didn't help at all in avoiding the intravascular injection (back then I was using 1:200,000 or 5ug/ml).

 

[Oggg]

I usually skip the epi. Epi containing local anesthetics cost way more than plain solutions. Adding epi myself is time consuming and I don't see the benefit. Btw why aren't there any ropivicaine with epi solutions