Epi in nerve blocks?

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stephenpatrickd

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Hello all,
Thoughts on adding epi to local for nerve blocks with the goal of detecting intravascular injection?
Thanks much,
Spd
 
Are you using an ultrasound, or a nerve stimulator alone?
 
Yes this is a normal and viable option if you want to do it. I do it sometimes for my supraclavicular nerve blocks with 0.25% bupi and 1:200,000 epi.
 
No one uses bupi with 1:200,000?? Really?
 
stephenpatrickd said:
Hello all,
Thoughts on adding epi to local for nerve blocks with the goal of detecting intravascular injection?
Thanks much,
Spd
Click to expand...
I have one attending who likes to do this. No other attendings do though.
 
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I routinely add epi (all of our local is supplied plain, so I add 150 mcg epi to a 30 mL vial of local to get the desired 1:200,000 concentration)
 
2Fast2Des said:
I use it for the duration action
Click to expand...
Literally everything I've read indicates that this really isn't a thing if you're blocking with bupivacaine or ropivacaine. There is negligible to zero measurable difference in duration of action when using these LAs.

"Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review" Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review

academic.oup.com

Dexamethasone and Clonidine, but not Epinephrine, Prolong Duration of Ropivacaine Brachial Plexus Blocks, Cross-Sectional Analysis in Outpatient Surgery Setting

AbstractObjective. The primary aim of this study is to determine the effect of adding dexamethasone, clonidine or both with and without epinephrine to ropi
academic.oup.com academic.oup.com

"Epinephrine Does Not Prolong the Analgesia of 20 mL Ropivaca... : Anesthesia & Analgesia" https://journals.lww.com/anesthesia..._does_not_prolong_the_analgesia_of_20.60.aspx
 
Last edited:
abolt18 said:
But does it?
Click to expand...

To Clarify:

Epi is not used to identify intravascular injection - agree that's what US and aspiration is for.

The absolute number of mg of bupivicaine is responsible for longer block duration - thats what im going for.

The maximum recommended dose of local anesthetic (mg/kg) is higher with solutions containing epi.

Therefore, with local with epi, I am able to give a higher dose of marcaine overall.

This high dose leads to fast block onset, longer duration, and because of the epi, still within the recommended dosage on a mg/kg basis.

Sometimes, when enough kg are present, I'll give two separate 20ml 0.5% injections (fem block and pop block) for complex knees.

That's a lot of local and I feel better that epi is in the mix
 
Hoya11 said:
To Clarify:

Epi is not used to identify intravascular injection - agree that's what US and aspiration is for.

The absolute number of mg of bupivicaine is responsible for longer block duration - thats what im going for.

The maximum recommended dose of local anesthetic (mg/kg) is higher with solutions containing epi.

Therefore, with local with epi, I am able to give a higher dose of marcaine overall.

This high dose leads to fast block onset, longer duration, and because of the epi, still within the recommended dosage on a mg/kg basis.

Sometimes, when enough kg are present, I'll give two separate 20ml 0.5% injections (fem block and pop block) for complex knees.

That's a lot of local and I feel better that epi is in the mix
Click to expand...
So,
1) Where do you live that you have a patient population coming for knees that is small enough you have to worry about 40 ml?
2) Are you hiring?
 
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DocVapor said:
So,
1) Where do you live that you have a patient population coming for knees that is small enough you have to worry about 40 ml?
2) Are you hiring?
Click to expand...

LOL. I’m lucky enough to practice where most of my patients are not super obese. However, when I do get a morbidly obese patient, I always get a kick out of it when the surgeon looks at me with his 30mL syringe and asks

“How much of this can I give?”

Me: “120”
 
Hoya11 said:
To Clarify:

Epi is not used to identify intravascular injection - agree that's what US and aspiration is for.

The absolute number of mg of bupivicaine is responsible for longer block duration - thats what im going for.

The maximum recommended dose of local anesthetic (mg/kg) is higher with solutions containing epi.

Therefore, with local with epi, I am able to give a higher dose of marcaine overall.

This high dose leads to fast block onset, longer duration, and because of the epi, still within the recommended dosage on a mg/kg basis.

Sometimes, when enough kg are present, I'll give two separate 20ml 0.5% injections (fem block and pop block) for complex knees.

That's a lot of local and I feel better that epi is in the mix
Click to expand...

Absorption is not that great in the lower extremities. Epi doesn't do much for you. You can put in 20 and 20 without worrying about it. You would probably come down with LAST yourself if you knew how much local surgeons used to put in joints in the past.
 
SaltyDog said:
If you are using U/S and you are concerned about intravascular injection, the answer is to get better at U/S, not to add epi.
Click to expand...

I’m great with ultrasound (toot toot). But, I had an adductor recently with negative aspiration but significant heart rate change after 5-10 ccs of injectate. Easily saved me from a disaster.

Can someone convince me why I shouldn’t be putting epi in my blocks?
 
Hoya11 said:
To Clarify:

Epi is not used to identify intravascular injection - agree that's what US and aspiration is for.
Click to expand...

I’m willing to bet that the vast majority of occurrences of LAST are following a negative aspiration. Does anyone inject following + heme? Lol. Epi is a fantastic IV indicator.
 
SaltyDog said:
Apparently not. 😉 :poke:




There is some (admittedly weak) data that epi increases chances of nerve injury.
Click to expand...

That adductor — good local spread on U/S. My guess is I had a venous puncture and withdrew the needle some. Probably had some local track back through. Point is, good spread on U/S isn’t a sure thing.

Epi is great.
 
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SaltyDog said:
With lido - yes.

With bupi - no.
Click to expand...

why do you believe this to be true?

many sources indicate increased bupi maximum dose with epi vs not.. and why would it make sense for lido and not bupivicaine?
 
Hoya11 said:
many sources indicate increased bupi maximum dose with epi vs not
Click to expand...

Can you please provide one of these sources. I have never seen a published max dose for bupi with epi v bupi w/o epi.

Sure it might make physiologic sense, but how much of a difference does it make? 1mg/kg, 2mg/kg, 12mg/kg???

If you’re going to make the (unconventional) claim, the onus is on you to provide the proof.
 
SaltyDog said:
Can you please provide one of these sources. I have never seen a published max dose for bupi with epi v bupi w/o epi.

Sure it might make physiologic sense, but how much of a difference does it make? 1mg/kg, 2mg/kg, 12mg/kg???

If you’re going to make the (unconventional) claim, the onus is on you to provide the proof.
Click to expand...
just google it, many sources come up, but here's one:

Maximum Recommended Doses and Duration of Local Anesthetics

See also: Medication ErrorsReference by ExampleExample calculation - lidocaine when administered without vasoconstrictionTotal dose that can be usedMaximum dose of lidocaine (plain, without vasoconstrictor) is 4.5 mg/kg (not to exceed 300 mg)Example patient weight - 10 kgTotal dose that can be used
medicine.uiowa.edu medicine.uiowa.edu

many list 2-2.5 without epi, 2.5-3 with epi.. this was something i just always assumed , epi stops the vascular uptake of all LAs and thus prolongs the action
 
Hoya11 said:
To Clarify:

Epi is not used to identify intravascular injection - agree that's what US and aspiration is for.

The absolute number of mg of bupivicaine is responsible for longer block duration - thats what im going for.

The maximum recommended dose of local anesthetic (mg/kg) is higher with solutions containing epi.

Therefore, with local with epi, I am able to give a higher dose of marcaine overall.

This high dose leads to fast block onset, longer duration, and because of the epi, still within the recommended dosage on a mg/kg basis.

Sometimes, when enough kg are present, I'll give two separate 20ml 0.5% injections (fem block and pop block) for complex knees.

That's a lot of local and I feel better that epi is in the mix
Click to expand...
Im glad you clarified that for us...
 
Hoya11 said:
just google it, many sources come up, but here's one:

Maximum Recommended Doses and Duration of Local Anesthetics

See also: Medication ErrorsReference by ExampleExample calculation - lidocaine when administered without vasoconstrictionTotal dose that can be usedMaximum dose of lidocaine (plain, without vasoconstrictor) is 4.5 mg/kg (not to exceed 300 mg)Example patient weight - 10 kgTotal dose that can be used
medicine.uiowa.edu medicine.uiowa.edu

many list 2-2.5 without epi, 2.5-3 with epi.. this was something i just always assumed , epi stops the vascular uptake of all LAs and thus prolongs the action
Click to expand...

That's not a source. I'm with salty. And I was trained by a few of the authors that are mentioned in their references section. Epi doesn't help bupi and can possibly damage nerves from what I've read. I put it with my lido in neuraxial but don't use it besides that.
 
GassYous said:
That's not a source. I'm with salty. And I was trained by a few of the authors that are mentioned in their references section. Epi doesn't help bupi and can possibly damage nerves from what I've read. I put it with my lido in neuraxial but don't use it besides that.
Click to expand...
Anyone with data regarding nerve injury associated with epi addition to blocks?

And are you guys not adding epi because of the concern for injury... or because of the extra step? I’m trying to quantify the downside in my mind. It appears minimal.
 
patriot6 said:
And are you guys not adding epi because of the concern for injury... or because of the extra step? I’m trying to quantify the downside in my mind. It appears minimal.
Click to expand...

In my mind, there is potential downside (nerve injury - I believe that data comes from review of the closed claims database), and no upside (I don't need it as a vascular marker, and it doesn't prolong my blocks).
 
SaltyDog said:
In my mind, there is potential downside (nerve injury - I believe that data comes from review of the closed claims database), and no upside (I don't need it as a vascular marker, and it doesn't prolong my blocks).
Click to expand...
I think it's from animal studies that they showed the nerve damage.
 

Anesthesiology

pubs.asahq.org pubs.asahq.org
Epi enhances lido potency and alters distribution within nerve

Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z: Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block. Anesth Analg 2001;93:1327–1331.
pubmed.ncbi.nlm.nih.gov

The effects of adding epinephrine to ropivacaine for popliteal nerve block on the duration of postoperative analgesia: a randomized controlled trial - PubMed

Trial register.nl identifier: NTR3330 , keyword TTFR.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Epi does not lengthen duration of ropi

journals.lww.com

Benefit and Harm of Adding Epinephrine to a Local... : Anesthesia & Analgesia

d with epinephrine, with the same local anesthetic regimen without epinephrine, reporting on duration of analgesia, time to 2 segments regression, or any adverse effects. Trial quality was assessed using the Cochrane risk of bias tool and a random-effects model was used. Trial sequential...
journals.lww.com journals.lww.com
Metaanalysis of 70 trials, epi adds maybe an hour of analgesia at most

Neurosurgery

academic.oup.com academic.oup.com
Apparently this article shows that bupi 0.5 has minimal effect on nerves as seen under electron microscopy but with epi there's some damage. I can't access this article but another article that references this one says that this is what it shows.

In general I try to keep my anesthetics as simple as I can. I just draw everything up in as few syringes as possible and use the minimum amount of medication. I don't get when people mix prop and etomidate or use sux for a fast intubation when roc alone is fine. If something doesn't help and can possibly hurt, I eliminate it.
 
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Do people who use epi in blocks also believe that epi given IM in a code is worthless?
 
woopedazz said:
Do people who use epi in blocks also believe that epi given IM in a code is worthless?
Click to expand...
150 mcg versus 1 mg? Plus it’s diluted into a huge volume in a nerve block that isn’t quickly absorbed. I agree it slowly gets absorbed, but I’ve done lots of nerve blocks with epi in the mix and have never seen a HR change.
 
I have no strong opinion, in a higher vascular area I like epi as an additional intravascular indicator, so I will use it in a supraclavicular or adductor. I think it’s stupid in something like a fem or pop.
 
I’ve always done it for ultrasound ISBs (w/ pulse ox beeping) with the idea of detecting intravascular, but I’ve never seen heart rate jump up. Maybe it’s not worth the time and theoretical risk. I do think aspiration alone is inadequate, need to see local spread. But realistically not sure how many different things one can focus on effectively (aspiration, local spread, heart rate, hot nurse...)
 
dipriMAN said:
Or the old through and through technique
Click to expand...

Slightly different “through and through” but in the olden days we used to do transarterial axillary blocks. We’d deliberately insert the needle into the axillary artery and advance through the backwall until we got negative aspiration and dump half the local there. Then withdrew the needle until we got negative aspiration and dumped the rest of the local in front of the front wall. Epi was useful for those.
 
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