Usage of Epinephrine Mixed With Lidocaine in Plastic Surgery

Abstract

Plastic surgeons commonly administer subcutaneous epinephrine to reduce intraoperative blood loss. The authors hypothesized that there are safe and effective concentration of epinephrine for vasoconstriction and their durations. The aim of this study is to summarize the existing literatures for the usage of epinephrine mixed with lidocaine in plastic surgical field. In 1903, Braun reported that adrenaline prolonged the local anesthetic effects of cocaine. The Parke-Davis Company began selling cocaine with adrenaline, as well as combining adrenaline with new synthetic local anesthetics. Based on a review of the literature, concentrations between 1:50,000 and 1:400,000 are equally effective and provide superior vasoconstriction compared with more dilute solutions. If epinephrine is further diluted, its onset and time to peak serum concentration are delayed, and its duration of action is shortened. When lidocaine is used without epinephrine, duration of anesthesia is shortened reverse proportionally to the lidocaine concentration. When lidocaine is used with epinephrine, duration of anesthesia is prolonged proportionally to the lidocaine concentration. With slow injection rate in the soft tissue, the maximum safe dose of lidocaine is approximately 3 mg/kg plain and 7 mg/kg when mixed with epinephrine. Lidocaine may protect the myocardium because of its antiarrhythmic activity, which is the rationale for infiltrating lidocaine mixed with epinephrine in general anesthesia. In plastic surgery, subcutaneous infiltration of epinephrine-lidocaine solution is performed to reduce intraoperative blood loss. Even in general anesthesia, infiltrating lidocaine mixed with epinephrine may protect the myocardium because of its antiarrhythmic activity.

The Effect of Subcutaneous Epinephrine Dosage on Blood Loss in Surgical Incisions

“…We have to consider that the optimum safe dose of local anesthetics is more dependent on the route, rate and the site of injection than the drug load. 13 As mentioned before, site and sort of surgery affect optimum concentrations of epinephrine; while in dermatologic plastic surgeries, epinephrine in 1:50,000 concentration is used to reduce the amount of bleeding with satisfying results. 14 The prevalence of cardiovascular toxic adverse effects has been observed to increase in a dose dependent manner.…”

“…If epinephrine is more diluted, its characteristics such as onset and time to peak serum concentrations may be influenced and also the duration of action is shortened. 13 …”

Incidence of Hypotension and Associated-risk Factors in Epidural Anesthesia With 2% Lidocaine and Epinephrine During Elective Cesarean Section, Efficacy and Safety Assessment

“…E. Bjornestad and coworkers [29] found 20% and 30% of visceral pain in their study with epidural lidocaine and epidural 2-chloroprocaine respectively, while Yicheng Yang and colleagues [38] found an intraoperative pain incidence ranged at 70% and 47.5% respectively in epidural ropivacaine-morphine and epidural ropivacaine-morphinedexmedetomidine. It is actually known that epinephrine has some properties of antinociceptive and enhances the duration of analgesia used together with LAs [39,40] . Furthermore, recent researches by Aliza Olapour et al [41] said that lidocaine's sensory and motor block were superior to the Ropivacaine's, and epinephrine was found to exert an essential role [39] .…”

Maximum Dose of Plain Epinephrine in Plastic Surgery: Room to Explore

“…The pharmacokinetics of these epinephrine-local anesthetic combinations has been well studied, leading to well-established guidelines for maximum local anesthetic doses. 1 However, local anesthetics have an associated toxicity risk and prevent impulse transmission/stimulation of motor nerves, which is particularly relevant in peripheral nerve surgery. As an alternative, plain epinephrine may be used to decrease blood loss and minimize blood within the surgical site.…”

“… 5 A recent review of the literature demonstrated that concentrations of epinephrine between 1:50,000 and 1:400,000 provide superior vasoconstrictive effects compared with dilute epinephrine concentrations. 1 …”