Epinephrine routine for surgery under local without IV?

FreespiritedFem said:

I'd like to know more about when "epi" is used prior to
surgery, especially when injected along with the local
anesthetic. Is it virtually always used provided the
patient is not sensitive to it? Are there any surgeries
done under local when it's normally NOT used? How long has
it been used routinely during surgeries under straight
local? Any details would be appreciated.

It is routinely blended with local anesthetics because it
causes vasoconstriction (constriction of local blood
vessels), which prolongs the action of the anesthetic by
slowing its dispersal to the rest of the body. If the
anesthetic is properly administered, usually no systemic
effects are evident; but large doses or improper
administration might allow some systemic effects to become
obvious. This is especially important for patients at risk
(heart problems, etc.). The amount of epinephrine in the
anesthetic is quite small (one part in 50,000 or 100,000 for
dental preparations, for example).

I had a ton of local anesthetic (xylocaine + epinephrine)
for a root canal once, and after a couple of injections the
systemic effects hit me, and it wasn't very pleasant,
although I recognized the nervous feeling as an effect of
the epinephrine. I advised the dentist of it but he had
already finished administering his anesthetic anyway. It
wore off after a minute or two. Sure makes one feel
panicky, though.

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I did read about the anxiety reaction from epi, which I found strange since
it's not a psych drug. I'm wondering if the heart racing some experience is
what really causes the anxiety. Do you know if epi was routinely used for
surgery as far back as the early 1980's? Thanks for your info. I think I've
had replies from your name before. Do you have a med background by any chance?
Just curious, as I realize many laypeople have great health and medical
knowledge also. 🙂 Sherry

Mxsmanic said:

FreespiritedFem said:

I'd like to know more about when "epi" is used prior to
surgery, especially when injected along with the local
anesthetic. Is it virtually always used provided the
patient is not sensitive to it? Are there any surgeries
done under local when it's normally NOT used? How long has
it been used routinely during surgeries under straight
local? Any details would be appreciated.

It is routinely blended with local anesthetics because it
causes vasoconstriction (constriction of local blood
vessels), which prolongs the action of the anesthetic by
slowing its dispersal to the rest of the body. If the
anesthetic is properly administered, usually no systemic
effects are evident; but large doses or improper
administration might allow some systemic effects to become
obvious. This is especially important for patients at risk
(heart problems, etc.). The amount of epinephrine in the
anesthetic is quite small (one part in 50,000 or 100,000
for dental preparations, for example).

I had a ton of local anesthetic (xylocaine + epinephrine)
for a root canal once, and after a couple of injections
the systemic effects hit me, and it wasn't very pleasant,
although I recognized the nervous feeling as an effect of
the epinephrine. I advised the dentist of it but he had
already finished administering his anesthetic anyway. It
wore off after a minute or two. Sure makes one feel
panicky, though.

Usually reaction to vasoconstrictor in a local
anesthetic (in the dental setting) is due to
intravascular injection. This is usually after an
inferior alveolar nerve block, though it can happen
in any injection. However, I have had patients so
sensitive they can feel it even when there is no
intravascular injection. I know this because a
patient once told me, so I notated on the chart to
use only anesthetic without vasoconstrictor. I
forgot though, and after giving an injection she
looked at me and said, "You used epinephrine,
didn't you?" I 'fessed up, and was more careful
after that. ;-)

Steve

FreespiritedFem said:

I did read about the anxiety reaction from epi, which I
found strange since it's not a psych drug.

It governs the fight-or-flight feeling that you get in an
emergency; that's the feeling it produces in systemic
administration. You feel very jittery without quite knowing
why. If you know what's causing it, you can ignore it to a
certain extent, but it's still very uncomfortable, as it's
just like the feeling you have after narrowly missing an
accident or something (and understandably so, since it's the
very same substance).

Quoted message said:

I'm wondering if the heart racing some experience is what
really causes the anxiety.

It might have a part in it, especially if you worry a lot
about your heart.

Quoted message said:

Do you know if epi was routinely used for surgery as far
back as the early 1980's?

It has been used for longer than that for local anesthesia.

It is not used for general anesthesia, as it serves no
purpose in that case. Remember, the idea of including it is
just to slow the dispersal of a local anesthestic from the
site at which it was administered (tooth, arm, wherever).

Quoted message said:

I think I've had replies from your name before. Do you
have a med background by any chance?

Medicine is a hobby for me, not a profession.

Quoted message said:

Just curious, as I realize many laypeople have great
health and medical knowledge also.

There are lots of lay people who are knowledgeable in many
areas. One need not do something for a living in order to
know something about it.

--
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me directly.

Steven Bornfeld said:

Usually reaction to vasoconstrictor in a local anesthetic
(in the dental setting) is due to intravascular injection.
This is usually after an inferior alveolar nerve block,
though it can happen in any injection.

In my case, I only felt it after several repeated
injections for a root canal. I suspect it was just the
total dose that did it, although I suppose some
intravascular penetration is possible. He was a very good
dentist, though, so I'm not sure.

In every other case, at lower, single or limited doses, I've
felt nothing. Even in the case where I felt it, it was very
transient--I knew it might happen and perhaps I was just
very sensitive to any change. But I knew that the
_irrational and unjustified_ feeling of panic had to be
coming from some chemical cause. It was disagreeable, but I
worried more about the cardio effects than the general
anxiety (but I have no CV history so I probably worried for
nothing). I did mention to the dentist that I could feel the
epinephrine, but since he had just finished the injections,
it mattered not.

Quoted message said:

However, I have had patients so sensitive they can feel it
even when there is no intravascular injection.

Maybe I was in that category ... although I've never felt it
in any other circumstances than for that root canal. It
faded very quickly (30 to 60 seconds, I'd say).

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Mxsmanic said:

Medicine is a hobby for me, not a profession.

(!)

Quoted message said:

Everybody should have a hobby. I tried dentistry as
a hobby, but found it

really didn't cut it as a hobby.

Steve

Mxsmanic said:

Steven Bornfeld said:

Usually reaction to vasoconstrictor in a local anesthetic
(in the dental setting) is due to intravascular injection.
This is usually after an inferior alveolar nerve block,
though it can happen in any injection.

In my case, I only felt it after several repeated
injections for a root canal. I suspect it was just the
total dose that did it, although I suppose some
intravascular penetration is possible. He was a very good
dentist, though, so I'm not sure.

Anyone can make an intravascular injection in
susceptible areas. We use aspirating syringes--that
is, we can draw back into the syringe to see if
we're in a blood vessel--if we are, we'll see blood
coming into the syringe. If this happens we move the
needle, but if there's bleeding in the area we may
then get a little blood on aspiration no matter how
we move it, and if we move it enough to avoid blood
we're often too far away from the nerve to achieve
adequate anesthesia. It's just one of those things.

Quoted message said:

In every other case, at lower, single or limited doses,
I've felt nothing. Even in the case where I felt it, it
was very transient--I knew it might happen and perhaps I
was just very sensitive to any change. But I knew that the
_irrational and unjustified_ feeling of panic had to be
coming from some chemical cause. It was disagreeable, but
I worried more about the cardio effects than the general
anxiety (but I have no CV history so I probably worried
for nothing). I did mention to the dentist that I could
feel the epinephrine, but since he had just finished the
injections, it mattered not.

Well, the other issue is that if the injection is
intravascular, there may not be enough in the area
of the nerve to achieve anesthesia. It is wise to
avoid anesthetic solutions with vasoconstrictors
with a significant cardiac history or uncontrolled
hypertension, but the actual amount of
vasoconstrictor is pretty small--most solutions
used have only one part epinephrine to 100,000 in
the solution.

Quoted message said:

Quoted message said:

However, I have had patients so sensitive they can feel it
even when there is no intravascular injection.

Maybe I was in that category ... although I've never felt
it in any other circumstances than for that root canal. It
faded very quickly (30 to 60 seconds, I'd say).

It almost always is dispersed quickly.

Steve

Steven Bornfeld said:

(!)

Why the surprise?

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Steven Bornfeld said:

Well, the other issue is that if the injection is
intravascular, there may not be enough in the area of the
nerve to achieve anesthesia.

He did a remarkable job in that respect. The specific tooth
needing the root canal was absolutely dead to the world once
he administered the anesthesia (and it had been excruciating
only a few minutes before). And none of the surrounding
teeth or tissue were numb; no "fat cheek" feeling or any
numbness anywhere at all. This was a third molar on the
bottom, if that makes any difference. Very nice work, in any
case. I almost fell asleep in the chair several times during
the root canal.

Quoted message said:

It is wise to avoid anesthetic solutions with
vasoconstrictors with a significant cardiac history or
uncontrolled hypertension, but the actual amount of
vasoconstrictor is pretty small--most solutions used have
only one part epinephrine to 100,000 in the solution.

He did ask if I had any history before beginning.

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