Hypoperfusion following the injection of epinephrine in human forearm skin can be measured by RGB analysis but not with laser speckle contrast imaging

Abstract

Background: The time taken for epinephrine to achieve its optimal effect during local anesthesia has recently become the subject of debate. The time from injection to commencement of surgery is traditionally quoted to be 7 to 10 min, while recent reports claim that it may take 30 min to achieve maximum hypoperfusion, which would prolong the time required for surgical procedures. The discrepancy may be related to difficulties associated with the techniques used to measure blood perfusion. The aim of this study was to test two methods of determining the time to maximum hypoperfusion.

Methods: Laser speckle contrast imaging (LSCI) and red, green, blue (RGB) analysis of images obtained with a commercial digital camera, were used to monitor the effect of infiltration with commonly used local anesthetic preparations: lidocaine (20 mg/ml) + epinephrine (12.5 μg/ml), lidocaine (10 mg/ml) + epinephrine (5 μg/ml), and lidocaine (20 mg/ml) alone, in healthy subjects.

Results: LSCI showed a paradoxical increase in signal after the injection of local anesthetics containing epinephrine, probably due to a change in the laser penetration depth resulting from blanching of the skin. However, RGB analysis of digital photographs gave more reliable results, showing skin blanching that corresponded to the expected effect of epinephrine in local anesthetics. The time to maximum effect was found to be 7 (range 5-10) minutes for 12.5 μg/ml epinephrine, and 9 (range 7-13) minutes for 5 μg/ml epinephrine in lidocaine.

Conclusions: RGB analysis of digital images proved to be a valid technique for monitoring the effect of local anesthetics with epinephrine in human skin. The technique requires only a commercial digital camera and constitutes a cheap, simple method. The optimal delay between epinephrine injection and incision, to minimize bleeding, was found to be 7 to 9 min, which is in good agreement with common surgical practice.

Keywords: Epinephrine, surgery; Hypoperfusion, blanching; Laser speckle contrast imaging; Local anesthesia; RGB analysis; Skin, perfusion.