Safety of Lidocaine with Epinephrine in Toe Injections

Evidence Supporting Safety in Digits

• Multiple systematic reviews and randomized controlled trials have conclusively demonstrated that adding epinephrine to local infiltrative anesthesia is safe for use in digits, including toes, with no cases of necrosis reported 1, 2.
• The American Academy of Dermatology guidelines give a strong recommendation (Level A) for the addition of epinephrine to local anesthesia on digits 2, 3.

Benefits of Using Epinephrine with Lidocaine

• Prolongs the duration of anesthesia by approximately 200% when used in concentrations of 1:50,000, 1:100,000, or 1:200,000 1.
• Reduces the need for tourniquet use during procedures 1.
• Slows mobilization of the anesthetic, reducing peak blood levels and potential systemic toxicity 3.

Recommended Technique

• Use the lowest effective concentration of epinephrine (typically 1:100,000 or 1:200,000) to provide adequate pain control and vasoconstriction 1.
• Buffering the lidocaine with sodium bicarbonate can decrease the pain of injection 3.

Conclusion

• Current evidence strongly supports the safety of lidocaine with epinephrine for toe injections, with significant clinical benefits including prolonged anesthesia and improved surgical field visualization 1, 2, 3.

Local Anesthesia with Bicarbonate Addition

Safety and Efficacy

• The American Academy of Dermatology guidelines support mixing local anesthetics with various additives, including bicarbonate, for dermatologic procedures, with no raised safety concerns 4

Clinical Application

• The addition of bicarbonate to lidocaine with epinephrine is compatible with standard dermatologic procedures, including biopsies, excisions, and wound closures, and is simple to perform, inexpensive, and safe for use in digits and other anatomical locations 5, 6