I have read that epinephrine added to the lidocaine is a bad idea for a use in circumcision. Is this true?
A really interesting comment; because others contemplating circumcision under a local might have mistaken concern about it, I'll try to give as good an answer as I can.
The idea about being cautious in using epinephrine is right, but it's rarely contraindicated in circumcision: some qualifying if's and where's may have gotten lost in what you recall. Epinephrine or any drug that produces local vasoconstriction is definitely to be avoided in areas where it could compromise adequacy of haemoperfusion and predispose to slow healing or infection by anaerobes, potentially setting the stage for sloughing or even (ta-da!) gangrene.
The textbook example is that one does NOT do a ring block of a toe or finger. Why then is a penis different from a finger? Because its blood supply is enormously greater (the incoming dorsal artery is of such caliber as not to have its blood flow significantly impeded by the vasoconstriction epinephrine would induce) and more distributed, with a Byzantine net of anastomoses amongst myriad smaller vessels. Structurally, the area of interest consists of highly vascularised connective tissue (external to Buck's fascia) surrounded by a LOOSE, distensible integument. This allows expansion when swelling occurs either as a result of the injection, or later as a response to surgical trauma. The blood vessels traversing the region are NOT therefore unduly compressed.
The situation with a finger or toe is quite otherwise: the only blood supply is essentially through four small arteries, two located on either side dorsally and two on the palmar or plantar aspect of each. The skin covers each digit tightly and is essentially non-distensible without producing a lot of compression within the surrounding tissues. And at the center of everything there is a solid, unyielding core of bone. Circulatory insult had best be avoided in a body part with relatively restricted circulation in the first place - note that our fingers and toes often get cold, while our cock rarely does.
In the right circumstances, epinephrine can do all sorts of good things. As an adjunct in local anesthesia, it can both minimize bleeding and hold the anesthetic agent in place longer, so you need use less of it. Dentists inject epinephrine with the local anesthetic agent to get solid, long-lasting nerve blocks or to infiltrate around the operative site.
Nothing ever comes without a downside: the very vasoconstriction that allows you to kick a patient out of impending haemodynamic shock and circulatory collapse could precipitate a crisis in one with hypertension, a circumstance to be avoided! Systemically, it accelerates heart rate and can make people feel nervous, anxious and edgy for awhile.
Epinephrine is an appropriate and valuable adjunct in achieving good local anesthesia and perhaps in bettering haemostasis during circumcision or any number of other minor surgical procedures.. The amount actually employed for the operation would be unlikely to produce any systemic effects in the normal adult. Thanks for bringing the matter up for discussion.
-- Check
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