Reversal of Digital Ischemia with Phentolamine After Accidental Epinephrine Injection

Extensive skin necrosis following total hip arthroplasty performed through the direct anterior approach

BACKGROUND

Total hip arthroplasty is a widely performed surgical procedure, which enables patients to regain mobility, alleviates pain, and improves overall quality of life. Periarticular multimodal drug infiltration (PAI) is increasingly being used as an effective postoperative pain management, decreasing the systemic consumption of opioids. Extensive postoperative skin necrosis without a deep joint infection as a complication of total hip arthroplasty with PAI has not yet been described.

CASE PRESENTATION

A 71-year-old patient who underwent total hip arthroplasty of the right hip for primary osteoarthritis through the Direct Anterior Approach presented postoperatively a large area of necrotic skin at the incision. Joint infection was excluded. An extensive debridement was performed and the tissue defect was reconstructed by a pedicled anterolateral thigh flap. The skin maintained a satisfactory appearance at 1 year postoperatively, and the hip was pain-free with restored ranges of motion. The patient was able to walk with no support and without limitation.

CONCLUSION

We address the possible risk factors, discuss the use of epinephrine in PAI and explore possible treatment options for such a complication.

Accidental Digital Ischemia by an Epinephrine Autoinjector

Epinephrine is the first line of management of anaphylaxis. Autoinjectors rapidly deliver epinephrine in anaphylaxis in the community. Patients and caregivers have safety concerns regarding their use. Accidental digital injection is a frequently encountered problem that can lead to digital ischemia. Immersion of the affected digit in warm water and topical nitroglycerine are usually used. If the symptoms persist, the patient discomfort and the possible risk of losing the digit might require an invasive approach. Local infiltration with phentolamine is mentioned in different case reports. We report a case of successful management of digital ischemia from epinephrine auto injector using phentolamine.

The potential value of exosomes as adjuvants for novel biologic local anesthetics

The side effects of anesthetic drugs are a key preoperative concern for anesthesiologists. Anesthetic drugs used for general anesthesia and regional blocks are associated with a potential risk of systemic toxicity. This prompted the use of anesthetic adjuvants to ameliorate these side effects and improve clinical outcomes. However, the adverse effects of anesthetic adjuvants, such as neurotoxicity and gastrointestinal reactions, have raised concerns about their clinical use. Therefore, the development of relatively safe anesthetic adjuvants with fewer side effects is an important area for future anesthetic drug research. Exosomes, which contain multiple vesicles with genetic information, can be released by living cells with regenerative and specific effects. Exosomes released by specific cell types have been found to have similar effects as many local anesthetic adjuvants. Due to their biological activity, carrier efficacy, and ability to repair damaged tissues, exosomes may have a better efficacy and safety profile than the currently used anesthetic adjuvants. In this article, we summarize the contemporary literature about local anesthetic adjuvants and highlight their potential side effects, while discussing the potential of exosomes as novel local anesthetic adjuvant drugs.