Vasoconstrictor Additive in Local Anaesthesia Pregnancy: Use with caution — epinephrine causes uterine vasoconstricton; minimal risk with small doses in local anaesthesia; avoid large volumes near uterus.

Epinephrine (Adrenaline) in Local Anaesthesia

Brand names: Xylocaine with Adrenaline, Lidocaine + Adrenaline

Adult dose

Dose: 1:200,000 epinephrine (5 mcg/mL) combined with lidocaine; 1:100,000 (10 mcg/mL) for oral/dental. Volume per field: as required for infiltration. Tumescent: 1:1,000,000 (1 mcg/mL) in liposuction. Digital blocks: 1:100,000 or 1:200,000 is safe

Route: Intradermal / subcutaneous injection (with local anaesthetic)

Frequency: Single perioperative infiltration; repeat dosing subject to total dose limits

Max: Epinephrine: 200–250 mcg total dose in one session (cardiac risk with higher doses); concurrent with lidocaine: max lidocaine 7 mg/kg with epinephrine (vs 3 mg/kg without)

Vasoconstriction from epinephrine: (1) reduces bleeding in surgical field; (2) slows local anaesthetic absorption — increases duration of anaesthesia 2–3× and increases safe dose ceiling. MODERN EVIDENCE: epinephrine in digit blocks IS SAFE — multiple studies (Denkler 2001, Wilhelmi 2001; 2877 cases, 0 necrosis) have definitively disproved the historical contraindication; phentolamine antidote available.

Paediatric dose

Route: Intradermal/subcutaneous

Frequency: Single perioperative infiltration

Max: Epinephrine dose guided by lidocaine dose limit (7 mg/kg with epinephrine in children)

Safe in children with same considerations as adults. Paediatric plastic surgery routinely uses lidocaine+adrenaline for facial lacerations and minor procedures.

Dose adjustments

Renal

Not applicable — local use with minimal systemic absorption at standard doses.

Hepatic

Not applicable.

Clinical pearls

Digital block epinephrine — myth debunked: the historical teaching 'never use adrenaline in digits' originated from historical case reports using cocaine and non-pH-buffered acidic solutions with high concentrations. Modern systematic reviews (Thomson et al. 2007 — 2877 cases with lidocaine+epinephrine digital blocks) show zero cases of digital necrosis. Antidote phentolamine (0.5–1 mg SC) reverses vasoconstriction if needed. Many UK plastic surgery units now routinely use digit blocks with 1:200,000 adrenaline
Buffering reduces vasoconstrictive side effects: pH-buffered lidocaine+adrenaline (adding sodium bicarbonate 1:10 ratio) reduces pain on injection AND improves tissue pH — reducing localized acidosis-related ischaemia risk. Also speeds onset of anaesthesia
Tumescent anaesthesia: in liposuction, superdilute adrenaline 1:1,000,000 in large volumes (1–3 L) — peak systemic absorption occurs 12–14 hours post-injection (not immediately); total epinephrine doses can reach 50–70 mg — cardiac monitoring during and after procedure is mandatory

Contraindications

IV injection (accidental intravascular injection — potentially fatal tachyarrhythmia and hypertension)
End-arterial injection in areas with true end-arteries — historically digits/penis/ear considered end-arteries; MODERN EVIDENCE: digits are NOT true end-arteries (anastomotic connections exist) — safe with buffered lidocaine+epinephrine; penis and ear: additional caution still warranted

Side effects

Tachycardia and palpitations (systemic absorption)
Anxiety (adrenergic stimulation)
Hypertension (large volume or accidental intravascular injection)
Tissue ischaemia (historical concern for digits — now evidence-based to be extremely rare with modern techniques)
Pallor at injection site (expected vasoconstrictive effect — not ischaemia)

Interactions

MAOIs (hypertensive crisis — avoid within 14 days)
Beta-blockers (unopposed alpha stimulation — hypertension with tachycardia; rare with local doses)
Volatile anaesthetics (halothane — myocardial sensitisation; avoid or use minimal epinephrine dose)

Monitoring

HR and BP (during and after large-volume infiltration)
Digital/tissue perfusion (capillary refill, colour — reassurance of adequate perfusion)
Total lidocaine dose (concurrent tracking — weight-based maximum)
Signs of intravascular injection (immediate tachycardia, pallor, anxiety = stop immediately)

Reference: BNFc; BNF 90; Denkler K. Plast Reconstr Surg 2001 (digital epinephrine); Thomson CJ et al. Plast Reconstr Surg 2007 (2877 cases); MHRA SPC Xylocaine with Adrenaline; BNFc. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators