Post-traumatic Digital Gangrene Associated with Epinephrine Use in Primary Raynaud's Phenomenon: Lesson for the Future

Limb Necrosis in the Setting of Vasopressor Use

BACKGROUND

It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis.

OBJECTIVE

To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy.

METHODS

A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded.

RESULTS

The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups.

CONCLUSION

The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

Adrenaline auto-injector injuries: Practical considerations in emergency management in a tertiary hand surgery unit

Adrenaline auto-injectors are the first line treatment for anaphylaxis in the community setting. Both anaphylaxis and auto-injector carriage are increasing in prevalence. Adrenaline auto-injector injuries are common and most often involve the hand or digits. Such injuries carry a risk of ischemic necrosis due to profound vasoconstriction, especially if there is undying vascular pathology such as Raynaud's disease. The effects can be readily reversed with local infiltration of phentolamine. A survey was circulated to 40 clinicians working in the emergency and hand surgery departments of a major urban center. Knowledge of adrenaline duration of action and its reversal (agent, dose and location in the hospital) was assessed. All clinicians working within the two departments were eligible for participation. Only 25% of clinicians surveyed were aware of the duration of action of adrenaline. Half were aware of the correct reversal agent and only 20% knew the correct dose. Only one person was aware of phentolamine's location within the hospital. There is relatively poor clinician knowledge surrounding adrenaline reversal and a lack of easily accessible information available about dosing and drug location within the hospital. Given the time dependent nature of adrenaline auto-injector injuries Emergency Departments should consider stocking phentolamine in an emergency drugs fridge within the department along with a dosing guide. This is likely to greatly reduce time from presentation to treatment and thus the chances of digital ischemia progressing to necrosis.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility

SUMMARY

Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Digital ischemia after lidocaine with epinephrine injection in a patient with primary Raynaud's phenomena

Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature supports the overall safety of this, significant physiologic changes accompanying epinephrine can disproportionately affect vascularly compromised patients, such as in Raynaud's phenomenon. The literature is reviewed and a case presented regarding the dangers of epinephrine injection in this population.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

Repurposing Cilostazol for Raynaud's Phenomenon

Raynaud 's Phenomenon (RP) results from exaggerated cold-induced vasoconstriction. RP patients suffer from vasospastic attacks and compromised digital blood perfusion leading to a triple color change at the level the fingers. Severe RP may cause ulcers and threaten tissue viability. Many drugs have been used to alleviate the symptoms of RP. These include calcium-channel blockers, cGMP-specific phosphodiesterase type 5 inhibitors, prostacyclin analogs, and angiotensin receptor blockers. Despite their variety, these drugs do not treat RP but rather alleviate its symptoms. To date, no drug for RP has been yet approved by the U.S Food and Drugs Administration. Cilostazol is a selective inhibitor of phosphodiesterase-III, originally prescribed to treat intermittent claudication. Owing to its antiplatelet and vasodilating properties, cilostazol is being repurposed as a potential drug for RP. This review focuses on the different lines of action of cilostazol serving to enhance blood perfusion in RP patients.

Carpal Tunnel Syndrome Surgery: What You Should Know

Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.

Surgical site infection leading to gangrene and amputation after ambulatory surgical care of an ingrown toenail: a case report

Background

Currently, the management of ingrown toenail (onychocryptosis) ranges from conservative medical management to surgical treatment. Surgical management is typically performed as an outpatient procedure due to it numerous advantages such as the simplicity of the technique and the low incidence of postoperative complications. The most common postoperative complications are recurrences and surgical site infections, whereas gangrene complicating a surgical site infection has been scarcely reported. We are reporting a rare complication following ambulatory surgery untimely requiring amputation.

Case presentation

A twelve-year-old boy was referred to our orthopedic surgical department for a surgical site infection complicating an initial surgical management of a left ingrown big toenail leading to a dry gangrene of the affected toe. The gangrene toe was amputated under peripheral nerve block and the patient was discharged home the same day on antibiotics, analgesics and with sessions of rehabilitation and psychological support planned. The postoperative course was uneventful at 6 months of follow-up.

Conclusion

The authors report this case to draw clinicians’ attention, especially wound care specialists, orthopedists and podiatrists to this rare but potentially debilitating disease.

Conceptual origins, current practice, and views of wide awake hand surgery

This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.