Assessment and Management of Hand Ischemia

Clinical Presentation and Assessment

The American Society of Anesthesiologists recommends assessing for signs of hand ischemia, including skin color changes, such as pallor, mottling, or cyanosis of the hand/fingers, in patients who develop increased pain and numbness after lidocaine injection during carpal tunnel surgery 1
The assessment should also include capillary refill time, with delayed (>2 seconds) or absent refill being a sign of ischemia 2
Temperature changes, such as cold fingers compared to the contralateral hand, should also be evaluated 3
Pulses, including radial and ulnar artery pulses, and digital pulses if palpable, should be assessed 1
Motor function, including the ability to move fingers, should be evaluated 1

The American Heart Association recommends having lipid emulsion 20% readily available wherever lidocaine is used, in case of systemic toxicity 3, 5, 2
The initial management step should include stopping any ongoing injection immediately 1
Assessing hand perfusion, including color, temperature, capillary refill, and pulses, is crucial 2
Monitoring vital signs for systemic toxicity signs, such as cardiovascular monitoring (ECG, pulse oximetry, blood pressure every 5 minutes during initial infusion), is essential 4, 1

The American Society of Anesthesiologists recommends being prepared for potential pharmacologic intervention, such as phentolamine for epinephrine-induced vasospasm, if ischemia is present 1
Having lipid emulsion readily available is crucial in case of systemic toxicity 3, 5, 2
Documenting findings and preserving any equipment for investigation is important 3, 2