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Surgical Procedure re: Lidocaine
As I went about researching how to do digital blocks in preparation for my implantation, I received a lot of conflicting advice about whether lidocaine with epinephrine, as opposed to plain lidocaine, is dangerous in a digital block. I had a couple friends doing their magnet implantations that called it off because someone told them their lido with epi was going to give them gangrene.
I spent some time today and read a few studies that have found that lidocaine with epinephrine is safe to use in digital blocks, and the risk for digital ischemia is not present. I wrote up a more full blog post with sources on my site here, but wanted to also make a post here in the hopes of letting future implanters doing research know that if the only lido they have is lido with epi, they're just fine to do a digital block.
Remember, trust those who know more than you, but trust research as well - part of the hacker ethic is critical evaluation! Don't put blind faith in traditional dogma; always seek the most recent, relevant studies and proof. Trust, but verify.
Comments
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I have had lido with epi for something more invasive than a magnet (pulled bone chips from shattered finger tip) and the doctor said it helped with bleeding.
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"One does not clean watches in inkwells" Bunnel
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What do you mean by that?
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Read @cassox blog?
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Right - that was talking about tourniquets, not anaesthesia, though?
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Lido with epi is not totally safe unless you are a trained professional.So, what you need to consider is that those sources make total sense if you are a trained hand surgeon. Doing hand work is hard and using lido + epi in a situation that you are not skilled, on yourself, in un-ideal conditions, will often make things more difficult and possibly lead to damage.Seeking the most recent and relevant data is totally important. But you need to be honest in what relevant means. Relevant to someone who has had a lifetime of doing delicate surgery work on a delicate area, or relevant to the person with a scalpel in their kitchen? Because these are two different things.Everyone please remember that when you are working on a body, reading something is no substitute for having experience. This is why we are all here, to get experience. However, this means that you need to take small steps and be careful.
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Ok, I like your blog. I really need to start working on mine again someday. However, I do feel a need to provide constructive criticism here. The biggest one? You never mentioned dosage or intent. So first off, what is the point of epinephrine in lidocaine?
I think you need to add this info. The point is vasoconstriction - which in turn keeps the lidocaine in the area and increasing the duration of analgesia. Lid+ Epi can maintain a nerve block for 3 to 4 hours. This is a totally unnecessary duration for the procedure. The only reason to go for epi in this case is perhaps it's all you have.
2nd - tourniquet. If your going to use lido + epi, this changes a number of other factors... particularly it precludes the use of a tourniquet on the digit. The tourniquet and epi both provide hemostasis. Pick one or the other. I would update your blog to mention this.
3rd - dosage. Very important. The meta study for example found 1.7% of those that received Lidocaine with Epi required treatment... generally for cardiac symptoms. It differentiated between "high dose" and "low dose" and states that no one receiving low dose required treatment. However, the way it was described makes absolutely no sense, and for me, discredited the study. It states that the only patients treated for reactions was due to accidental injection of high dose epinephrine 1:1000. 1:1000 is not a dose, but rather a concentration, and it's the appropriate dose for subcutaneous injection. 1:100,000 is used as part of ACLS guidelines to treat AMI, specifically VT or VF.
Take a look at the packaging:
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If you open up the box, 1:100,000 is a luer lock style attachment ready for an immediate push. It's looks nothing at all like an epinephrine a 1:1000 bottle. I mean, you'd literally have to draw it up with a blunt draw needle into a separate syringe for injection. Furthermore, No ER doc plays around with mixing up lidocaine and epinephrine. It just doesn't happen. It's a pharmocologists job. That entire section makes no sense at all. I could see some freak or idiot accident... sure... but nearly 2% of doctors in a study with like 1800 participants... and 2% of the docs bust out an ACUTE CARDIAC LIFE SUPPORT DRUG out of the crash cart, and start drawing it up and MIXING it with lidocaine... so that a boo boo on someones finger doesn't hurt so bad? It just doesn't sound reasonable. So anyhow, my point is that you should research and provide some dosage information regarding the use of lidocaine with epinephrine. Lidocaine alone doesn't require as close monitoring of dosage. I think you should add maximums etc. for safety if you think epinephrine is a good idea. I personally still don't advise it as I think it adds an unnecessary extra source of complication. Don't misunderstand me here though. I'm not trying to sound authoritarian or anything. We're both dudes doing research here and I'm not trying to say mine is better. I'm just discussing it.
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Whoops. The above is a picture of Lido. Here's the pic of epi.
http://acls-algorithms.com/wp-content/uploads/2011/05/acls-drugs-epi.jpg
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Really appreciate the constructive criticism! I'll add some info re: hemostasis in that you need to pick lido with epi OR a tourniquet, not both.I'm hesitant to dosages primarily because of what @glims outlined - while I feel okay making an uninformed decision from what I understand of a number of studies, putting hard and fast dosage recommendations is implying an entirely new level of knowledge I definitely don't have. I'm not concerned legally, but I don't want to be offering guidelines for something I have absolutely zero expertise in. Making sense of studies' conclusions is one thing; recommending dosages for a drug I've never even used myself (at least with plain lido I can give anecdotal recommendations) is entirely another.I'm not so much saying lido with epi is a good idea, as you mentioned that I was, but rather that lido with epi is not a one way trip to losing your finger, as it often is regarded as in the dogma - while it should be treated cautiously, it is not necessarily contraindicated for digital work. I'm definitely not recommending it over lido (since plain lido is way less complicated to monitor, as you mentioned), and certainly have no clue where to begin for dosing it haha :)
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That's understandable. Your inspiring me to update and clean up my blog stuff too.
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Just made a quick post.Haha that's good - I know I don't have many viewers on my blog, but I do as much SEO as I can in the hopes that someone will see it and find it helpful in the future... Especially considering how much your blog is pointed to as a paragon reference for self magnet implantation, I'm sure the entire community would be thrilled to have it look even cleaner and up to date :D
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So, just out of curiosity because of @cassox post about Hemostasis, What would happen if you used both the Lido+epi and a tourniquet?
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Lidocaine with epinephrine serves as a vasoconstrictor to reduce bloodflow to the digit. Common wisdom suggests that would cause ischemia and necrosis. However, studies have shown that not to be the case - although it does still vasoconstrict regardless. Using another method of hemosstasis such as a tourniquet would also stop bloodflow. Combining a tourniquet with lido/epi would vasoconstrict and physically compress the blood vessels, almost definitely cutting bloodflow off so much that the digit is in danger. You gotta choose one or the other; using both cuts off too much bloodflow.
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That's what I suspected. Just wanted to double check.
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I had a chance to crack open a crash cart today anyways, so I thought I show you what I'm talking about with the epinephrine concentration differences.
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Can see the pic but not the detail; any high resolution?
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I would recommend not doing that. if someone really wants epi, it's not all that hard to get a hold of. Shipping someone epi might pose an actual liability risk, as opposed to magnets or w/e
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Well, I want some free epi. Apparently it's totally inactivated in the GI tract BUT! some more recent studies have found that it can absorb really effectively sublingual. I've been considering trying low dose epi - but of course a tiny dose wouldn't be worth an injection. Sublingual though? Hmmm... a novel stimulant for me.
Of course, I wouldn't go on a public forum and ask for someone to do something illegal. If I was serious, I would have PM'd you. Just thinking out loud.
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There are so many stimulants (and non stimulants) I'd try before epinephrine...at least one that would lend itself to a euphoric experience or focussing. What attracts you to epi specifically?
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Nothing in particular beyond novelty. Because we're discussing low dose, I would imagine the effects to be somewhat similar to a norepinephrine reuptake inhibitor... which I'm not terrible fond of. I've tried the vast majority stimulants available. Each has certain advantages and drawbacks. Amphetamines for example are superior to methylphenidate Hcl, but there's the whole issue of neurotoxicity. A prescription is easy to obtain so legality isn't a problem, but there are some long term behavioral shifts imho (and the opinion of various studies.) Provigil/nuvigil/etc. are all ok. Awake without the up. Unfortunately over the long term - elevated liver enzymes and the need for monitoring, etc.
Adenosine inhibition - i.e. caffeine sure, sure. Good stuff. So is ephedrine/psuedoephedrine, but there are potential long term cardiac issues. Also each of these stimulants have varying effects on cognition and memory, mix differently with various meds and substances. There's a lot to it. Many many stimulants are either indirectly or even directly affecting acting on the sympathetic nervous system. Epinephrine is the endogenous ligand for this pathway, so it only makes sense that a low dose sampling would be a worth trialing. Now, don't mistake this as being some kind of attempt or interest in getting high or anything. Epinephrine isn't euphoric in the slightest. It's probably nasty like ephedrine; however it's inhalable, insulflatable, and absorbes through mucous membranes etc. It's interesting.
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Eesh. Isn't there an antidote or something you could take?
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