INTRAOPERATIVE “HIGH DOSE” EPINEPHRINE INFILTRATION IN CLEFT PALATE REPAIR
Nelson E. Castillo, M.D., Darren Smith, M.D., Joseph Madia, MS-IIII, Gary DeCesare, M.D., Sanjay Naran, MS-III, Franklyn Cladis, M.D., Matt Ford, MS, CCC-SLP, Lisa Vecchione, DMD, MDS, Shao Jiang, M.D., Joseph Losee, M.D..
Childrens Hospital of Pittsburgh, Pittsburgh, PA, USA.
BACKGROUND AND PURPOSE: Local infiltration of epinephrine prior to surgical procedures is a well-accepted technique to promote vasoconstriction. Typically, the dose of epinephrine is limited by the co-administration of local anesthetic, as well as the risk for arrhythmogenesis and hemodynamic changes. In addition, some controversy exists regarding the acceptable dose of epinephrine given to children. This retrospective review examines the use and safety of “high-dose” epinephrine in palatoplasty at our Cleft-Craniofacial Center.
METHODS: A retrospective review of the use of epinephrine in primary palatoplasty at a tertiary children’s hospital from 2003-2007 was performed. Operative and anesthetic records were reviewed for hypertension (SBP>120 or DBP>70) and tachycardia (>190bpm) as defined by pediatric advanced life support guidelines, as well as dysrhythmias, intra-operative, and post-operative complications.
RESULTS: 102 cases of consecutive primary palatoplasties performed by a single surgeon were identified. After the induction of anesthesia, and prior to incision, patients received an initial epinephrine infiltration (without local anesthetic) up to a maximum 10 mcg/kg. The average total dose of epinephrine administered during palatoplasty was 12.8 mcg/kg (range 3.2 to 75.0). Doses up to a max of 10 mcg/kg were administered as needed at 30-minute intervals. No instances of clinically unstable tachycardia or hypertension occurred. 21.6% of patients (22/102) experienced an instance of hypertension, and only 13.7% of these (14/102) were related to epinephrine administration. A single case of tachycardia secondary to epinephrine administration was identified. All hypertensive and tachycardic events were successfully treated with analgesia or increased anesthesia. No dysrhythmias, transfusions, or intra-operative complications occurred. One (1%) post-operative fistula was identified.
CONCLUSION: Locally infiltrated “high-dose” epinephrine during palatoplasty can be safely used as a means of vasoconstriction. Doses reaching a maximum of 10 mcg/kg, administered as needed at 30-minute intervals, do not appear to be a significant risk for hemodynamic instability, intra-operative, or post-operative complications.