Phentolamine Rescue for Digital Ischemia Following Lidocaine with Epinephrine Local Anesthesia: Case Presentation, Review of the Literature and Treatment Options.

The use of low-dose 1 percent lidocaine with epinephrine (1:100,000) has changed the practice of hand surgery. The safety of lidocaine and epinephrine in hand surgery has been well documented. Although rare, epinephrine-induced digital vasospasm can occur leading to tissue necrosis and amputation. Fortunately, digital ischemia can be reversed with phentolamine. We present a case of epinephrine-induced vasospasm following the use of 1 percent lidocaine with 1:100,000 epinephrine injected for a small finger flexor tendon and nerve repair. The multiple risk factors for digital ischemia and the role of phentolamine as an antidote to reverse epinephrine-induced ischemia are reviewed. Reversal of epinephrine-induced vasospasm using phentolamine rescue should be available to any provider using lidocaine with epinephrine in the hands and digits. Additionally, in more rural healthcare areas, a prophylactic post-procedure phentolamine injection might be considered in patients with multiple comorbidities which may predispose them to epinephrine-induced vasospasm.