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Can Elimination of Epinephrine in Rhinoplasty Reduce the SideEffects: Introduction of a New Technique Abdoljalil Kalantar-Hormozi • Alireza Fadaee-Naeeni •Siavash Solaimanpour • Naser Mozaffari •Hamed Yazdanshenas • Shahrzad Bazargan-Hejazi Received: 6 September 2010 / Accepted: 24 January 2011Ó The Author(s) 2011. This article is published with open access at Springerlink.com We aim to provide evidence that despite not (4–6 mg/kg/h) with an infusion pump, in addition to administering epinephrine, (1) the amount of hemorrhaging N2O–O2 (50%). Atracurium was repeated (5 mg every during surgery will not change, (2) surgery time will not 20 min). Patients in the control group received an epi- increase and may even be shorter, and (3) there would be nephrine (1/100,000) injection to the nose, and patients in fewer cardiovascular-related consequences.
the intervention group did not. All patients received One hundred thirteen patients were enrolled and dexamethasone (8 mg IV) and metoclopramide (10 mg IV).
randomized into the control (n = 74) and intervention At the end of the operation and before extubation, the muscle groups (n = 39). During the primary open or closed rhi- relaxants were reversed with prostigmine (0.35 mg/kg) and noplasty operation, anesthesia was managed by continual We found (1) no statistically significant associa- tion between epinephrine injection and hemorrhage during or after surgery (P = 0.949), (2) a statistically significant association between epinephrine injection and complica- 15 Khordad Hospital, Tehran, Irane-mail: kalantarj@yahoo.com tions, and (3) the group that did not receive the injectionhad fewer complications (P = 0.01). With respect to the duration of surgery, we did not detect any statistically Shahid Beheshti University of Medical Sciences, Tehran, Iran significant associations between the groups.
Elimination of epinephrine during rhinoplasty as an alternative procedure may lead to the same surgery Guilan University of Medical Sciences, Guilan, Iran outcomes if not a better one. Studies with a larger sample size are needed to further substantiate these findings.
S. SolaimanpourPersian General Hospital, Tehran, Iran Epinephrine Á Lidocaine Á Rhinoplasty Á Local H. YazdanshenasTehran University of Medical Sciences, Tehran, Irane-mail: hyazdanshenas@yahoo.com With increasing demands for plastic surgery in recent Charles Drew University of Medicine and Science,1731 E. 120th Street, Los Angeles, CA 90059, USA years, the number of rhinoplasties has also shown an e-mail: shahrzadb@ucla.edu; shahrzadbazargan@cdrewu.edu upward trend. The anatomy of the nose, with its vascularstructure and limited area for maneuvering, restricts the surgeon’s access and visibility during a rhinoplasty.
Department of Psychiatry, David Geffen School of Medicine,University of California Los Angeles, Los Angeles, CA, USA Therefore, most surgeons have been using lidocaine/ epinephrine (i.e., 2% ? 1/100,000; this is the combination As highlighted in the above-cited literature, there is a that we refer to, for similar terms, throughout the article) debate among surgeons regarding the use of epinephrine with local anesthetics as a way to locally anesthetize and with local anesthetics as a way to locally anesthetize and prepare the region for operation. Indeed, this method has prepare the region for operation. This debate is partly due become a standard procedure and current practice for most to the paucity of research providing convincing evidence for a safe dose of a lidocaine/epinephrine combination, Local anesthetics containing epinephrine are also rou- especially for patients with a history of myocardial tinely used in functional endoscopic sinus surgery (FESS) infarction or those who are sensitive to epinephrine or mainly for hemostasis []. In a survey of 360 otorhinolar- preservatives that are contained in lidocaine/epinephrine yngologists in the UK, the majority of the surgeons reported using cocaine preoperatively because it provides a greater The overall goal of this study was to provide empirical operative field. Nearly 70% of these surgeons reported using evidence that administration of lidocaine/epinephrine with cocaine and epinephrine together. They considered cocaine local anesthetics does not have to be considered an indis- to be safe with epinephrine more so than with lidocaine pensable procedure in rhinoplasty. Specifically, we aimed Of concern are cardiovascular side effects of epinephrine to provide evidence that despite not administering lido- [, , ]. Sigg et al. [] compared the hemostatic effect of a caine/epinephrine, (1) the amount of hemorrhaging during high concentration of ornipressin (5 IU/10 ml) lidocaine in surgery will not change, (2) surgery time will not increase patients undergoing rhinosurgery. They reported that under and even may be shorter, and (3) there would be fewer halothane/enflurane anesthesia, a patient’s blood pressure cardiovascular-related consequences. We hypothesized that and heart rate did not rise and remained virtually constant up rhinoplasty patients who do not receive lidocaine/epi- to 15 min following local infiltration of ornipressin into the nephrine as a local anesthetic (case/intervention group) nasal tissues. However, patients who were anesthetized with compared to their lidocaine/epinephrine-receiving coun- diazepam/fentanyl experienced an elevation in blood pres- terparts (control group) will be less likely to (1) have extra sure following infiltration of ornipressin (1-ornipressin/ hemorrhaging during/after surgery, (2) have prolonged epinephrine).Therefore, they recommended against the use surgery time, and (3) develop cardiovascular-related com- of a high concentration (2-high concentration of mipressin/ plications, including arrhythmia, hypertension, tachycardia, epinephrine) for patients with blood pressure dyscrasias.
Others have warned surgeons about the rise in plasma epinephrine concentrations within minutes of epinephrineinjection Hasselt et al. [compared plasma catechol- amine concentrations after administering vasoconstrictorsolutions by Moffett’s method or submucosal infiltration of epinephrine (4.4 ml of 1:80,000) and lignocaine (2%) in 20patients undergoing elective nasal surgery. They reported This was a randomized control pilot study conducted in that plasma epinephrine concentrations increased by 44.3 Punzdahe Khordad Hospital, a plastic surgery center affil- times to a peak of 9.9 nmol/l (1,813 pg/ml) within 1 min, iated with Shahid Beheshti University of Medical Sciences.
whereas in patients who received Moffett’s solution con- Patients were recruited to the study by posting study flyers taining epinephrine (1 ml of 1:1,000), the peak level of in the surgery center from May 2008 to May 2009. Inter- epinephrine was 1.27 nmol/l (232 pg/ml) occurred 10 min ested patients who called in were screened by the study after instillation of the solution (P \ 0.01).
coordinator. If eligible and still interested, an initial Cotton et al. argue against the so-called ‘‘safe dose’’ appointment for the informed consent procedure, further of epinephrine (i.e., 1.0 kg-1 during halothane anesthesia).
screening, and collection of baseline information and They reported that the outcomes of infiltration of ligno- measurements was scheduled. To be eligible for the study, caine (21 ml of 0.5%) with epinephrine (1:200,000) to the male and female patients had to meet all the following facial area of rhinoplasty patients, and injection of ligno- inclusion criteria: (1) be 18 years old or older, (2) sched- caine (40 ml of 0.5%), bupivacaine (0.25%), and epi- uled for a primary open or closed rhinoplasty operation, (3) nephrine (1:200,000) to patients undergoing brachial have no history of or current cardiovascular diseases and plexus block were different based on the site of adminis- disorders, (4) have normal values for all the preoperation tration. There was a 566% increase in plasma epinephrine laboratory test results (PT, PTT, and INR), and (5) willing concentration 2 min after cessation of injection in the to sign an informed consent form. Patients who were par- rhinoplasty group, while they observed only a 112% ticipating in another study and/or could not meet the increase in the plasma concentration of epinephrine 10 min aforementioned criteria were excluded from the study. The after completion of the block in the brachial plexus group.
rest of the study procedures were conducted in three stages.
(male, female), age (18 and older), weight (kg), and pulserate (PR) (beats/min).
During a scheduled initial visit, the following procedureswere conducted to find out if the subjects met all the study requirements and if it was safe for them to be involved inthe study. To do so, the study coordinator once more All the operations (primary open and closed rhinoplasties) screened potential subjects for participation eligibility and were performed using the standard technique/protocol explained the research protocol and all its details to them.
without any changes. The steps to perform open rhino- Patients were given ample amount of time to review the plasty were carried out in the following order: Typically, informed consent form and were given an opportunity to the operation began by giving general anesthesia. This was ask questions of the coordinator and/or physicians who followed by the injection of anesthetic solution (lidocaine/ were involved in the trial. Only after all of the patients’ epinephrine), and finally making a columellar incision. The questions and concerns were answered did they sign and steps to perform closed rhinoplasty were first administering date a written informed consent form. Only patients who general anesthesia, followed by injection of anesthetic met all the study eligibility requirements and signed he solution (lidocaine/epinephrine), and finally making an informed consent form were entered into the study and were scheduled for the baseline assessment. The principle Of note, however, is that for the patients in the inter- of the study protocol was approved by the ethics committee vention group, the second step in both the open and the of Shahid Beheshti University of Medical Sciences.
closed rhinoplasty was eliminated (i.e., they did not receivethe standard dose of lidocaine/epinephrine injection during the surgery), and we made the incision right after generalanesthesia. Patients in the standard care group did receive During the baseline visit, all enrolled patients received a the standard dose of adrenalin injection before starting physical examination, and preoperation tests and sub- sequent information were recorded. They also filled out a As is known, septoplasty can prolong the duration of the baseline patient information sheet, including their contact rhinoplasty operation. To eliminate the threat of procedure information; number of physician-diagnosed diseases, spe- bias, patients who needed a septoplasty were equally cifically cardiovascular diseases; past operations; allergies; divided between cases and control groups.
and medication history, including number and types of anyover-the-counter Again, all patients with any indication of cardiovasculardiseases were removed from the study.
At first, all patients were premedicated with midazolam(1 mg IV) and remifentanil (1–1.5 lg/kg). Then they were anesthetized with nesdonal (5 mg/kg) and atracurium(0.6 mg/kg) as muscle relaxants. After 2 min, patients were In this stage participating patients were randomly assigned intubated with an appropriate tracheal tube and the cutoff (using pre-group-assigned sealed envelopes) to either the tube was filled with air and its pressure became constant at intervention group (n = 39) or the control group/standard Following the injection, the septal flap was elevated and the submucosal area was resected. The nasal tip operationwas performed by transcartilage incision. Finally, the dorsal hump was flattened by rasp and cartilage excision usingscissors and a blade, and osteotomy was also performed.
The study outcome variables include hemorrhage recorded Anesthesia was managed by continual infusion of rem- as \50 cc, between 50 and 100 cc, and [100 cc; surgery ifentanil (14–20 lg/h) and propofol (4–6 mg/kg/h) with an duration recorded in minutes; and post-surgery temporary infusion pump, in addition to N2O–O2 (50%). Atracurium cardiovascular complications measured as any sign of was repeated (5 mg every 20 min). Then epinephrine was arrhythmia (yes, no) and hypertension. Hypertension was injected into the nose of patients in the standard care group measured as minimum vs. maximum blood pressure (BP), (control group), but patients in the intervention group did where patients with systolic B160 and diastolic B80 were not receive this injection. All patients received dexameth- grouped in the normal BP category and those with systolic asone (8 mg IV) and metoclopramide (10 mg IV).
[160 and diastolic [80 were grouped in the abnormal BP At the end of the operation and before extuba- category. Other variables in the study include gender tion, muscle relaxants were reversed with prostigmine (0.35 mg/kg) and atropine (0.175 mg/kg). Except for the Table 1 Overall characteristics of the sample (n = 113) elimination of the lidocaine/epinephrine injection for the intervention group, all procedures used during the opera-tion were considered standard measures or techniques for any rhinoplasty surgery. During and after the operation, exact recordings of possible arrhythmias, blood pressure fluctuations, and pulse rate variations were registered in both the intervention and the standard care group. More- over, all patients were asked if they were suffering from cardiac symptoms (i.e., chest pain) after the operation.
Recovery time after the operation, the amount of bleeding, and patient satisfaction were also recorded.
Univariate analysis using descriptive statistics (i.e., fre- quency, percentage, mean and standard deviation) was used to present distributions of the main variables in the study. Independent sample t tests and v2 tests of association were used, when appropriate, to evaluate differences in the main outcome variables (i.e., hemorrhage, surgery dura- tion, post-surgery temporary cardiovascular complica-tions) between the intervention and the standard care group. A P value of less than 0.05 was considered statis- tically significant. Data were analyzed using the SPSS ver.
The main purpose of this study was to demonstrate thatadministration of epinephrine with local anesthetics doesnot have to be considered an indispensable procedure in recorded, the association was not statistically significant rhinoplasty operations. One hundred thirteen patients were (P = 0.161). With respect to the duration of surgery, using enrolled in the study and randomized into the control/ a t test, the average surgery time for the intervention group standard care group (n = 74) and the intervention group was recorded as (mean ± SD) 113.7 ± 22.6 min com- (n = 39). The majority of patients were female (87.6%).
pared with the standard care group whose operation time Participants’ mean age and standard deviation was was 149.8 ± 23.9 min; the difference between the two 25.4 ± 7.3 years. No statistically significant associations groups was statistically significant (P = 0.001) (Table ).
were detected between the intervention group and thestandard care group with respect to the baseline charac-teristics (age, gender, weight, BP) (Table ).
We hypothesized that patients without injection of epi- nephrine (the intervention group) will have less hemor- There has been an upward trend in the number of rhino- rhaging, fewer complications, and a shorter surgery time.
plasties in recent years. Also, more surgeons are using Results of the v2 test of associations indicated no statisti- epinephrine during the surgery. This study evaluated cally significant association between epinephrine injection whether elimination of epinephrine during the operation and hemorrhage during or after surgery (P = 0.949).
would make any difference in the amount of bleeding Although more complications were recorded for patients in during and after surgery, the length of the operation, and the standard care group who received epinephrine (i.e., one cardiovascular-related complications, including arrhyth- patient with arrhythmia, one patient with HTN, and three mia, hypertension, tachycardia, and post-surgery chest patients with both complications) than in patients in the pain. Our findings showed that elimination of epinephrine intervention group for whom no complications were in fact significantly shortened the length of surgery from Table 2 Association between epinephrine, sex, age, hemorrhage, and complications across the intervention and control groups 149 min (average length of surgery in the control group) to short-lasting tachycardia was detected. There was also an 113.7 min (average length of surgery in the intervention increase in the pulse rate during lateral osteotomies.
group) (P = 0.001); reduced the number of expected John et al. reported that all patients showed a marked complications in the intervention group, even though this increase in plasma epinephrine concentration within 4 min association was not statistically significant; and did not add of injecting epinephrine 1:80,000 and 2% lignocaine.
Therefore, they warn surgeons to be aware of this marked Our evidence raises the possibility that elimination of but unpredictable systemic absorption of locally infiltrated epinephrine during rhinoplasty as an alternative procedure vasoconstrictors during any functional endoscopic sinus may in fact lead to the same surgery outcome if not better.
Indeed, we observed fewer complications among a few In a preliminary study, Yang et al. reported that patients who did not receive epinephrine. This finding adds among FESS patients, epinephrine (1:200,000) contained to the existing concerns regarding the use of epinephrine to in 2% lidocaine or saline did cause temporary hypotension locally numb the area of operation during rhinoplasty.
and other hemodynamic changes that lasted approximately Previous studies have suggested that during rhinoplasty 4 min. Surgeons have also been cautioned about the pos- injection of epinephrine was more likely to elevate the sibilities of drug interactions with the lidocaine/epineph- patient’s blood pressure, thus raising the risk of cardio- vascular-related side effects. Koeppe et al. [] argued that In the current study, there was less of a chance of car- injection of even a very small dose of epinephrine as a diac issues by not using epinephrine; there were two local anesthetic can increase plasma catecholamines. In complications in the control group: one patient with their study, overall cardiovascular-related side effects of hypertension and one with an arrhythmia. Even though this prilocaine and lidocaine were reported at 5.9% of rhino- was not found to be significant, not using epinephrine did plasties and 8.1% of face-lifts, percentages that they not add any additional cardiac complications and did not believed were quite high for such procedures. They increase the amount of bleeding in the intervention group.
strongly suggested that surgeons should use ropivacaine Nonetheless, elimination of epinephrine did significantly more often since it offers significant advantages in both reduce the duration of surgery and we did observe a trend efficacy and prolonged duration of analgesia. According to toward fewer complications in the intervention group.
their findings, use of ropivacaine also reduces the risk foradverse side effects due to less toxicity.
Demirtas et al. studied the hemodynamic effects of lidocaine/epinephrine in healthy patients who underwentrhinoplasty procedures. They concluded that after the This study was a randomized control pilot study. Patients injection of these medications, a mild to moderate and were randomized to either the intervention group (only lidocaine injection) or the control group (lidocaine with epinephrine). We aimed to show that epinephrine can beavoided in the local anesthetic solution used for rhinoplasty.
1. Koeppe T, Constantinescu MA, Schneider J, Gubisch W (2005) Current trends in local anesthesia in cosmetic plastic surgery of the Our results indicate that elimination of epinephrine for a head and neck: results of a German national survey and observations few patients in the intervention group reduced the number on the use of ropivacaine. Plast Reconstr Surg 115(6):1723–1730 of anticipated cardiac-related complications. Furthermore, 2. Yang JJ, Li WY, Jil Q, Wang ZY, Sun J, Wang QP, Li ZQ, Xu JG elimination of epinephrine did not add any additional risk (2005) Local anesthesia for functional endoscopic sinus surgeryemploying small volumes of epinephrine-containing solutions of of bleeding assessed intraoperatively by sponge count and lidocaine produces profound hypotension. Acta Anaesthesiol total aspirate. Our findings also showed that elimination of epinephrine reduced the length of surgery in the interven- 3. De R, Uppal HS, Shehab ZP, Hilger AW, Wilson PS, Courteney- tion group, which could be partly due to the 5–10 min Harris R (2003) Current practices of cocaine administration by UKotorhinolaryngologists. J Laryngol Otol 117(2):109–112 saved by not having to inject the lidocaine/epinephrine.
4. Demirtas Y, Ayhan S, Tulmac M, Findikcioglu F, Ozkose Z, Yalcin These findings raise the possibility that elimination of R, Atabay K (2005) Hemodynamic effects of perioperative stressor epinephrine during the rhinoplasty could be an alternative events during rhinoplasty. Plast Reconstr Surg 115(2):620–626 procedure that may in fact lead to the same surgery out- 5. Sigg O, Pirsig W, Hirlinger WK (1983) Ornipressin as vasocon- strictor in rhinosurgery. Rhinology 21(2):159–164 come if not a better one. Studies with a larger sample size 6. van Hasselt CA, Low JM, Waldron J, Gibb AG, Oh TE (1992) can help further substantiate these findings.
Plasma catecholamine levels following topical application versusinfiltration of epinephrine for nasal surgery. Anaesth Intensive The authors are grateful to the staff of Punzdahe Khordad Hospital, a plastic surgery center affiliated with Shahid 7. Cotton BR, Henderson HP, Achola KJ, Smith G (1986) Changes in Beheshti University of Medical Sciences, for their rigorous collabo- plasma catecholamine concentrations following infiltration with ration in patient recruitment and data collection. The project was large volumes of local anaesthetic solution containing epinephrine.
entirely funded by a grant from Shahid Beheshti University of 8. John G, Low JM, Tan PE, van Hasselt CA (1995) Plasma catecholamine levels during functional endoscopic sinus surgery.
The authors have no conflicts of interest or financial ties Clin Otolaryngol Allied Sci 20(3):213–215 9. Asaadi M, Anagnoste SR (1995) The use of cold normal saline for vasoconstriction in rhinoplasty. Plast Reconstr Surg 96(3):751–752 This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per-mits any noncommercial use, distribution, and reproduction in anymedium, provided the original author(s) and source are credited.

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