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Medical Forum / General / General / March 2004Epinephrine routine for surgery under local without IV?
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. Sherry > 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.  SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. 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 > 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). > 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. > 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). > 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. > 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. SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. > Medicine is a hobby for me, not a profession. (!) > Everybody should have a hobby. I tried dentistry as a hobby, but found it really didn't cut it as a hobby. Steve > (!) Why the surprise? SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. I've had two biopsies under local since 1981 and an impacted wisdom tooth removed in the late 70's, so there's a good chance I've had epi already. After the injections for the biopsies I had no anxiety symptoms (other than the ones I had BEFORE the injections :) ) but I do remember having anxiety symptoms after the injections post 1990 with dental work, either root canals or drilling. At least if I have the anxiety, I'll chalk it up to the epi, at least if it's not unbearable. I plan to make a couple of phone calls to friends announcing the 'start' of my procedure after my first round of injections, which I assume will contain epi. Maybe that will help with any anxiety symptoms. Thanks for your answers and to all other posters contributing to this thread. SHerry >>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 [quoted text clipped - 18 lines] > 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 > 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. > 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). SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. >>Usually reaction to vasoconstrictor in a local anesthetic (in the >>dental setting) is due to intravascular injection. This is usually [quoted text clipped - 5 lines] > 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. > 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 [quoted text clipped - 5 lines] > 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. >>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 > 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. > 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. SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. I have labile hypertension (controlled by meds but my systolic is not usually as low as 120 but it's not usually 150 either). Also I have "whitecoat" hypertension. My primary care knows about the epi I will be having and he said he's not concerned. Also planned is to take at least 5 mg. valium to help with the whitecoat. I still find it strange that a nonpsych drug can directly cause anxiety symptoms. Sherry > I have labile hypertension (controlled by meds but my systolic is not usually > as low as 120 but it's not usually 150 either). Also I have "whitecoat" > hypertension. My primary care knows about the epi I will be having and he said > he's not concerned. Also planned is to take at least 5 mg. valium to help with > the whitecoat. I still find it strange that a nonpsych drug can directly cause > anxiety symptoms. Sherry Well, meds can have all kinds of side effects unrelated to their primary intended effect. But while tremor and lightheadedness can be associated with anxiety, the epinephrine doesn't directly cause anxiety. But because it acts on the autonomic nervous system (also provoked by fear and physical threats--the old fight-or-flight response), its effects can certainly feel like anxiety. Steve > I still find it strange that a nonpsych drug can directly cause > anxiety symptoms. It produces changes that we associate with anxiety, since the same substance is released internally in our bodies when we are frightened, when we panic, when we are startled, and so on. It doesn't really produce anxiety per se, but it produces the tensed, ready-to-flee state of the body that we normally only experience when we are suddenly anxious. SignatureTranspose hotmail and mxsmanic in my e-mail address to reach me directly. My doctor will have to use epi for my surgery under local. :/ Sherry |
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