Epinephrine Use in the Fingers
Bibliographic record
Abstract
Sir: We thank Drs. Mandrekas and Zambacos for their interest in the elective use of epinephrine in the finger and for their confirmation of its safety in their experience. We have heard from several other groups around the world who have also been routinely using adrenaline electively in the finger with no adverse effects. Our own interest in adrenaline in the hand began with the large clinical experience of excellent Canadian hand surgeons, including Bob MacFarlane, Pat Shoemaker, John Fielding, and Mike Bell, who had a combined experience of well over 100 surgeon-years of elective injection of epinephrine into fingers without a single loss of a digit. There was a clear disconnect between the real experience of these good surgeons and the myth of epinephrine danger in the finger, which is still erroneously taught to many medical students and quoted in some major textbooks. We confirmed that phentolamine was a reliable and safe reversal agent for epinephrine-induced vasoconstriction in the finger by enrolling 18 Dalhousie University alumni hand surgeons among volunteers to have their own fingers injected with epinephrine and phentolamine.1 We then undertook a prospective study of 3110 consecutive cases of elective epinephrine injections by nine surgeons in six cities. This study confirmed that not one patient experienced any necrosis, and not even one patient required phentolamine rescue.2 Keith Denkler’s landmark article3 showed that there was not one case of lidocaine with epinephrine causing finger infarction in the world literature from 1880 to 2000. This work led us to the discoveries in our current article, which indicate that the likely source of the epinephrine myth was degenerated acidic procaine. Why is this topic a very important one? We were first interested in elective use of epinephrine in the finger so we could operate on these patients under pure local anesthesia. The main goal was to avoid the tourniquet, anesthesiology, and dependency on main operating rooms, which can be difficult to access in Canada. We then found other important benefits, which included improving the results of our hand surgery team by communicating with pain-free (tourniquet-free) patients during surgery and having them actively move reconstructed structures so that adjustments could be made before the skin was closed. This has been particularly helpful in tendon repair, tendon transfer, tenolysis, finger fractures, and so on. We no longer have to subject older hand patients with medical problems to the risks of sedation. We have also found it much cheaper and much more comfortable for patients to have tourniquet-free carpal tunnel and trigger finger releases in the clinic or office outside the main operating room. Almost all of our hand surgery procedures are now performed with the patient under pure local anesthesia, with no tourniquet and no sedation (wide awake approach), outside of the main operating room with field sterility. For much of the world that cannot afford the expense of a main operating room and general anesthesia, this approach will be a major step forward for hand surgery. Donald H. Lalonde, M.D., M.Sc. Christopher James Thomson, M.D. Keith Denkler, M.D. Anton Feicht, Ph.D. Division of Plastic Surgery Queen Elizabeth II Health Sciences Center Dalhousie University Halifax, Nova Scotia, Canada
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.008 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".