A waiting time of 7 min is sufficient to reduce bleeding in oculoplastic surgery following the administration of epinephrine together with local anaesthesia

Abstract

ABSTRACT.Objective: The time taken to reach maximal haemostatic effect following local anaesthesia with epinephrine is generally believed to be <10 min. This is based on clinical experience and indirect measurements of perfusion using methods such as laser Doppler flowmetry and oxygen spectroscopy. However, the only study in which bleeding has been measured quantitatively in an intra-operative setting in humans showed that the full haemostatic effect was not achieved until 30 min after anaesthesia. The aim of this study was to determine the time taken to reach maximum haemostatic effect when using epinephrine for local anaesthesia in oculoplastic surgery. Methods: Intra-operative bleeding following infiltration anaesthesia with either lidocaine 20 mg/ml (2%) or lidocaine + epinephrine 12.5 lg/ml (1:80 000) was measured after 7, 15 and 30 min in the eyelids of 16 patients undergoing upper eyelid blepharoplasty. Results: Bleeding was decreased by 74.6% (with 95% CI, 6.16-87.6%) 7 min after the injection of lidocaine + epinephrine (p = 0.0048) compared with lidocaine without epinephrine. There was no further decrease in bleeding after 15 or 30 min (p = n.s.). Conclusion: The optimal time for skin incision in eyelid surgery is within 7 min of injection of lidocaine with epinephrine. Waiting longer does not lead to a further decrease in bleeding.

Evaluating Clinical Outcomes for Determining the Optimal Delay to Skin Incision under WALANT: A Prospective Series of 34 Patients from a Low-Resource Tertiary Setting

“…Our findings are, moreover, in agreement with those by preceding authors [ 14 – 19 ]. Larrabee et al [ 17 ] injected epinephrine with either lidocaine or saline into the skin of piglet trunks and found maximal vasoconstriction, measured by laser Doppler flowmetry, to occur at about 5 to 7 min in most of the cases.…”

“…Similarly, O'Malley et al [ 18 ] recorded maximal vasoconstriction following epinephrine injection in the neck of patients undergoing head and neck surgery after 3 to 4 min, while Ghali et al [ 14 ] found maximal decrease in blood flow following injection of epinephrine to happen after 8 min in the face and 10 min in the forearm. Additionally, Hult et al [ 19 ] estimated intraoperative bleeding in the eyelids of 16 patients undergoing upper eyelid blepharoplasty and found significant decrease in bleeding at 7 min following epinephrine injection, with no further decrease at 15 and 30 min thereafter. In a recent study by Sheikh et al [ 15 ] on porcine flank flaps injected with epinephrine and lidocaine, low level of perfusion, measured by laser speckle contrast imaging and laser Doppler flowmetry, was already observed after approximately 2 minutes following the injection.…”

Hyperspectral Imaging to Study Dynamic Skin Perfusion after Injection of Articaine-4% with and without Epinephrine—Clinical Implications on Local Vasoconstriction

“…Regarding the bloodlessness of the surgical field, there is controversy in the literature about the time interval required between injection and incision. While some authors consider less than 7 min sufficient [ 22 , 23 ], others recommend 13 [ 5 ] or even more than 25 min [ 13 ]. This could be due to different anatomical regions (eyelid versus forearm, neck, oral mucosa/gingiva), different concentrations of epinephrine or LA, too small case numbers as well as fundamentally different study protocols (e.g., close spacing of the injection sites in the eyelid area with result falsification as well as unsuitable drug combinations compared) and measurement methods (spectroscopy versus blood loss measurement).…”

“…This could be due to different anatomical regions (eyelid versus forearm, neck, oral mucosa/gingiva), different concentrations of epinephrine or LA, too small case numbers as well as fundamentally different study protocols (e.g., close spacing of the injection sites in the eyelid area with result falsification as well as unsuitable drug combinations compared) and measurement methods (spectroscopy versus blood loss measurement). For example, Hult et al compared lidocaine-2% with (1:100,000) and without epinephrine in terms of a measurable hypoperfusion based on collected blood volume [ 22 ]. Regardless of the fact that subcutaneous injection in the area of the upper eyelid is difficult to standardise in the absence of a regular subcutis and direct muscular support in most cases [ 24 ], choosing plain lidocaine-2% as the control site must be rated critically due to vasodilatation by all amide-LA [ 25 , 26 , 27 ].…”

Insulin syringe for anaesthetic injection in ptosis surgery: A randomised controlled clinical study

“…This is also a re ection of previous research that found that waiting 7 minutes before skin incision in eyelid surgery is enough to achieve a maximal haemostatic effect following the induction of local anaesthesia using epinephrine. 29…”